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DR SARTOR: So a 75-year-old. He had a radical prostatectomy about 5 years before, had recurrence and received salvage radiation burns and didn’t work. And his PSA was going up. And it turned out that his PSA doubling time was about 8 months.

DR LOVE: What was his PSA at that point?

DR SARTOR: PSA of 4.6.

DR LOVE: So Bob, I know you’ve been very vocal in conversations I’ve had with you over the years about this issue of when to start androgen deprivation in PSA-only disease. How about this situation, 75-year-old man, doubling time of 8 months, 4.6 PSA?

DR DREICER: I spend a lot of time talking to people about the implications of ADT. I worry about the 10% increase in body weight that many patients experience. It concerns me a great deal.

I guess I’m an old guy and I’m worried about making old guys get heavy and the impact on their blood sugar control in the absence of evidence that I’m actually helping them. But there’s no right answer. And it’s a challenge.

DR LOVE: And in this specific situation, how do these numbers strike you?

DR DREICER: I would not have initiated therapy.

DR LOVE: Susan, would you have started therapy?

DR SLOVIN: I would not. The funny thing is, depending on the Gleason’s score, there’s such heterogeneity about how the cancers will ultimately behave. And with some of these patients you just want to sit it out and really try to let it declare itself. So I would not. Again, I agree with Dr Dreicer.

DR LOVE: Mario, would you start or not?

DR EISENBERGER: No. I don’t think so. I think we would wait.

Many times what drives us to do something is the reaction of the patient’s anxiety. The data on someone who’s got a PSA doubling time of 8 months, if you do nothing it will take in excess of 5 years until they develop bone metastasis. And if you then diagnose bone metastasis, the survival is somewhere around 6 to 7 years. So there’s time for it. And the patients usually accept that easily.

DR LOVE: So I’m glad we’re starting out with a little bit of controversy here. But I have to go back to you, Bob, the PSA doubling time is 4 months. Does that change what you’d do?

DR DREICER: I’d image. But if I don’t see metastasis, I’m not compelled to start ADT.

DR LOVE: So describe the numbers that would get you to treat.

DR DREICER: If you have a patient who comes in and he’s 8 months out from a radical prostatectomy, has a Gleason 10 tumor, positive nodes, his PSA is 5, I’m going to treat the patient without overt disease.

DR LOVE: So what were you thinking at that point, Oliver?

DR SARTOR: Interesting case. And the discussion, one of the things that I think may not be in the room with the urologist, who would typically have started with a PSA of 0.2 and rising. And I think the prevalence in the United States, the practice in the United States, is to treat early with ADT, too early. And I actually just made note in an editorial that we really don’t have a clue. But this fellow’s PSA anxiety was — he was basically going to go down the street and get somebody else to have him treated, if I didn’t treat him. And that’s a common scenario, because in America we all have choices about where we go for healthcare. And he was very anxious and he wanted to do something about it. So I used 6-month intermittent hormones.

DR LOVE: What’s his current situation?

DR SARTOR: He just restarted his second cycle of ADT after being off for about 11 months. He did recover his testosterone.

DR LOVE: And what was his quality of life like during the recovery? Did it improve or change?

DR SARTOR: He did. He felt more energetic. His primary problem was fatigue. And I think one of the things that Matthew has helped us understand is a lot of the effects, the sarcopenias and osteoporosis, a little muted when you have short-term effects. It’s these long-term cumulative effects that really add up. Short-term hot flashes, sexual dysfunction and some fatigue, maybe some emotional issues, this guy actually felt better because his PSA was down and he was all excited about that.

DR LOVE: Any comments about this case still? William?

DR OH: I’m going to defend Oliver here and just say that obviously, in the room with these patients, it’s very, very difficult because of all the variables that you heard from all of us that we incorporate. And in Oliver’s editorial, which came out in the New England Journal, he points out that really there is no study that tells us in the rising PSA population when and how to start hormonal therapy. So at the end of the day there’s a lot of personal decision-making that comes really related to the patient and their physician around what’s right for each individual patient.