Patrick McLaughlin, MD - on ADT

Hi Mr Boger

Thank you for your question

I do remain more selective about ADT than most doctors and come at all prostate cancer therapy decisions as a dual challenge of cure and quality of life. The additional caveat is that the individual patient is the final arbiter of what constitutes acceptable quality of life. For example, I had a very athletic former NCAA basketball player who had soft indications for ADT, read about the potential downside and immediately ruled it out. For him it was an easy decision -" i would rather die than lose that quality of life". My current practice is to have men read carefully about ADT and weigh it as you would any medical decision; is the benefit worth the risk or downside? Unfortunately ADT is commonly given on the fly without informed consent. It is often justified by the idea there is a proven survival advantage, without actually sizing that advantage or dealing with the fact that the downside(temporary or permanent hit to QoL) may outweigh the small advantage. That is if you are lucky and live longer but the time you gain is severely compromised then in a much deeper sense you have merely survived longer, but your quality of life years are lousy. So even when there is a real advantage on study, say 5-10%, the chance that an individual patient  receiving the therapy will benefit will only be 5 or 10%. So for 90% of patients their fate is sealed - they will either fail or be cured. So unless there is an outrageous difference in survival beyond a small, statistically significant difference which may reflexively trigger doctors to add ADT, you have to weigh this decision very carefully.

My take is that based on MRI anatomy the major value of ADT is local, and the guys I favor ADT in have gross disease beyond the prostate. They dramatically respond to ADT and this response is fairly complete at 4- 6 months or less. So on that graph if I told you the update has a statistically significant advantage ot ADT you should not take that at face value but should weigh the actual benefit.18 months of ADT is life changing therapy - from mood disorder and sever depression to penis size decrease, loss of muscle mass, loss of vitality, all to try to gain a 5 or 10% advantage that you personally only have a 5-10% chance of gaining.

I see combined beam and brachy as allowing safe reduction or elimination of ADT. I cannot comment on your specific situation.

I am a seed implant /LDR advocate and see a biological advantage to that over HDR, but you are good hands with Dr Hsu. If you choose brachy make sure you do it with a doctor who does this for a living. My personal bias is that ADT is more necessary with HDR than with LDR. I discuss this in a recent paper - a review of LDR in Seminars of Radiation Oncology just published(see attached). There is a thorough critique of ADT, the level of which you will not find anywhere else - pay special attention to the Table summarizing ADT effects. A paper from England published last year measured the QoL in early stage men versus end stage men and found no difference! This is referenced.

I personally think this can be devastating to quality of life and in some cases of cardiac events can result in death decades before prostate cancer would have taken that toll.

I have attached a talk I gave at the same conference earlier this year - Cure and Quality of life. I discuss individualized therapy and one aspect of prostate cancer medicine that no one has studied carefully - how personality influences or even dictates decisions. I have a web site called in my prostate (inmy<>) that is essentially a musical guide to prostate cancer. On it individuals speak from their personalty bias and this becomes a virtual support group with fellow patients chiming in. Trusting your gut is important, but your gut(personality bias) can also steer you to a bad decision you later regret.

Some think this is making light of a very serious subject, but I don't see it that way and did not intend that way at all. I see it as a very accurate capture of the complexity of modern treatment decisions.

The video incorporates this material and discusses what I term advocacy based practice. Again I am trying to get at the emotionally charged, personality driven aspect of these critical decisions.

So I am glad you have carefully consider the role of ADT. The Merrick papers cited(see below) prove limited or no ADT with good combination therapy can cure select high risk patients - you may be one of them.

I am quite busy and have limited my travel, but as winter sets in it would not take much to talk me into a visit to California.

Hope this info is helpful

Bill McLaughlin MD

Professor Radiation Oncology

University of Michigan