Tracks 1-4
DR TAPLIN: When I met this patient, his first words to me were, “I’d rather
die than receive hormone therapy.” As a priest, he had known people on
hormone therapy who had been very depressed. Apparently he knew someone
on hormone therapy who committed suicide. Also, he’s Internet savvy,
spending a lot of time on the computer reading about the negative side of
hormone therapy, unable to put it into context.
DR LOVE: Was he concerned only about the depression or did he have other
concerns?
DR TAPLIN: He was concerned about everything. He’s afraid that he will be unable
to practice his profession because of depression or a lack of energy. He has the strongest
bias against hormone therapy that I’ve ever seen in my 20 years of practice.
He was open to radiation therapy, but our radiation oncologist did not feel it
was appropriate for him given the extent of the lymph node disease and the
rapid doubling of his PSA.
DR LOVE: Did you have any trials that he was eligible for?
DR TAPLIN: We didn’t have a trial open at the time, but we’ll be opening
a study for high-risk PSA relapse combining docetaxel, bevacizumab and
hormones. In this trial, after the patients complete the chemotherapy they will
continue the bevacizumab and hormones for another year.
I discussed standard care with him, which I believe would be combined
androgen blockade, consideration of intermittent hormone therapy and bicalutamide
at 150 milligrams to potentially abrogate some of the side effects. I also
recommended he consider chemotherapy and hormone therapy, but he’s so
concerned about the hormones that it’s been a difficult decision for him.
DR LOVE: Dave, how would you approach this patient?
DR CRAWFORD: We talk about rapid PSA doubling times, but this patient has a
rapid, rapid, rapid doubling time. I’ve not met many men who want to receive
hormone therapy in the adjuvant setting. Years ago, when we were conducting
studies with combined androgen blockade in metastatic disease, patients were
happy to tolerate it to get rid of their bone pain or to be able to urinate better.
However, in the adjuvant setting patients are concerned about the side effects
of hormone therapy, such as hot flashes, weight gain, loss of libido, change in
muscle mass, mental changes and cardiovascular effects.
DR LOVE: Would you consider bicalutamide monotherapy as compared to
traditional LHRH agonist therapy or MAB for this patient?
DR CRAWFORD: We don’t have data on bicalutamide monotherapy for patients
with biochemical failure. I’ve seen the studies with bicalutamide at 50, 150 and
400 milligrams, and I believe that in metastatic disease and locally advanced
disease, it’s not quite equivalent to combined androgen blockade or monotherapy
with an LHRH agonist. My recommendation for this patient would be that he
needs everything, including combined androgen blockade, and I believe I could
talk our medical oncologist into docetaxel-based chemotherapy.
DR LOVE: Is there a correlation between PSA doubling time, the rapidity of
progression of disease and response to chemotherapy?
DR TAPLIN: I don’t know of any data. We always try to give patients with
particularly aggressive disease the hope that chemotherapy might work better
in rapidly dividing cells. However, I don’t know of any data that support that,
and my clinical impression is that it’s a mixed bag.
Select Publications
