The catch The patient is exposed to radiation. Finding the right tracer marker (carbon-11, choline, glucose, NaF) to be used with the test is challenging because the technology is developing so quickly. In some cases, patients have problems with insurance coverage for this test.
ProstaScint Scan
Advantage The ProstaScint scan can suggest whether or not cancer has returned after localized treatment for prostate cancer, especially in the areas around the prostate.
The catch This test is of little value for a man with HRPC. Also, the accuracy of this test has been questioned.
Transrectal Ultrasonography (TRUS)
Advantage A TRUS involves no radiation exposure. It is the gold standard device to obtain prostate tissue biopsy samples.
The catch The TRUS is not a good test by itself for detecting a tumor in or near the prostate.
X-ray
Advantage In traditional X-ray procedures, the patient receives a low amount of radiation exposure. The tests can be done quickly.
The catch X-rays only show something when it is more obvious and takes up a lot of space, such as an infection, fracture, or cancer in the lungs or the ribs. They are not as good at finding small-to-moderate amounts of cancer or bone loss.
In upcoming chapters, we’ll consider a number of currently recognized FDA-approved treatments for HRPC and drugs that are in phase-3 testing. As you read those chapters, you will get more detailed information on the full scope of possible therapies to discuss with your physician to determine the best course of action for your individual situation. Following the sections on treatment, we’ll spend some time discussing side effects and offer suggestions on preventing and mitigating them. Remember, an informed patient can better weigh his options and make an educated choice on treatment plans.
Notes
Three Minimal Treatment Options
Here is one quick tip—you may want to be SURE that you have HRPC. You can elect to get a total testosterone test, preferably with the blood drawn in the morning when testosterone levels are generally highest. For HRPC, your blood testosterone should be less than 50 ng/dL (1.7 nmol/L). In a very small number of situations (fewer than 5 percent), a rise in PSA is not due to HRPC, but rather due to an actual rise in testosterone. In such a case, the patient is considered to have HRPC even though he did not really have it. Rather, the therapy used to reduce testosterone levels was not able to completely get into the blood and effectively reduce testosterone to castration levels.
After establishing that you do, indeed, have HRPC, there are many options you should consider, along with your physician.
Three Minimal Treatment Options for Early HRPC When the PSA rises several times while a man has castrate levels of testosterone (less than 50 ng/dL [1.7 nmol/L]), there are a few quick options that need to be considered for some patients before other options come into play.
Some men have a rising PSA on ADT, but no signs or symptoms of metastatic disease. These men have non-metastatic HRPC (PSA-only relapse), and they have a higher risk of developing cancer in the bones in the future. However, this can take many years to occur. Thus, these men do not truly qualify yet for the FDA-approved metastatic HRPC treatments. So, what to do? Treat this disease with the FDA-approved drugs, something else, or not at all? A couple of minimal approach treatment options to HRPC may be attempted before other drug treatments, namely observation (rarely used) and, more commonly, the use of a low-dose anti-androgen, followed by anti-androgen withdrawal (AAWD). At some point, more aggressive treatments, such as secondary hormonal therapies, become a better option. Keep in mind that several different secondary hormonal treatments involve multiple options that can be used by themselves, one at a time (sequentially), or, in some cases, together. More information on each of these minimal treatment options follows.
OPTION 1 Active Observation/Surveillance
Some men with a low PSA, or a PSA that takes a long time to double in number (prolonged PSA doubling time), and no signs or symptoms of metastatic disease are potential candidates for undertaking no additional treatment for a certain period of time, as long as most of these men remain on ADT and are monitored regularly by a doctor.
OPTION 2 Low-Dose Anti-Androgen Pill
Please note that this is also considered a form of secondary hormonal treatment by some physicians, especially when taking higher doses of these medications. For more information on use of a higher dose anti-androgen pill, see chapter three.
One way to remove 90 to 95 percent of male testosterone is to get an LHRH injection or an orchiectomy (surgical removal of the testicles). However, another 5 to 10 percent of testosterone is produced by the adrenal glands. One way to block the impact of that extra testosterone is to add a drug that blocks the androgen receptor (AR), simply known as an anti-androgen. There are three anti-androgens used in this situation, namely bicalutamide, flutamide, and nilutamide.
Therapy using LHRH treatment (or orchiectomy) plus an anti-androgen pill is known by several names, including combined androgen blockade (CAB), combined androgen deprivation treatment, maximum androgen blockade (MAB), and complete androgen suppression. Regardless of the name, such therapy is a simple approach to use to determine whether the PSA can be stabilized or even reduced.
In a review over a decade ago of twenty-seven randomized clinical trials for locally advanced or metastatic disease studying the benefits of ADT (LHRH) alone as compared to combined ADT (LHRH plus a low-dose anti-androgen), researchers found only a small benefit (approximately 2 or 3 percent over five years) in survival for some patients receiving the combined therapy. Thus, most anti-androgens are used when the PSA increases on ADT; using them can lower side effects and cost.
Dosage A range of low-dose anti-androgen options exists.
Advantages These drugs are simple to take. There are now some generic options, so check availability and price, please. They can have some effectiveness when given in higher doses for HRPC patients, especially when used in the early stages of HRPC (see also secondary hormonal options in chapter three). If a patient responds quickly to one non-steroidal anti-androgen, he is likely to respond to the other two after that one anti-androgen loses effectiveness.
The catch These pills are not inexpensive. Also, if the AR is blocked, the small amount of estrogen in a man’s body may become more potent, so breast pain (mastalgia) and breast enlargement (gynecomastia) are not uncommon. Also, these drugs can cause sexual dysfunction and increase the risk of gastrointestinal problems, hot flashes, and liver toxicity.
What else do I need to know? It should be kept in mind that the amount of cancer is generally inversely related to the impact of the anti-androgen pill. So, men with asymptomatic, non-metastatic disease have a much greater chance of responding favorably as compared to men with symptoms and metastatic disease.
Remember,
