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Old 01-03-2009, 10:21 AM   #1
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Question chemo and recurring prostate cancer: not the best option at this time ?

Hi folks,

Yesterday I was at the Juravinski cancer center in Hamilton, ON and got to talk to a good radiation oncologist. After looking at my particular case, it was decided to do a couple of scans before going ahead with the radiation ( which was my choice, the radiation that is ). I have a bone scan scheduled and a MRI is coming up. The oncologist wants to see if they can find any trace of the cancer in the pelvic area. He was quite frank with me and confirmed my own suspicions that a Gleason 8 recurring cancer could be anywhere, but that the only real hope for a cure is the radiation. He also admitted that with the low psa count that I have, the scans will probably be negative but he wanted them done anyway, which is okay with me.

My psa velocity seems to be slowing down. In the 2 months after finding out I had recurring cancer, my psa went from 0.1 to 0.16. They did another psa test at the center yesterday and in the month since my last test, my psa only went up to 0.17 or 0.01 in the month. So that would be down from 0.03per month in the previous 2 months. I guess that's a good sign. ( right now, I'm looking for any kind of good sign! ).

I did ask about chemo therapy since my cancer seems to be dividing quite quickly and since chemo attacks rapidly dividing cells, wouldn't chemo be an option for me? He told me that there is a clinical study underway at Juravinski as we speak to address that particular situation. He said that there probably will be some definite answers regarding this particular situation within the next 5 years. If the radiation doesn't do the job, I'll ask him if they are looking for a guinea pig to experiment on!

So everything is on hold now until the scans are done. More waiting.

Lionel

 
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Old 01-03-2009, 11:44 AM   #2
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi Lionel. Good luck with the bone scan. I hope it shows negative and radiation can be your cure. I was diagnosed with metastatic pc 6 years ago with cancer already spread to my pelvic bones. After 4 years on hormone treatments my cancer became refractory. I went through a round of chemo on taxatere. 1 treatment every three weeks for 10 weeks. It reduced my psa down to 1 which was fantastic, but it is not a cure. It will not kill all of the cancer cells and the cells that survive are able to continue to grow. So that another round of chemo a year or two later will be less effective, because the remaining cancer cells are the cells that survived the first round. I would not go through chemo again knowing what I know now. I hope your scans come back negative, but if not, don't give up hope. I have survived 6 years now with many more to go from having it in my bones. Best of luck with your scans. Dave

 
Old 01-04-2009, 08:07 AM   #3
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi Dave,

Thanks for your reply. A couple of questions came to mind while reading your post. I hope you don't mind answering them for me, if that's okay with you.

First, what grade of cancer did you have? Was it a Gleason 8? Secondly, you mentioned you would not go through chemo again. Was that because the side effects were too severe?

You also mentioned that after 4 years, the cancer became resistant to the hormone treatment. If you could elaborate a bit on the type of hormone treatment you had, I would appreciate that because it's quite likely I will be following that same road if the radiation doesn't work. There is another poster on this board ( Jim ) who is going into his nineth year on hormone therapy. He seems to be having good luck with it. He is very knowledgeable about this subject and I wouldn't be surprised if he is telling his doctors what they should be doing with regards to the hormone treatment.


Thanks in advance for any information that you could provide. Every bit of info helps!

