1. This just published study does not yet appear in PubMed; therefore, key details are not yet available except through the Journal of Clinical Oncology.

However, at the moment there is a basis for serious questions about the value of this study from my viewpoint as a nearly seven year survivor on intermittent hormonal blockade therapy. (I have now been on Lupron, one of the GnRH agonist drugs, for a total of 47 months on an intermittent therapy program.)

First, the real lesson of the study may be that men who need hormonal therapy are more prone to diabetes and heart disease, rather than hormonal therapy being a substantial cause of those diseases. It works like this. The vast majority of prostate cancer patients in 2006 are not given hormonal blockade except briefly unless they have a more serious case of prostate cancer, and that goes even more strongly for men treated in the 1990s. While the study addresses degrees of spread, I'm guessing (without seeing the abstract or study) that this means the "stage" of the cancer; the news accounts do not address such critical clues as the PSA level and velocity and the Gleason score, a key indicator of aggressiveness. I'll bet the other indicators suggest more serious cancer for those in the hormonal blockade group, though those patients would seem to have equally serious cases with the non-blockade group if you look just at the stage.

Dr. Charles Myers, Jr., a medical oncologist specializing in prostate cancer who is well-known in the survivor community, has compared a diagnosis of prostate cancer to the canary in the mine shaft that dies. In other words, a diagnosis of prostate cancer means that a number of aspects of health are probably out of whack, not just prostate health. A more serious case of prostate cancer suggests that other conditions are also greater concerns, and diabetes and heart disease are two of the most prominent problems likely to be associated with prostate cancer. The study should have the PSA, Gleason, and other details that will enable us to judge the equality of the groups.

While a few years ago I would have assumed that study designers would have ensured coverage of such key data, I have learned that this is not always so; also, sometimes when the study does cover such data, the media do a poor job of reporting.

And speaking of reporting, note that in the associated story here and in the version I read in this morning's Washington Post there was no reporting of the actual percentages of those with diabetes and heart disease in the two groups. This is an important omission. Look at it this way. While the Post report noted that men on blockade were 44% more likely to develop diabetes, 16% more likely to develop heart disease, and 11% more likely to have a heart attack or die suddenly from heart failure, it did not give us any idea whether the base percentage was, say 1%, such that a 44% increase would have been only to a total risk of 1.44%, or a much more substantial percentage. This is obviously critical for those thinking about blockade. I tip my hat to those reporters who give us the absolute as well as the relative percentage.

The Post, to its credit, did quote a researcher from the National Cancer Institute, Lori Minasian: "These data raise the possibility these agents may have these risks, but I don't theink the data raise to the level yet where men should not take hormone therapy."

The reports did address disease mechanisms, and what they said was plausible, though not yet convincing. It is well established that the drugs tend to increase weight gain, especially around the abdomen, and there is evidence they may increase insulin resistance in some men. Both of these could contribute to diabetes and heart disease. However, the expert medical oncologists I follow strongly advise a program of nutrition and exercise that is likely to counter these mechanisms, at least in part as well as to counter other health problems. Personally, I have a good cholesterol ratio, good other heart indicators, and no diabetes as established by regular exams and tests.

Stay tuned.

Jim (web site: http://www.mycancerplace.com/profile.php?id=147)

Posted at 8:54PM on Sep 19th 2006 by Jim Waldenfels

2. I am a diabetic who has also had bypass surgery for coronary artery disease. I have also been diagnosed recently with prostate cancer metastasis after having had an extremely low psa for nearly ten years since radiaton and brachytherapy. My health for years (I am now 76) has been very good and I am pain-free (at least for the moment). But I am supposed to be given my first (one-month) shot of Lupron in a few days and am terrified. Are there any responses from diabetics and/or men who have had bypasses and have been on Lupron a while? Many thanks for posts from such people discussing their experiences.

Posted at 1:17AM on Oct 3rd 2006 by harold b segel

3. Hi Harold,

I hope you will not feel so terrified of hormonal blockade therapy as you learn what is involved. It's disadvantages are often greatly exaggerated, and side effects can be well managed for most of us. I have been on intermittent hormonal blockade for 81 months now, nearly seven years (the 47 months mentioned above was the time I was on Lupron).

