When to Start Hormone Therapy?
Dear OncoLink "Ask The Experts,"
I have prostate cancer, had a radical prostatectomy in 1999, then 13 wks of radiation in 2004 with a serum PSA of 0.26 ng/mL. As of July 2007, my PSA is 3.3 ng/mL. I know that hormone therapy is my only treatment option, but when should I start?? I have gotten 4 different opinions, ranging from now, to waiting until the PSA is at 5 or 10. Are there any statistics on the optimal time to start?
Richard Whittington, MD, Associate Professor of Radiation Oncology at the University of Pennsylvania School of Medicine, responds:
This is the classic question. Ask 3 doctors and get 4 answers. There is a great deal of controversy because the clinical studies are contradictory, and the treatment has side effects. I guess my recommendation to patients is usually to start androgen ablation when the PSA reaches a level of 8 to 10 ng/mL. The reason for this is that relatively low PSA levels or slowly rising PSA levels may not be a problem for years. If a man lives for 10 to 15 years and is on hormones the entire time, then there is an increased risk of osteoporosis, loss of muscle mass, and rate of accumulation of atherosclerotic changes in blood vessels, which may then increase the risk of heart attack or stroke. On the other hand, there is a large British trial that was published in the British Journal of Urology in 1999 which showed that men lived longer and their quality of life was better when the hormones were started before a man had symptoms. In my experience, it is rare to see symptoms when the PSA is less than 20. For this reason, if the PSA goes from 4 to 8 in a year, I would recommend starting hormones, but if it took 5 years to go from 4 to 10, I might be inclined to watch the disease until it got to 15. I guess the key is that when you ask for an option and get an answer, you should follow it up with a "Why?" If the reasons sound good, go with that opinion.