Have a great day. Lionel

 
Old 01-04-2009, 08:48 PM   #4
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi Lionel. I think Jim's story gives all of us hope. When my biopsy was positive (12 out of 12, gleason 7) I was scheduled for a bone scan before Radiation. The bone scan showed my lower left side pelvic bone was positive. 6 years later that has spread to my entire pelvic bone. I have had a little pain over the years but nothing too severe. The first hormone treatment that I had was Flutemide, 3 pills each day. After that kicks in I had Eligard injections every six months and dropped the Flutemide. I am still on the Eligard because not all of the cancer cells are refractory. Some will still respond to the hormones. The worse side effect of the hormone treatment is that you will become impotent and completely lose your libido. I believe Jim is on a triple blockade, and he can tell you more about that. I wish that I had done the triple blockade. You hate to think that there was something beneficial you could have done, and didn't do it. I would'nt have chemo again for 2 reasons. They say the main benefit of chemo is to improve quality of life. Statistics show it does not increase lifespan at all. As far as quality of life, the side effects hurt your quality of life. My hair fell out. My fingernails and toenails fell out. I had more fatigue than I could deal with. Worst of all I spent 5 weeks in the hospital with a staph infection throughout my entire body because my immune system was impaired. As far as quality of life issues for me, fatigue and pain, both can be better dealt with by using medicine. Pain meds, bisphosphonates, EPO, and radiation. I really hope your scans are negative. Let us know, and hopefully Jim will read this and tell you about his triple blockade. Best regards. Dave

 
Old 01-06-2009, 01:47 PM   #5
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Quote:
Originally Posted by flyfisher37 View Post
... If you [Dave] could elaborate a bit on the type of hormone treatment you had, I would appreciate that because it's quite likely I will be following that same road if the radiation doesn't work. There is another poster on this board ( Jim ) who is going into his nineth year on hormone therapy. He seems to be having good luck with it. He is very knowledgeable about this subject and I wouldn't be surprised if he is telling his doctors what they should be doing with regards to the hormone treatment.
... Lionel
Happy New Year Lionel,

and congratulations on that slowing PSA rise!

Your plan to pursue radiation with the center looks good to me, and I'm wondering if they are planning to use hormonal blockade therapy as support, as is often done. My impression is that research indicates substantially better results for radiation when it is backed up by radiation , but the doctors may feel that blockade is not needed in your case.

As Dave indicated and as the Juravinski expertise indicates also, chemo at this point would be an investigational approach without a whole lot of encouraging research findings yet to support it, in contrast to some solid and encouraging results for radiation or the combination of radiation and blockade for recurring prostate cancer, including cases like yours. I know that chemo has been used for at least a decade at the beginning of hormonal blockade for some challenging cases, but my impression is that even the leaders are not yet strongly endorsing that approach, especially where radiation is a good and timely option.

Don't forget that you had some encouraging features in your case that partly, at least, counter the Gleason 8 pathology. One is that your PSA did not increase by more than 2.0 in the year before you were diagnosed (D'Amico and team) . Another is that it is taking you at least three years before your recurrence is reflected in a PSA reaching 0.2 (Friedland and team) . Also, remember the good news from research on Gleason 8 to 10 recurring cancers after RPs that are treated with radiation: a great many respond very well to radiation, indicating that the cancer in many recurrences is still within the range of pelvic radiation . I started a thread (now locked) that includes some key leads and details on that on Feb. 6, 2008, entitled "Gleason 8 (and higher cancer: not good but not always the end of the world."

You're right about my being active in working with my doctor. He is a long-experienced and I think very capable general oncologist with an open mind, and he agreed with my request to move from double to triple hormonal blockade, after reviewing some informal studies I gave him as well as some leads to key fellow medical oncologists who were now enthusiastically using that therapy. However, when he has a strong view, he lets me know the key points, and I've followed his lead instead of my preliminary desires on several important issues. I think that all part of a good relationship between an empowered patient and an fine doctor . I get the feeling you have that kind of relationship with the doctors at the Juravinski cancer center.

There are some dietary tactics you could try at this point, while keeping a close eye on frequent PSA results, before commiting fully to radiation or the combo with blockade. One is to consume high quality pomegranate juice or an equivalent high quality capsule. Another is to make sure you are getting enough quality vitamin D3 to get your 25 hydroxy vitamin D blood test level to the 50 to 100 range. Many men have been able to reverse, halt or slow recurring PSA rises with those tactics, but all of us would like to see more research teams report the same encouraging results, which has not happened yet. That said, the existing research has proven that such tactics are enough for some men! Other nutritional and lifestyle tactics might also help.

