Posted by CLDing on February 14, 1998 at 19:48:27:
In Reply to: Mestatic Ca Prostate posted by hinwai on February 14, 1998 at 07:14:40:
Hin Wai,
Thanks for posting this case. It is time we discuss this problem but I am sure the writing
on the wall is never read by people who should read them!! Anyway we should discuss this.
Clinicians can very simply be divided into purist, impurist, and fence-sitters. We have a
lot of impurist and fence-sitters or one-uppers who sees it a necessity to add on a
treatment modality just to complete the picture or if consulted for a second opinion must
add on something just to feel one-up, not because of any evidence-based medicine.
Concomittant XRT is not on here. It should be considered if there is not response to
hormonal manipulation and he has focal symptomatic disease. XRT is not without its
complications. In the MRC II trial for CaP done in the early 80s, one of the exclusion
criteria for local XRT was age>65 years. Reason was simply that XRT has its
complications which can be very severe. I want to pose the situation - if this man
develops a serious or bothersome complication from XRT and decides to seek compensation,
what does evidence-based urology say? Can anyone of us testify for his action or just
refuse to give a medical report that XRT was not indicated at this juncture. It has long
been overlooked that overtreatment can be a cause of litigation.
Coming to the story of Flutamide and Estracyt. Giving MAB to this man is not
evidence-based, but again often practised in this country by people taught by drug
companies not by peer literature. Geoff Chisholms initial suspicion of Labrie's TAB (now
MAB) in 1985 when I discussed Labrie's early results with him in Edinburgh, has proven to
be correct. Of course one can say the situation is still debatable. I had a patient who
returned from Singapore after an orchiectomy and put on 250 mg Flutamide daily (by a
urologist there). This man is a big white man!! This is the type of nonsense done.
Flutamide is not without side effects. We are fed with papers which suggest that it works
while those which suggest it does nothing at all is kept from us. John McFarlane (now
consultant urologist at Kirkaldy) did a study on this drug in 83/84 for HRPC and found it
quite useless. The side-effects (mainly distressing GIT symptoms) are significant at the
recommended dosage. Crawford's initial conclusion from the first study was age <65 and with minimal disease, and I must emphasise the advantage was MINIMAL. I do use Flutamide on an informed basis young, minimal disease patient who can afford it and understands the side effects and questionable benefits who are keen to take it on the long term.
I think I
should stop my emotional outburst on this atrocities. This is an area which I think a
consensus should be quickly posted through the Academy. It would seem to be less urgent
than BPH, because there are many such unnecessary cocktails dished out to patients at
great expense.