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Advanced stage prostate cancer can present itself in one of two ways: firstly, a patient can be diagnosed initially, based on biopsy and clinical staging of the disease, at a Gleason stage that can be considered advanced due to the aggressiveness of the cancer cells seen in the pathologist's review. In some cases wherein the Gleason stage may not be considered aggressive = 6, other diagnostic tests, e.g. endo-rectal MRI may indicate that cells have escaped the prostatic capsule, which could potentially cause a recurrence of the disease after primary therapy. It has been shown that 20-30% of patients have the disease recur after a primary therapy (surgery or radiation).

More commonly advanced stage disease presents itself after primary therapy and a rise in PSA level is noted. In some cases, if the increase is noted early and the PSA level has not exceeded 1.5 and the patient did not have surgery, salvage radiation is an option that has proven to be effective in curing approximately 25% of the patients who failed primary therapy.

Typically, the usual course of treatment for advanced stage disease is a form of hormonal therapy, also called androgen ablation that seeks to remove testosterone from the system because testosterone contributes to the growth of the cancer cells. You should note that typical hormone therapies are NOT curative and that your system will at some point become hormone/androgen independent (the cancer recurs). Because of the complex nature of the disease, at the time that the PSA begins to rise, you should consult with a medical oncologist along with your urologist to determine what the best therapeutic approach should be implemented for your situation.

Dr. Maha Hussain of the University of Michigan Cancer Center speaks about the controversy between intermittent and continuous androgen deprivation therapy.

The options that are available are:

Orchiectomy - this is surgical removal of the testicles to eliminate the roughly 90% of testosterone produced by the testicles; obviously this procedure is permanent and cannot be reversed. Other options to eliminate testosterone are noted as follows.

LHRH agonists - the brain generates signals, luteinizing hormone releasing hormone (LHRH), that cause the testicles to produce testosterone. The single agents used in this protocol are usually lupron or zoladex

Nonsteroidal antiandrogens - approximately 10% of testosterone is produced by the adrenal glands; the utilization of a nonsteroidal antiandrogen, such as, flutamide (Eulexin) or bicalutamide (Casodex), in conjunction with one of the above procedures is called complete androgen blockade (CAB) is theorized to help improve survival, but very little evidence exists to support this hypothesis. Additionally many patients that have been on CAB for an extended period may experience a rise in PSA; in these cases usage of the nonsteroidal antiandrogen should be stopped.

Other therapeutic options to consider, based on investigative clinical experience or on-going clinical trials, are:

Intermittent Androgen Blockade (IAB) - as the patient's PSA level normalizes, he may be cycled off and on the hormonal blockade to extend the period of effectiveness of the hormonal therapy before the patient becomes hormone refractory/androgen independent, i.e. the diseases progresses

Herbal Therapy - certain herbal supplements, such as PC-SPES and others, have been shown to have effects in controlling both androgen dependent and androgen independent cancers. Given that this class of treatment does not fall under the same guidelines for testing, efficacy, etc. as other drugs, it is important that you undertake their use only under the guidance of your doctor

American Society of Clinical Oncologists - patient and professional information relative to all products, treatments, latest publications, etc.

Adjuvant Therapy - prior to surgery or radiation; a discussion as to the benefits of hormonal treatment

Intermittent Hormonal Therapy – evolving technique designed to maintain androgen dependence thereby prolonging survival and decreasing long term side effects.




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