The mild generic drug finasteride (formerly Proscar) might also do the job, as might its sister drug (same drug class) Avodart. By the way, in October 2000 after attending the National Conference on Prostate Cancer 2000 in Long Beach, California, a conference primarily designed for patients, I had decided to start a short course of supportive chemo in addition to blockade if the Lupron plus Casodex with finasteride started two weeks earlier could not bring my PSA below .1. Fortunately, the addition of Proscar (finasteride) broke a log jam for me. My PSA, after appearing to be leveling off around .6 after nine to ten months (with just a couple of weeks also including Proscar), fell by 50% within a month of adding Proscar, and it continued falling until it reached less than 0.01! I'm a believer!

There are more tactics, such as using Celebrex and statin drugs, but those are longer stories that I'll mention only briefly nere. There was a recent post that mentioned favorable results for Celebrex and Lipitor for prostate cancer induced in mice. While that kind of research is very preliminary, it is encouraging, and there are studies in humans that support the use of Celebrex, though not yet conclusive, and of statin drugs like Lipitor.

Good luck in this new year!

Jim

 
Old 01-06-2009, 01:51 PM   #6
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Re: chemo and recurring prostate cancer: not the best option at this time ?

With respect to dustydigger's post, I would note a couple of things. First, I do not think it is true that studies show there is no average life extension as a result of chemotherapy. There may be some "study" that shows this, but at least taxotere (the most common first line chemotherapy used in cases of advanced or metastatic p ca) is thought to have some benefit with regard to life duration. On average, that benefit is relatively modest (a few months), but that's just an average and in some cases it can be materially longer. Second, not everyone has these very difficult side effects. Some people have very little side effects from taxotere. People react differently.

 
Old 01-06-2009, 04:09 PM   #7
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi Dave,

I'm always interested in comments from chemo veterans because that may be in my future some day, and I appreciate your account. My thanks. Of course, I'm hoping that does not happen and a cure will be found that will avoid the need. However, this disease does teach us that it helps to be prepared.

I'm adding some comments in green.


Quote:
Originally Posted by dustydigger View Post
Hi Lionel. I think Jim's story gives all of us hope.

I have actually completed nine years as a survivor and am confidently heading into my tenth (also knocking on wood ).

... I am still on the Eligard because not all of the cancer cells are refractory. Some will still respond to the hormones. The worse side effect of the hormone treatment is that you will become impotent and completely lose your libido. I believe Jim is on a triple blockade, and he can tell you more about that. I wish that I had done the triple blockade. You hate to think that there was something beneficial you could have done, and didn't do it.

My impression from communicating with other patients and learning from doctors who are experts in hormonal blockade that moving to double or triple blockade at this point might still do the job for you. I can't remember if you and I ever went over this aspect on the board, so I'll ask whether it was ever proved that blockade could no longer control the cancer? I am strongly convinced that many doctors and prostate cancer researchers decide much too early that blockade no longer works, instead of doing a workup that would prove that one way or the other . I would not be surprised at all if jumping the gun on that decision was not typical, perhaps even the overwhelming pattern - thinking blockade has failed just because the PSA is rising when only one blockade drug is being used. Here are some things to consider:

Blockade is designed to virtually eliminate testosterone as a fuel for prostate cancer, but many, many doctors do not even add on the simple blood test to measure it as one key indicator that the blockade is working . Even if a doctor does measure it, for some reason many feel that a testosterone level of 50 or below is adequate proof that a "castrate" level has been achieved, meaning the level where prostate cancer cells are being starved of a key fuel. I've encountered this view among researchers several times, and I've done my best to counter it because the leading hormonal therapy doctors I follow are all convinced that the testosterone should be 20 or below to really shut it off as fuel. On the other hand, if testosterone is higher but the PSA is below 0.05, then that is a separate indicator that blockade is working. (I think that is not a common scenario, but my own testosterone was 22 in December 2006 when my PSA reached less than 0.01 during my second cycle of full therapy, the trigger point I had chosen for going off therapy (stopping Lupron and Casodex, keeping finasteride and the bisphosphonate) for the second time.)