By the way, there have been a number of studies of the the degree of seriousness of recurrent prostate cancer. One of them I find particularly interesting, from Johns Hopkins, uses three factors to predict whether a recurrence will be serious or mild, perhaps so mild that no treatment is necessary. One of the three is whether recurrence occured within three years of surgery. Assuming radiation works the same (a substantial If), you have that made. Another factor is whether the original Gleason was less than 8 or 8 to 10. The third related to doubling time since recurrence. You can read an overview of the study with tables at http://www.urology.jhu.edu/highlights/10.php. Another study stresses that doubling time is the most important aspect.

A group of us on combined hormonal blockade correspond by listserv email, and some of us have had diabetes and heart problems. You can find us at the free www.prostatepointers.org service under the CHB listserv.

Are you planning to attend our International Convention on Prostate Cancer in Reston, Virginia from October 19-22? Several leading experts on hormonal blockade will be presenting talks and answering questions. Details for registration and the agenda are at www.cancer-foundation.org. The conference is primarily for patients rather than professionals but features many leading experts.

Jim (web site: http://www.mycancerplace.com/profile.php?id=147)

Posted at 8:47PM on Sep 28th 2006 by Jim Waldenfels

4. The study behind the story is now available on PubMed at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16983113&query_hl=1&itool=pubmed_docsum, so I have answers to the concerns I raised in Comment #1.

This
was a simple associational study that apparently simple checked
whether men were on hormonal blockade and checked whether they had
diabetes, coronary heart disease, myocardial infarction, or sudden
cardiac death. It compared rates for men on hormonal blockade to
rates for men not on hormonal blockade. Based on just the study
abstract, it appears no effort was made to control for the
seriousness of the case. Therefore, it appears likely to me, that
men on blockade had more instances of diabetes, mycocardial
infarction, etc. simply because they had more serious cases of
prostate cancer and/or were older. Reinforcing this view is the fact
that most of the study period was in the 1990s, a period when men
treated with blockade were very likely to have more advanced cases or
be judged too old for other therapies, thereby more prone to diseases
associated with aging like diabetes and cardiovascular
disease.

Therefore, the studies finding are not at all
surprising. In fact, it would be surprising if the study had not
found these results. Frankly, I do not see that this study adds to
our knowledge of hormonal blockade treatment for this disease. I was
not able to obtain free online access to the full paper, so I may have
overlooked key points, but I consider this unlikely as authors usually
put those key points in the abstract.

The abstract did not
provide the base percentages upon which increased risks were based.
I expect the full paper probably does provide those
numbers.

Gregory, Dalene, anyone, am I overlooking something
here? Do you agree with me?

Jim

Posted at 9:28PM on Sep 28th 2006 by Jim Waldenfels

5. I highly recommend joining one of the mailing lists specific to your disease over at ACOR. (I recommend this to all the cancer patients I see.)

Here's one for you:
http://listserv.acor.org/archives/prostate.html
Notice there are over 1200 who subscribe to this one alone. Most are very active lists.

If you are getting too many emails form the list, get all of them in digest format.

all lists:
http://listserv.acor.org/archives/

Posted at 8:19AM on Oct 3rd 2006 by Michelle

6. I was diagnosed & treated with EBRT in early 2004. I had a TIA in october and triple CABG in december 2004. During cardio rehab, I started having excessive rectal bleeding which was diagnosed as radiation enteritis/proctitis. I have had three surgeries since to stop the bleeding and discharge plus the general nature of the 'incontenence' as it happens without warning.
Also have problems with urinary functions and often find my clothing wet after voiding, making it impossible to interact socially in most any setting a person can imagine.
I shall be 65 soon. I'm totally broke and about to loose my paid medical insurance that allows me to have the prescription medications I need according to my doctors. I am totally stressed, can't sleep, and trying to keep suicidal thoughts away.
Doc has me scheduled for a thallium stress test friday and I simply don't want to bother.
What can i do to find a reason for living once the need to survive is gone?

Posted at 2:51PM on Oct 4th 2006 by Charlie