Patients with prostate cancer who receive primary treatment with surgery (radical prostatectomy) or radiation therapy, and who have increasing PSA levels after their treatment but without symptoms may have nothing to gain from starting immediate therapy with hormone medicines instead of waiting until symptoms develop, report researchers from Johns Hopkins Hospital in Baltimore. The article, by lead author Patrick C. Walsh, MD, appears in a recent issue of theJournal of Urology, (Vol. 166: pages 508-516).

Walsh, co-author of the book, Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer, is a professor of urology and director of the Brady Urological Institute at The Johns Hopkins Medical Institutions.

In the article, Walsh writes: “If patients are followed carefully at short intervals with periodic histories, physical examinations, serum prostate specific antigen (PSA), creatinine measurements (a blood test which indicates whether or not the kidneys are working properly), and periodic bone scans, disease progression can almost always be detected before patients have symptoms.”

“There is a lot of hormone therapy given early,” Walsh tells the ACS News Today. He says patients should be cautious about beginning hormone therapy too soon.

The journal article looks at previous studies written for physicians and other scientists. Walsh reports much of this debate over the controversy of hormonal therapy in his latest book, which is written for patients and their significant others.

In his article, as in the book, Walsh makes the case that in men whose cancer has spread beyond the prostate, early hormonal therapy does not provide any improvement in survival. But it does have disadvantages, he writes, such as loss of libido, breast enlargement, and hot flashes.

He recommends in the journal article that more clinical trials are needed to answer the question whether early hormone treatment provides enough benefit to outweigh these risks, as opposed to holding off starting hormones until the patient becomes symptomatic.

More and more prostate cancer patients are becoming aware of the viewpoint Walsh puts forward, says Abraham Mittelman, MD, associate professor of medicine and associate professor of microbiology and immunology at New York Medical College.

“The question is whether to start immediately on hormone therapy or wait until patients develop symptoms,” says Mittelman, a member of the American Cancer Society’s prostate cancer advisory group. “If you read this paper, there is no clear answer.”

Mittelman supports Walsh’s assertion that more clinical trials are needed to determine whether hormone therapy started before symptoms develop can lengthen survival. But only about 10% of prostate cancer patients are willing to enter clinical trials, he says. Some patients are unwilling to risk being on the placebo, and others are unwilling to risk the side effects of the treatment.

Mittelman says that some patients do want to start hormone therapy before symptoms develop if their PSA levels begin to rise dramatically. But for most others with no symptoms, he says, he uses the same type of “watchful waiting” that Walsh recommends.

The authors point out that for men who have undergone radical prostatectomy and then have a rising PSA, the average time from the first detection of the rising PSA to the development of tumor spread in the bone is eight years. They conclude that it is in these patients where physicians and patients must make careful decisions as to whether or not the benefit of starting hormone treatment outweighs the risk.

The biggest problem with hormone therapy, Walsh writes in his latest book, is that while some prostate cancer cells respond to hormones, other cells are resistant to them, and those resistant cells are the ones that can grow and kill despite the hormone treatment. However, Walsh stresses that if prostate cancer is caught early, it is a curable disease through surgery and radiotherapy.

Hormones, he writes in his book, do prolong life and ease many symptoms of advanced prostate cancer. But there is no evidence that it provides any advantage when given earlier than a patient needs it, Walsh writes.