Although Lupron is effective for reducing testosterone, some testosterone is still present because the adrenal glands produce the hormone DHEA, which can be converted to testosterone. In order to further reduce testosterone effects, another drug is frequently given. This drug is called flutamide or Eulexin. Two capsules are taken orally every 8 hours. This drug prevents testosterone from combining with its protein receptor, thus effectively stopping any residual effect from testosterone on the prostate cancer. This combined treatment is called either the complete hormonal blockade or combined hormonal blockade. It is abbreviated CHB. This method of treatment was championed in the early 1980's by Dr. Ferdinand LaBrie, a physician in Canada. During the early 80's I occasionally sent a patient to Canada for this treatment because it wasn’t available in the United States. However, in 1989, the FDA approved the use of this approach here in the United States.
The combined hormonal blockade treatment has a number of side effects, including hot flashes, nausea, anemia, and complete sexual impotency. However, if the treatment is stopped sexual potency may return. The major problem with this treatment is the fact that it is usually temporary. Prostate cancer eventually escapes the inhibition by testosterone deficiency in a few years. When it does, the disease is hard to treat and the patient often does not recover.
Because of the characteristics of prostate cancer that I’ve described previously related to its tendency to be slow growing and often not be fatal as well as the harshness of the available treatments of radical prostatectomy or external beam radiation, some physicians have taken the position that a reasonable alternative to therapy is "watchful waiting." In other words, once early prostate cancer is diagnosed with a biopsy, rather than operating or giving external beam radiation, the patient is simply followed and observed. Treatment is only given if symptoms develop or if the patient shows evidence of spreading of the cancer. In one study carried out in Sweden, this method was used. The survival rate was no worse than in studies in which prostate cancer patients received immediate treatment.
Another approach, which is generally supported by a prostate cancer support group known as PAACT, is to administer the combined hormonal treatment early to prostate cancer patients in stages A and B, rather than in just C and D. At the end of 6 months to a year, the patient goes off the hormonal therapy and his PSA’s and clinical examination are watched closely. If their is no evidence of cancer, the patient is left alone. If their is evidence of cancer progression, then several options are considered including radical prostatectomy, external beam radiation, brachytherapy, which involves inserting radioactive implants into the prostate, and cryosurgery, a type of freezing of the prostate. Whether or not this approach of using combined hormonal blockade in the early stages of prostate cancer turns out to be useful, remains to be seen.
I give my patients the opportunity to choose a different path to "watchful waiting". I suggest that they use an elevated PSA or a positive biopsy for prostate cancer as an opportunity to go on an alternative cancer therapy program. The patient is told that something is out of balance in his body and needs to be changed. The nature of prostate cancer, the various tests, the various conventional approaches to prostate cancer and the various options related to alternative cancer therapy for prostate cancer are discussed with him. A variety of videotapes and books are suggested for the patient to review. Then we come to an agreement as to what would be reasonable for him to do.