One day, as new and better drug therapies and combinations are developed, it may be possible to cure prostate cancer at any stage—or at least to restrain it, to make sure that it never leaves the prostate, or that it stays well-differentiated and slow-growing rather than becoming an aggressive, lethal invader of tissue and bone.

But that day is not here yet.

This is the part of the book we wish we didn’t have to write, and that nobody would ever have to read. When prostate cancer is advanced, when it has swept through the prostate to the lymph nodes or bone, the options for treating it are limited. Cure is no longer possible. Instead, your doctor’s goal is to stave off the cancer—to buy more time, to alleviate symptoms and, finally, to ease debilitating pain.

There are many schools of thought on treating prostate cancer that has spread beyond the prostate to the lymph nodes or bone (stage N+, M+, Di, or D2). All of them involve hormone therapy—shutting down the hormones that feed the prostate and nourish the cancer. (This is also called “hormone deprivation” therapy.) But there are huge differences in medical opinion: Should hormone therapy begin while a man still feels fine, or should it wait until symptoms begin? Should it target the hormones that most directly involve the prostate, or should it try to smother all the body’s androgen (male hormone) activity? This idea of turning off all androgens is called total androgen blockade (or total androgen ablation), and many doctors believe in it. But is this total shutdown necessary?

And what’s the best method of stopping these hormones? Think of a car going through a series of checkpoints—points A, B, C and D—to cross over a border into another country. You want to stop this car from reaching the other side. At what point do you stop it? Do you set up a roadblock at Point A, the first stop along the way? Or do you simply wall off the border at Point D, so the car can never cross over? Or do you divert the car at some point in between?

The androgens that affect the prostate reach their destination through a process, involving several steps, that begins in the brain. Medical roadblocks are now available to stop or detour this process at Point A (the brain), Point D (the prostate), or at several spots in between. Some of them work better than others, and some are more expensive. But ultimately, all of these means of hormone therapy will fail to control the cancer. This treatment failure may take years if a man is lucky and has a tumor that’s particularly responsive to hormone therapy. It may only take months if he’s not—if he has a faster-growing tumor that doesn’t respond well to hormone therapy because many of its cells are indifferent to it.

*161\201\8*