Does PSA test really work, long term Zoladex harmful?

My father has Prostate Cancer with gleason 9. PSA test show no sign of cancer, but after a biopsy, revealed gleason 9. Cancer spread to lymph nodes but not yet to bones. Traveled to Dr. Tewari but said it was beyond surgery. Did Radiation Theraphy two years ago and has been on Zoladex since. Follow up PSA test comes up no cancer. Father is feeling healthy.
Question 1: Because of previously tested for PSA test that did not revealed cancer, but only to find in Biopsy to reveal a gleason 9, would the PSA test now after radiation therapy really show that Prostate Cancer has gone or dormant ? What other test can be done to confirm the result of Radiation Thereapy?
Question 2: Father has been taking Zoladex injection for two years. Oncology doctor recommends, "he get off of Zoladex becuase the body might get use to the medication because it won't be as effective in the future. Also, getting off Zoladex can tell if Prostate Cancer is dormant and see if PSA level increases". Urologist believes, "in taking this injection indefinitely, as it is dangerous to get off due to cancer's likelyhood of returning". Which doctor is more correct? What is your oppinion?

Father is having ED as well as no sexual activities from Zoladex, but that's a small price to pay. Please advise. Thank you in advance.

[HeinrikMD]

Hi,

For question 1:
The PSA is used to detect relapsed disease. If it is rising, then it would mean the disease is returning. Of course other tests such as imaging tools like a bone scan would also tell if the disease has progressed. However, the PSA tends to catch the disease earlier before it even spreads to the bones. Hence, the doctor generally looks at the PSA and any symptoms which may be worth investigating.

For question 2:  
Unfortunately there is no clear answer for this. What is clear is that patients with lymph node involvement like your father do benefit from the Zoladex after the radiation. There is no clear benefit as to continuous treatment, nor consensus as to how long constitutes adequate therapy.
If you discontinue now, we already know that the benefit has been achieved (some patients only take the medications for 6 months after the radiation). If you choose to continue, the benefit is not very clear and the safety issue is  likewise unknown. For breast cancer patients, there are hormone therapies that last for 5 years, safety issues involve bone loss/fractures and lipids/heart disease. Of course it would be difficult to estimate how it will go for men - but the heart disease may be worse.

At this point you may have to make a value judgment. If you are the type to take on risks and unknowns, and he is doing well, you may consider continuing but with monitoring for adverse effects. If you are more conservative, you could consider discontinuation.

[Tommyt262]

Sincerely thank you very much for your time and information.
Definitely, it would be great to know that his cancer is dormant and stop the medication. But why would his Urologist tell him to continue indefinitely. Is it because he thinks cancer has spread into bones or it was a gleason 9?
Is there any other type of treatment if cancer comes back even with continued use of Zoladex?
Would it prolong life to stop hormone usage now, and start back up if any trace of PSA ever comes back?
Thank you again for your time and effort in answering our questions.

[HeinrikMD]

Hi,

Perhaps the urologist feels that the treatment is going really well, and withdrawal of the drugs must be responsible for it. However, it is really not possible to say whether it was the response to the radiation that is still working, or it is the hormones. As I mentioned before, this is a value judgement as there is no clear superior course of action.

There are secondary hormones and chemotherapy that can be used if Zoladex is no longer working.

Holding the hormones now or continuing it would not translate in a survival gain. Put another way, the survival at this point would not change whether you continue the hormones or not. Hence, the benefits are not clear. The risks/harm, of course may be hard to measure but they are believed to be increasing as there are cumulative effects of hormones particularly on bone and the cardiovascular system. Hence, in this situation, the risk-taker would continue treatment, the risk-adverse, would choose to discontinue treatment.

[tinter]

I was diagnosed with an advanced mestatic prostate cancer that had advanced into my hip bone, lympth nodes and top part of my femur 18 months ago.
I've had no operations (other than a Turp) as the cancer was considered to far advanced.
Originally the the Gleeson score was 7 and my PSA was 193.

After having had Zoladex implanted on a regular 3 month basis, my PSA count has been 0.1 for the last 9 months but the hot flushes have been killing me.

My urologist has referred me to an oncologist who claims like the previous forum poster to go off the Zoladex and have a break and monitor the PSA which not only gives the body a spell but doesn't let the cancer get use to the medication.
If it increases, then back on the implant.

Question....the urologist says it's like "letting the genie out of the bottle" and suggests to stay on the Zoladex 9tough out the flushes) seeing I've had such fantastic results but this thinking is totally adverse to what the cancer specialist has suggested.

Just who is right and understandably I don't know which way to jump.

Rob.

[Nateski]

I sometimes do not think these people (doctors) know what are talking about. I had T3 Prostate cancer. The doctor told me only two injections at first, then on my 2nd injection he wanted to give me two more which I told him no. He asked me why and I told him that the "hot sweats" bother me, I in-turn get angry! Especially when people ask me stupid questions about why I perspire, after telling them repeatedly why. All I want to know is when the effects will leave my body? I started my first injection in June, and my second  w/ "Radiation Therapy" in September 2007 after having a Radical Prostatemomy in January 2007. All I want to know is "WHEN" at least the sweating will cease. I was told if I am sweating this means the Zoladex is working.

[tinter]

G'day,
It certainly means that the Zoladex is active in your body and the hot sweats will not go away whilst ever you are on the 3 monthly implant like I am for the rest of my life.

It's one of those problems associated with medical science that keeps us alive by keeping the PSA level in check.

I had another PSA done only yesterday and again for the 4th lot of 3 months in succession, I'm at 0.1.
I'm off on Monday to get a further oncologist opinion from a different specialist to see what he reckons.