If suppression of testosterone is inadequate, there are a number of steps that can be taken, including both tests to assess the situation and tactics to rectify it. Sometimes the administration or storage of the LHRH-agonist (Lutein Hormone Releasing Hormone - activator, like Lupron, Eligard, Zoladex, Viadur, etc.) drug is faulty - not mixed properly, improperly refrigerated, past expiration date, delivery into fat instead of muscle, or casual stretching out of the prescribed shot interval instead of sticking to close to 28 day months and multiples (two months = 56 instead of 60, three months = 84 instead of 90, and four months = 112 instead of 120 days). Sometimes the patient just uses the drug up somewhat faster than the prescribed time, a situation that can be solved by shortening the interval between shots to less than 28 days per month.

A more powerful step is to add a drug in the "antiandrogen" class, such as flutamide or Casodex, but not stop it when the LHRH-agonist is started as you did. I know you have thought about this, but for the benefit of newer board members, some testosterone is made by the adrenal glands rather than the testes (normally 5% or less), but I've heard that in some men the adrenals can make up 40% of normal testosterone when the body senses that testicular testosterone production has been shut down. The antiandrogen drugs block the docking of androgen to prostate cells, thereby preventing their use as fuel. For metastatic cancer, the dose I hear usually recommended is three Casodex a day (for 150 mg), or an equivalently increased dosage of flutamide.

Then, even if there is adequate control of testosterone, the experts say that there may not be adequate control of DHT (dihydrotestosterone), which is a far more potent fuel for prostate cancer. I've learned that it is up to ten times more potent as a fuel than testosterone. DHT can also be measured, requiring just a little more blood to be drawn when the other vials are filled for PSA, etc. Fortunately, DHT, which is converted from some of the remaining PSA, can be virtually eliminated with the use of finasteride, or, usually even better, with Avodart, both of which stop most of the conversion of DHT from testosterone. (In addition, they have some other favorable impacts, such as decreasing the blood supply to new tumor cells.)



I would'nt have chemo again for 2 reasons. They say the main benefit of chemo is to improve quality of life. Statistics show it does not increase lifespan at all.

Old studies documented only a very short increase in survival for some chemo combinations, but there is encouraging news from newer studies. It is now accepted that the combination of Taxotere (docetaxel) plus prednisone increased survival in the study by about 2 1/2 months compared to the existing best regimen, mitoxantrone plus prednisone. Now 2 1/2 months may not sound like much for all the suffering, but that number is watered down because it is based on all men who were given the combo, rather than on the success of the many patients who responded to the drug. Apparently the responders did much better. (For non-responders, I've learned that good doctors will switch to something else when it's clear the drug isn't helping, which is usually clear within 90 days.

Do you have any observations of your own on that?

I was at a prostate cancer researchers' conference in October of 2007, and I brought up the difference between overall survival and responders' survival. I asked that researchers include both figures in their study results, and several top researchers indicated that was a good idea. They looked impressed; I'm convinced their response was more than just lip service.

I get a free newsletter published by the Prostate Cancer Research Institute. It's called "PCRI Insights," and there is an excellent article on chemotherapy in the May 2006 issue (Vol. 9, No. 2) entitled "Chemotherapy for Prostate Cancer: Why Bother?," by the late Brad Buess, the Executive Director of PCRI before his untimely death .


... Dave
Take care,

Jim

 
Old 01-06-2009, 05:46 PM   #8
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Quote:
Originally Posted by medved View Post
... but at least taxotere (the most common first line chemotherapy used in cases of advanced or metastatic p ca) is thought to have some benefit with regard to life duration...
Hi Medved,

I did not see your post as I was preparing mine, as I broke for dinner about the time you posted and did not recheck the board. I see it the way you do on all your points.

