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The paradox of testosterone and ADT
Prostate Cancer | Last Active: 2 hours ago | Replies (51)Comment receiving replies
Now you’ve got me excited. Dammit.
the modern prostate cancer checklist: Elevated PSA? Check—because who doesn’t love a biochemical mystery. Gleason score creeping into the “let’s panic politely” zone? Check. Cribriform pattern? Absolutely, the architectural nightmare of prostate pathology. Perineural invasion? Of course—it wouldn’t be a proper horror story without it. So, what’s next? Apply the “gold standard” treatment because, statistically speaking, that's what everyone else is doing, and individuality in medicine is just so passé. Genetic testing? Optional, especially if you prefer your treatment plans designed by coin toss. Scans that can’t detect anything smaller than 2.7 mm? Perfect—nothing like the illusion of thoroughness. PSMA PET scans? Surely you jest—those are reserved for people with actual budgets. And finally, let’s throw in some ADT to suppress testosterone in a tumor that clearly threw that hormone overboard years ago. Makes perfect sense—if you're a character in a Kafka novel.
Now, if someone had bothered to stray from the algorithmic playbook, maybe we could’ve had a conversation about precision medicine—genomic profiling, to determine actual tumor behavior rather than assuming it’s playing by textbook rules. Or how about considering the patient’s entire medical history—like maybe cardiac health, quality of life priorities, and whether the tumor is actually hormone-sensitive before launching hormonal carpet bombing. Perhaps even using imaging that works, like PSMA PET, instead of squinting at shadows on a CT. But no, why do that when we can march to the beat of a one-size-fits-all protocol and call it progress?
Replies to "Now you’ve got me excited. Dammit. the modern prostate cancer checklist: Elevated PSA? Check—because who doesn’t..."
I think it’s going to be difficult to find a case of prostate cancer that isn’t hormone sensitive. After many years of study, they have found that ADT Works, It suppresses testosterone, which then prevents the cancer from growing. Sure, How long the cancer will not grow depends on many things, But ADT works in almost every case to stop the cancer from proceeding.
Studies have found that a certain amount of ADT usage can not only suppress the growth of prostate cancer, but also in some cases can result in a cure. Only about 30% of prostate cancer cases have reoccurrences. Something must be working with the “standard of care”.
If you were on Medicare, which most prostate cancer patients are, The PSMA PET scan is not financially out of reach For most people.
In the future, we do expect a lot out of prostate cancer treatment. It would be nice if “precision medicine—genomic profiling, to determine actual tumor behavior” was perfected these days. Unfortunately, it’s not. Yes, in the future. We can expect genomic profiling to be done on the tumor and a custom treatment developed for each person, but this is not happening yet.
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Now, let’s not confuse the gold standard - or better, the standard of excellence- with what YOU are getting in way of treatment.
You absolutely SHOULD have genomic testing; you totally need to be worried about prolonged therapy on ADT if you are a cardiac patient (which you are).
So what I glean from all this is that you are not happy with your particular doctors, and budgetary constraints are preventing you - and your healthcare system - from exercising a true gold standard. That is most unfortunate!
I am extremely lucky to be living in the US, where optimal healthcare is available to those with either good insurance or money in the bank - both being even better. Many times I have paid privately out of pocket - my surgery cost me almost $65,000US 6 years ago by a top surgeon in NYC - A home equity loan I will be paying for a while!
So I truly do commiserate with those who cannot follow the same path. But you are obviously an extremely intelligent man and as such you know that you are the ONLY person who decides what treatment you wish to pursue.
If you don’t want more than 6 mos ADT because of its “only” 5% chance of a better outcome - and its increased chance of cardiac issues - DON’T take any more. Easy peasy!
Genetic testing? Perhaps the website @jeffmarc suggests can help you - don’t know the cost, if any, but certainly well worth it.
So you are certainly free to pursue a different course of treatment if you are so inclined. I don’t know your Drs personally, but we all tend to either love them or hate them. You’ll get a few “OK’s” but not many.
So the answer to all your frustration with the Canadian health care orthodoxy is simply this:
CARPE DIEM!…. And, of course, charm a lonely old widow out of her life savings so you can get the best treatment you deserve…Best,
Phil