12 months ago I was put on a course of tablets called "Androcur" to minimise the effect of hot flushes but the side effects knocked me around big time.
I became unnaturally lethargic, developed slurred speech, had problem with typing skills and all in all felt **** whilst on it.

In the end I put up with it for awhile (the flushes did subside) but the cost to my general well being was too geat and I went off it.

My urologist has also told me that Androcur in its own right has been known to cause tumors on very rare occasions by itself so if I can suffer the hots, better to stay on it.

It's a perplexing predicament to be in we prostate cancer sufferers..........is it quality of life or quantity of life?

Many regards,
Rob.
Melbourne, Australia

[HeinrikMD]

Hi,

On going off the Zoladex for a time:

The reference treatment for advanced prostate cancer is continuous treatment with the hormones.

The problem with this strategy is that there is no clear impact on survival. If this is the case, then there may be room for less aggressive treatment to improve quality of life. Such strategies have been tested and have not been found to be inferior to the continuous treatment strategy.

Of course at the end of it, individualization is best. If the PSA is rapidly rising, then the break from the hormones may not be worth it.

On when the effects will leave the body:

Depending on the drug whether it is designed to last a month or three months, then the effects tend to last this long.

On doctors not knowing what they are talking about:

There are a number of controversies indeed with prostate cancer treatment, and different doctors may have different angles on the problems.

I’d like to think that the diversity of opinions actually helps to arrive at better options and outcomes. If there was only one school of thought for everything, then we’d probably be teaching our children and grandchildren that the earth is flat.

[tinter]

Thank you so much for the time and support you have given we who suffer around the world with this tragic disease by posting here.

"Is there any time survival frame that could be considered usual" for patients who have had prostate cancer that had gone into the bone and now in remission?
ie. 1-3 years since diagnosis or possibly more?

I've had no other operations and treatments other than Zoladex for 18 months and now I'm taking a spell off it.

I'm in fine health currently other than suffering hot flushes.

Regards,
Rob
Australia.

[HeinrikMD]

Hi,

For patients with disease beyond the prostate, the estimated median survival is around 2 years.

The median survival is the experience of 50%, hence at least half of cases would be expected to reach the 2 year mark. It is not an upper limit where all cases are expected to die within 2 years.

Of course it would be more practical if the actual estimates until time of death for all patients (100% instead of 50%) could be estimated. While it is possible to follow-up patients until time of death, the median gives the better estimate for purposes of generalizability. Patients who survive well beyond this mark may have features that are unique to them (and which help them survive, but is hitherto unclear as far as scientific know-how is concernced) and thus, the issue of generalizing the experience of these few becomes apparent.

Each case should be appraised individually. A cancer that is advanced in an otherwise active person may have better chances for longer survival than an early cancer in a moribund person (who may have other diseases like heart disease and diabetes).

Stay positive.

[tinter]

Thx again Heindrik,
Based on your experience, would you advise me to go off the Zoladex hormone treatment till an increase in the PSA is detected as my oncologist suggests?
This he says could be 6-12 months.

His only caution is to monitor the PSA every 2 months instead of the usual 3 so as to keep a better eye on possible new cancer activity.

My urologist specialist tells me that since my last 4 implants taken at 3 monthly intervals have supplied a 0.1 level in the PSA every time which is very static, then that's a great sign.
Not good would be a widly fluctuating PSA whilst on the Zoladex treatment.


For us as men with this medical nightmare, we struggle to get information that can be construed as positively directional and right.
As laymen we want to make a calculated decision on the right course of action as to where we take what we have of our lives left remaining but you surely must understand the frustration.

What would you do if you were in my shoes?

Many, many thanks and as I've said there will be many prostate cancer patients around the world hanging off every reply of yours.

Regards,
Rob.....Austraila.

[HeinrikMD]

Hi,

There is confusion because the doctors are talking about 2 different things.

The urologist is recommending sticking to the program because it is successfully suppressing the PSA. This line of thinking is based on a theory that the PSA will correlate with a better survival.

The oncologist is recommending a discontinuation because the experience with maintaining the Zoladex until PSA does break free of its control, has been demonstrated not to impact on survival. Prolonged treatment complications are also not established. Hence, the oncologist would consider changing the treatment, since the goal is unclear, and the risks are not well-measured – making a determination of benefit and risk difficult (if not impossible).

Hence, the Urologist is making a recommendation based on theory while the oncologist is making a recommendation based on actual data. The urologist may not think the existing data is conclusive, or is not aware of it, or is influenced by actual experience with other patients that he/she has treated before.

The standard therefore, is still to continue without a break. But this is being challenged by newer data, especially since, the standard was established without anybody thinking of an alternative mode of delivering the therapy.

For me, the school of thought that “PSA suppressed always good”, represents too linear a frame of mind to model outcomes of disease. I also think that the most that can be done is to try and educate patients, to help them decide, not to decide for them.

At the end of it, there is no clear answer which is better.

If you feel great with the treatment, then you may continue it. But I’d keep an eye on your bones. The traditional continuous treatment usually sees a progression of disease before 2 year. The long term effects of Zoladex is not yet established. So while the recommendation to continue is sound, a guide on what to expect with prolonged treatment is sketchy.  

If you think a break may make you feel better, more active, then you may take it.

I hope I did not add more mud.

[tinter]

G'day Heindrik,
Are you a prostate cancer specialist if I may ask?
Regards,
Rob.

[farmerdave]

Has any body had any trouble with painful testicles when on Zoladex
thnks Dave

[walid13]

what is the likehood of patients with locally advanced prostate cancer (Gleason 9 ) on Zoladex to develop metastasis some where in the body espeacially bone and Brain