Treatment

TREATMENT

The most controversial aspects involving prostate cancer are the recommended methods of treatment which may be greatly influenced by the vested interests of the physician, the extent of their knowledge, experience with the treatments of the disease, and their adherence to their Hippocratic Oath.

The possession of a MD license or the title of urologist does not insure that the physician is qualified to treat prostate cancer.

Early detection is of paramount importance in the successful treatment of this number one cancer killer of men. The notion that we can hold off treatment until symptoms appear is foolhardy and increases the likelihood that the patient’s life span could be severely reduced or his life terminated in short order.

Lack of adhering to the proper administration or treatment modalities can only be considered as malpractice and a violation of the patient’s constitutional rights and could contribute to the patient’s early demise. The treatment modalities are:

1. Combination Hormonal Blockade: is the first and mandatory treatment regardless of the initial stage of the disease.

Combination therapy by definition is the use of TWO (2) medications, not (1) – both a LHRH agonist (Lupron®, Zoladex®, Eligard®, Viadur®, or Trelstar®) and an Antiandrogen (Eulexin® (Flutamide), Casodex®, Nizoral® with Hydrocortisone, or Nilutamide®), used sequentially, before a patient can be determined to be hormonally refractory. At times these 2 drugs are combined with a 3^rd drug, Proscar® or Avodart®.

Patient’s with organ-confined disease, confirmed by reevaluation, may opt for secondary therapy such as cryosurgery (freezing), brachytherapy (radioactive seed implant), or radical prostatectomy (RP), if they are willing to accept the morbidity of a RP.

No patient with metastatic disease qualifies for ANY form of secondary therapy.

2. Cryotherapy: Option for secondary therapy for those who qualify (Disease believed to be confined to the prostate gland). Cryosurgery is a partial or total freezing of the prostate gland. Success is very operator dependent.

3. Chemotherapy: Mandatory for those who become hormonally refractory, involving the use of different chemotherapy drugs.

4. Prostatectomy:

A. Radical Prostatectomy: Conventional open surgery, only for those who have organ-confined disease and are willing to accept the extreme morbidity, side effects created, lengthy hospital confinement, and exorbitant cost.

B. Laparoscopic Prostatectomy: The surgeon uses long instruments through small openings and maneuvers them with direct hand contact. This surgery is less invasive than a radical prostatectomy with less bleeding, quicker recovery, and fewer complications. Laparoscopic radical prostatectomy is associated with a steep learning curve.

C. Robotic Prostatectomy: The da Vinci® system is similar to laparoscopic in using long instruments through small openings, but uses a sophisticated master-slave robot instead of direct hand contact that incorporates 3-D visualization, scaling of movement and wristed instrumentation. Robotic prostatectomy is a safe, effective and reproducible technique for removing the prostate. Robotic surgery ushered in a new era of minimally invasive surgery that has challenged conventional open surgery.

5. Radiation:

A. Brachytherapy: Small radioactive sources (seeds) are actually implanted into the prostate gland.

B. External Beam Radiation: Another morbid procedure that can damage or destroy normal tissue and create residual effects that can impede normal body functions until death.

C. 3D-CRT (3D-Conformal Radiation Therapy): Three-dimensional conformal radiation therapy that was introduced in the 1980’s. It was the first radiation therapy that had the ability to conform the shape of the radiation beam to that of the tumor by using a three-dimensional study rather than a two-dimensional dose planning system like that of external beam radiation.

D. IMRT (Intensity-Modulated Radiation Therapy): IMRT evolved from the inability of 3D-CRT to irradiate tumors that are concave, surrounded by normal tissue, or in very close proximity to sensitive normal tissue, without causing excessive radiation exposure of adjacent normal tissue. IMRT incorporates inverse treatment planning and computer-controlled intensity modulation of the radiation beam.

E. Proton Beam Radiation: Subatomic particles that deliver high doses of radiation to the target tumor but reduce normal tissue radiation dose levels. The Physical characteristics of protons guarantee that for any given treatment plan they will always result in a lower total radiation dose to normal tissue than can be achieved with any form of x-ray therapy. For example, the total radiation dose delivered to normal tissue is 3-5 times less with Proton Beam than with IMRT.

6. Watchful Waiting: This attitude is promoted on the assumption that the patient’s disease will remain dormant for an extended period of time when there is evidence of the presence of the disease, if the patient agrees to accept the risks that he will be one of a small minority in whom the disease will remain dormant for a logical period of time – it is HIS decision.

7. Intermittent Hormonal Therapy (IHT): If undetectable presence of the disease and a low PSA (0.1) is accomplished after CHT, then IHT must be implemented at 12-13 months: PSA must be monitored on a minimum 3-month frequency. If the PSA rises more than .75 in 2 consecutive blood tests or reaches 5.0 - 10.0, CHT must be resumed without delay for another 12-13 months before going on IHT.

8. Vaccine Therapy (PROVENGE): May represent the first in a new class of active cellular immunotherapies that are uniquely designed to stimulate a patient’s own immune system. It would be a good alternative for late stage hormone refractory patients. Currently in clinical trials, PROVENGE will probably not receive FDA approval until 2009.

9. HIFU (High Intensity Focused Ultrasound): Uses high intensity focused ultrasound to rapidly heat and destroy cancerous tissue. Currently not approved in the United States, but is available in numerous other countries.

CAUTION: Hormonal refraction cannot be confirmed until all of the CHT Antiandrogens have been administered. Only then, can hormonal therapy be considered refractory and chemotherapy is instituted. A list of the Antiandrogens is contained in No. 1 above.

We highly advise that ALL patients maintain complete records of every visit to physician(s), clinics, laboratories, etc. After all, you are the patient, you are the one who has the disease, and you are the one who is footing the bill (whether it is by insurance, Medicare, Medicaid or cash). The money paid in to your HMO is for your treatment. Do not permit them to deny you your treatment of choice nor the type of physician you prefer. Keep your records in a safe place and when it is desirable to consult them, see to it that they are in folders in your briefcase, and in an easily accessible order.

Remember that you are in control of your own destiny. Protect your constitutional rights at all times.

In considering the potential side effects of treatment, we are forced to acknowledge the fact that NO two individuals are biologically constituted the same. Reactions to any form of treatment are not predictable, except for generalization.

The random classification of patients used to delay or postpone treatment is based on assumptions. Once the presence of the disease has been confirmed, watchful waiting is only courting disaster and hormonal blockade should be commenced immediately.

SIDE EFFECTS:

Nearly all side effects have definitive methods of treatment. Some may have more than one.

Some of the more common side effects are:

Gynecomastia – tenderness or enlargement of the breasts

Diarrhea – liquid stool

Hot Flashes

Impotence – termination of sexual abilities

Incontinence – uncontrollable urination

Red blood corpuscle deficiency

White blood corpuscle deficiency

Pain

New devices and medications are being introduced all the time; and as they are submitted to us, we thoroughly investigate each one to determine that there is sufficient evidence of authenticity before we will publish the relevant information in the newsletter. There are those who will seize on the opportunity of promoting their own financial welfare by preying on the fact that the patient has been informed that they have a life-threatening disease and are prone to believe anything that they hear.

It is abject stupidity that denies the efficacy of COMPLETE Hormonal Blockade as the initial form of treatment. CHT or Triple Hormonal Blockade® (THB) will downstage both the prostate gland and the tumor volume.

Don’t believe all you hear and only half of what you see. On the other hand, you are the one in the driver’s seat.

® Triple Hormone Blockade, Triple Androgen Blockade, and Finasteride (Proscar®) Maintenance are the registered trademarks of Robert L Leibowitz, M.D.