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I have been struck by how many patients ask me to measure their lipid panels as we work our way through the management for their prostate cancer. To be sure, it is important to know about cholesterol, triglycerides, and cardiac risks for both men and women. If you have never had a fasting lipid panel, you should get one. If you are not on a statin, you might consider that and read about the benefits for prostate cancer patients in one of my previous posts here or here. Knowing about cardiac risks for the general population is a terrific public health idea, and you can check out your own risks here. (If you are otherwise healthy, with good blood pressure and a non-smoker, it is sobering to play with that calculator and watch what happens to your risk with increasing age…the one thing you can’t do much about!)
But why continue to worry about heart disease once you have prostate cancer, especially if you have metastases and become resistant to hormonal manipulation? Do you need to continue to take your statin? There is a reasonable literature looking at the downside of polypharmacy in patients as they age, and the potential cost savings, and even improvement in quality of life by stopping some medications. Read this brief article for a good discussion on the topic.
Expanding this thinking to what blood tests we should worry about and how often to do them is an important exercise. In particular, I think we are all addicted (often too addicted) to the PSA test as I discussed in the PSA clock blog. There were many comments pointing out the necessity of following PSA to know the efficacy of changing treatments, and I agree with that. On the other hand, obsessing about PSA can definitely be a negative for your mental health and enjoyment of life. Don’t fall for the idea of daily measurements if someone comes out with a finger stick blood test for PSA!
Testosterone measurements, on the other hand, may be too infrequently measured in caring for prostate cancer patients, and compared to the costs of the newer ADT agents, or even the GnRH injections, they can be highly cost effective. A quick search suggests that measuring your T could be as little as $50 or probably 2-3x that in a hospital. If you have metastatic prostate cancer it is key to have the T level as low as possible. Some cancer cells become hypersensitive to even low levels of circulating T by over expressing the androgen receptor, and of course this led to the research on further blocking testosterone synthesis by drugs like abiraterone or the receptor by the “lutamides” (bicalutamide, enzalutamide, apalutamide, duralutamide). These drugs can cost in the range of $10K/month, so measuring T levels has minimal impact on the overall cost of care. However, in two abstracts presented at the recent ASCO meeting, the possibility of stopping GnRH injections in patients on abiraterone was studied. It makes sense that if abi completely blocks T synthesis in the testis, adrenal gland, and cancer cells, you might not need the injections. There is a good review of one of the abstracts here. I had always wondered about this, and it was nice to see it studied. The cost savings if this became a standard could be in the millions. (caution however – would need to be studied more carefully, and if someone missed abi doses, very rapid T increases would be seen due to high LH levels no longer suppressed by GnRH analog injections).
I realize this is far into the weeds for most patients, but maybe a take home message could be to discuss measuring your T levels once in a while with your physician, rather than just the PSA. And maybe you could go over what meds you might consider stopping at this point in your care. We doctors are too often pill pushers and as I try to say to every patient at every visit, [Please CLICK ON THIS ONE:] there is nothing more effective in general than increasing your exercise – often as effective as ANY additional pill or blood test!