Avastin for early-stage PC?

[WTL]

I was diagnosed with PC on Feb. 15, haven't decided on treatment yet, still getting tests and consultations. Gleason score 8; two biopsies show it's confined to right apex, rest of gland looks clean; second biopsy and MRI/bone scan show no escape from prostate. So far most doctors have suggested I'd have to go on hormone deprivation before any kind of surgery, and I do not want that in any way. The side effects are too debilitating, and there's no evidence it works well enough to justify those side effects.

I've just read about the anti-angiogenesis drug Avastin, used in advanced/metastatic cancers. The side effects are less drastic, though can be serious. I don't know if there's even a study going on about its use in early-stage confined cancer like mine, but I know that given the choice between Avastin and Casodex/Lupron I'd choose Avastin.

Any informed opinion/anecdotal history out there? The time is getting near when I have to choose my poison. And I'm wondering if, given my situation, whether any such treatment would be needed at all if I have, for example, surgery in May (doctor's schedules seem to make anything sooner impossible). Thanks.

[HeinrikMD]

Hi,

You have early disease.  I seem to have misinterpreted the statement "MRI/bone scan show no escape from prostate" to mean that you have bone metastasis.

You seem well-informed, thank you for proving me wrong. One of the limitations of this medium we use is that I cannot hear your voice or observe your facial expressions when you mention such things as: "doctors aren't sure whether they're treatments will work, so why shouldn't my plan work?" because the same words can be used by someone expressing emotions and by someone expressing plans.

I failed to mention that most trial settings are randomized. Meaning, you don't really get to choose to take which drug - you only get a chance at using it. But either way, you are getting a treatment that is adequate compared with current options.

You are correct that treatments move forward from advanced to early disease. I personally think treatments like Avastin could limit metastatic potential and would potentially revolutionize treatment in early disease; but while there is no limit on what we may think of - there is much limitation on what we can offer. Oncology actually gets special treatment in getting accelerated reviews for novel treatment options - however, for the patients, I understand it is never rapid enough.  

[WTL]

Point of clarification: I haven't had my consultations with Dr. Scholz and Dr. Kawachi yet; March 12 with Dr. Kawachi, just beginning paperwork with Dr. Scholz. I'm also planning a consultation with Dr. Pinski at USC.

And for the short paragraph about "not flying blind..." Somehow that insinuated itself into the middle of this post; it was supposed to be my conclusion. I was probably adding to the post here and there and didn't notice where the cursor was - the typing field for posting is very small.

[WTL]

Hi doc

Well, I'm sure I make erroneous assumptions, though actually I'm just asking questions.

I'm told I have early disease by the doctors I've seen - both urologists. I'm not sure what the definition of "early" is - my PSA in Dec. 2006 was 4.2, and no biopsy was recommended. A year later it was 6.7, and a month after that it was 8.8. Is that early stage.

MRI/bone scan show no metastasis - I realize neither of these scans can detect individual cells that may have escaped, but the MRI said no capsular penetration and no seminal vesicle or lymph node involvement, and the bone scan detected nothing wrong.

My second biopsy of 24 cores found one more tumor - Gleason 7 - in the same area, the right apex, as the two found in the first biopsy. The first biopsy (Gleason 8) went deep for the most part; the second biopsy concentrated on the periphery and on the neurovascular bundle. Again, as with the first biopsy and the MRI, no evidence of capsular penetration. Does this count as early stage? I'm just repeating what my doctors have told me, and they are good doctors with vast experience in the field. In this regard I'm lucky to live in LA, where there's an embarrassment of riches in prostate cancer research. One of my consultations is with Mark Scholz, a founder of the PCRI website and director of Prostate Oncology Specialists here in LA, and another is with Mark Kawachi, director of the program at City of Hope.

I am not flying blind here. Thanks for your insights and for all the good you do on this site. Your helpfulness is changing lives for the better.

As for side effects: I understand they vary in frequency and severity. I don't doubt I would have at least some side effects from taking either Avastin-type drugs or ADT drugs. Avastin is comparatively safe with few side effects, from what I've read, while ADT's side effects are strong and well-documented, from feminization to bone and heart problems - of course I realize that individual responses will vary, but many studies I've read in several venues, all of them reputable, by researchers in the field, cast doubt on ADT, on whether the cost in side effects and quality of life and even extension of life is sufficient to to justify the well-known benefit of inhibiting tumor growth. You read me wrong if you think I give little weight to the benefits of ADT; I'm just very aware of the very deleterious side effects and I'm being completely rational in trying to devise a cost-benefit analysis. From what I've read, this is a prominent controversy in the urology field, just like the dispute over whether 2.5 PSA or 4.0 PSA should be the number over which a biopsy should be performed.

True, I would be a willing guinea pig for Avastin if the doctors recommended ADT. If Avastin can do the job of inhibiting tumor growth well enough until I can begin treatment  - especially given the early stage and confined nature of my cancer -  without my having to grow breasts and have my testicles and penis shrink and bones begin to lose calcium and my heart begin to weaken, as could very well happen with ADT (and possibly never recover my own testosterone production, let alone sexual functions), of course I would want to choose Avastin, if it's available. No doctor has t recommended ADT for me yet - it's too soon, I'm still getting tests done and am just beginning consultations. But they have SUGGESTED it as a possibility. I'm seeing a surgeon and two oncologists in the next couple of weeks, when they can examine me and get a thorough look at my medical history.

The doctor who did my second biopsy was pleased with the results enough to say I probably would not have to have ADT - he was one who told me at first that I might need it - and he dismissed Avastin immediately because it's used only for advanced and metasticized cancer. He thinks I would be safe enough without ADT until May, which is the earliest he could fit me in for surgery (this would be HIFU, done in Europe).

But just as ADT used to be employed only for advanced, spreading cancer, especially when other treatments have failed, but is now also used in early-stage cancer, I guess I'm just anticipating that someone will soon be trying Avastin for early stages because of its significantly less drastic side effects. Avastin may be experimental for early stage, but it clearly does what it's supposed to do - inhibit formation of blood vessels that supply the cancer cells (and of course normal cells, too, which is where the hazard lies for wound healing, and other issues).

I haven't found any Avastin trial going on that addresses the issue I raise here.

[HeinrikMD]

hi,

There are current studies using agents similar to Avastin for prostate cancer but these are in combination with other agents, and these are for advanced disease.

I think you are making some erroneous assumptions:

All cancers are the same, so the therapies for one will necessarily work on any other cancer. If it works for colon it will work for prostate. Even prostate cancers have varied outcomes and may be someday reclassified as unique entities.

You think side-effects will occur without fail. These will happen in a percentage of patients and severity is likewise varied.

You think justification is a matter of having no risks for side-effects, you give little weight to whether the treatment will actually work.

Unfortunately, the doctor's philosophy of treatment is different from yours. Patients should be offered treatment that is known to work. Hence, something new gets to be tried first in patients who have more advanced disease and have less in the way of options. In your case, you would be risking foregoing effective treatments in favor of experimental ones.

If there is an ongoing clinical trial with sufficient basis to try avastin on prostate cancer then you could have yourself enrolled. Unfortunately, I don't think you'll find any. Colon cancer is the most studied disease with avastin and it has not crossed the threshold from advanced to early disease.

Are you sure you have early disease? What do you mean by "MRI/bone scan show no escape from prostate"?