Jim

 
Old 01-06-2009, 08:47 PM   #9
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi guys. First my appologies. I did understate the benefits of chemo. Originally my doctor told me that from studies the median increase in life expectancy was 2 months. I thought that must have been a mistake because why would anyone go through the difficulties of chemo for 2 months. I was told that 2 months was the median number. Some people got no benefit and some people got years of benefit, and that I should hope that I would get much more than the 2 months. It did reduce my psa but as soon as chemo stopped my psa began to rise again. I'm still alive and feeling well so did it give me extra time? I don't know. How can it be verified? I think I would be doing just the same without having it. When my psa began to rise I had my testosterone level checked and it was negligible. Thus I was told my cancer was refractory. I am seeing my oncologist soon and I will ask him about retrying with a triple blockade. I'm curious to see what my psa is since 6 months since last test when it was 17. All the best guys. Hang in there. Dave

 
Old 01-07-2009, 09:24 AM   #10
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Quote:
Originally Posted by flyfisher37 View Post
...I did ask about chemo therapy since my cancer seems to be dividing quite quickly and since chemo attacks rapidly dividing cells, wouldn't chemo be an option for me? He told me that there is a clinical study underway at Juravinski as we speak to address that particular situation. He said that there probably will be some definite answers regarding this particular situation within the next 5 years. If the radiation doesn't do the job, I'll ask him if they are looking for a guinea pig to experiment on!

...Lionel
Hi again Lionel,

I've had a chance to look at that May 2006 "PCRI Insights" article on chemo more carefully, especially the paragraphs under the heading "What About Chemotherapy in Earlier Stages of PC?" The author is addressing higher risk PC cases: "Generally speaking, high-risk PC is defined as having a PSA > 20 or a Gleason score of 8 or higher or a Clinical Stage of T3 or higher ...."

Apparently the level of enthusiasm for early chemo in support of a main therapy like radiation or hormonal (or a combo) is higher than I thought and is increasing, and that's based on "numerous small phase II trials using neoadjuvant and adjuvant chemotherapy [meaning before the main treatment or at the same time and/or after it] in men with high-risk PC have been performed, with encouraging results. That comment is based on this study: Gleave M, et al: High-Risk localized prostate cancer: A case for early chemotherapy. Journal of Clinical Oncology 23(32): 8186-8191, 2005. I just got directly to the abstract on [url]www.pubmed.gov[/url], a site we can use here because it is sponsored by the US Government, with this search string: " A case for early chemotherapy AND gleave m [au] AND 2005 [dp] ". By the way, Dr. Gleave is another one of your Canadian docs, from Vancouver, who is a leader in the international war on prostate cancer.

If you go to the abstract on [url]www.pubmed.gov[/url], you will get leads to other research. I don't have the time to research it, but I'm sure a lot of us would appreciate it if you happen to look into it further and would care to report what you found to the board.

Jim

 
Old 01-07-2009, 10:46 AM   #11
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Re: chemo and recurring prostate cancer: not the best option at this time ?

Hi Jim,

I'm going to post an excerpt from a site that I read ( one that you recommended ). It might answer some questions for people, who like myself, have been wondering about this aspect of recurring cancer treatment, and primary treatment as well.

"In prostate cancer, outcomes have not been improved significantly when neoadjuvant hormone therapy is used before surgery; although outcomes are improved when androgen ablation is combined with radiotherapy, many patients remain at risk for systemic recurrence. With recent data confirming improved survival data with docetaxel chemotherapy in metastatic disease, future trials are now focusing on earlier combinations of chemohormonal or biologic therapies in high-risk patients."

So it would appear that the use of chemo and other systemic methods are mostly in the clinical study stage at this particular time as I was advised by the oncologist that I talked to at Juravinski. This statement by Glease pretty much sumarizes the situation as it currently stands. It might seem somewhat discouraging, but every situation and individual is different and we have to play the cards that we are dealt and hope for the best. I'm sure that this subject could be debated at great length by people have first hand experience with this situation, but I won't get into it at this point in time simply because I'm too new here and haven't yet done an immense amount of research on the subject.

I do go to the cancer center this coming Friday for a CT simulation where they set me up for radiation treatments. That won't start though until the other tests are done first.

Keeping my fingers and toes crossed, Lionel.

 
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