Hi,
My Father now 80 yrs of age, when tested in 2007, his PSA was 461. He underwent an operation called 'Orchiectomy'. His PSA dropped to 277. He was diagnosed to have HRPC (Prostate Cancer) in Jun 2008. He was treated from Jul 2008 to Jan 2009 for HRPC by weekly Chemotherapy , and simultaneously received injections every month for bone thickening . His PSA dropped to 7.72. He was on Hormanal therapy since then till Jun 09. His PSA started risign 100 % every month from Jan itselt, and has reached 132 now.
At present he has an urge to pass urine every after 1/2 an hour, but he cannot empty the bladder full. Every time during urination, a little stool also comes out.
It someone can help me to know, if there is any way to stop the PSA rising, and if frequent urination problem can be treated?
Hi binu, and welcome to this board! I have faced a challenging case of prostate cancer myself, and that has led me to learn a lot about hormonal therapy and a fair bit about chemotherapy. I'll insert some comments in green.
Quote:
Originally Posted by binu
Hi,
My Father now 80 yrs of age, when tested in 2007, his PSA was 461. He underwent an operation called 'Orchiectomy'. His PSA dropped to 277. He was diagnosed to have HRPC (Prostate Cancer) in Jun 2008.
As you no doubt know, HRPC means Hormone Refractory Prostate Cancer; in layman's language, it means that the cancer is no longer controlable by hormonal therapy. There is a small community of like-thinking doctors specializing in treating prostate cancer in North America, especially advanced disease and challenging cases, that I am convinced has become much more expert and knowledgeable than most doctors treating the disease advanced disease. In particular, they have more or less reached a consensus in applying hormonal blockade. I am in my tenth year as a survivor, doing very well, following their advice on the particular approach known as intermittent triple hormonal blockade (with a bisphosphonate drug in support, a statin drug to help my odds of success, and a lifestyle program involving diet/nutrition/supplements (keyed around a Mediterranean diet), exercise and stress reduction). At diagnosis my PSA was 113.6, Gleason 4+3=7, all biopsy cores positive, most 100% cancer; however, a bone scan, a CT scan, and a ProstaScint scan were all essentially negative. I have twice achieved a PSA of less than (<) 0.01 using an ultrasensitive PSA test before switching to the "off therapy" phase. I'm giving this background so you will have an idea of my viewing point. I am a now savvy patient, but I have had no enrolled medical education.
Was there treatment in addition to the orchiectomy? That operation eliminates testosterone that is produced from the testes, but it does not control other sources of testosterone, its docking with cancer cells, or prevent its conversion to more dangerous DHT (dihydrotestosterone). The experts I follow would not consider a patient to be in the refractory HRPC state until he no longer responded to a combination of hormonal blockade, not just an orchiectomy or its medical equivalent. Your father may be able to find a doctor who understands this approach and could put it to work now, and see how your father responds.
These experts would insist on also using a drug in the "antiandrogen" class to block most of the docking with cancer cells as well as to create other beneficial effects. In the US, the preferred drug is Casodex; it is expensive, but it is more effective, more convenient, and better in its side effect profile. The most common alternative in the same antiandrogen class is flutamide. Other options that may be available are Nilandron (nilutamide) and Androcur (cyproterone acetate - not available in the US, I believe because of greater risk of cardiovascular complications).
They would also insist on adding a third class of drug, known as "5-alpha reductase inhibitors" (5-ARI). In the US, most of the experts favor Avodart, though finasteride, formerly known as Proscar, is also available (and is the drug I have been on). A few men do not respond well to Avodart because of a genetic problem, but they will respond to finasteride. (Incidentally, the first generic version of Proscar - finasteride - that I took was manufactured by the company run by the Indian doctor known as Dr. Reddy.) These 5-ARI drugs are highly effective in preventing conversion of any remaining testosterone to DHT, and they also cut down the supply of blood needed for tumor growth.
This program combined hormonal blockade program is compatible with chemotherapy.
He was treated from Jul 2008 to Jan 2009 for HRPC by weekly Chemotherapy , and simultaneously received injections every month for bone thickening .
Most likely he was getting infusions of a bisphosphonate drug. Aredia (Pamidronate) is the infusion drug that was commonly used until a much more powerful drug, Zometa, was approved by the US FDA (Food and Drug Administration) in 2001. Now that would be the strongly preferred drug for a case like your father's. It is quite expensive, but in the US it is usually well covered by insurance. It does have some potential side effects, especially when used frequently and long-term, but countermeasures can help to a degree. He should be taking calcium and vitamin D3 daily in support of the bisphosphonate therapy.
His PSA dropped to 7.72. He was on Hormanal therapy since then till Jun 09. His PSA started risign 100 % every month from Jan itselt, and has reached 132 now.
What a great response to chemotherapy! Since he had an orchiectomy, that is a permanent form of hormonal therapy. Were other drugs added since sometime last year? This is where using the full batch of drugs might make a critical difference. If not, the experts I follow switch to a more powerful antiandrogen, specifically ketoconazole with hydrocortisone in support. If that does not work, they will often try estrogen delivered through patches that are placed on the skin (known as "transdermal estrogen"). They may also use other agents, such as leukine.
In support of this, the doctor I follow most closely, Dr. Charles "Snuffy" Myers, MD, strongly advocates a lifestyle program.
Two excellent books describe hormonal therapy, other options I've mentioned, and the lifestyle program. They are: "A Primer on Prostate Cancer - The Empowered Patient's Guide," Dr. Stephen B. Strum, MD, and Donna Pogliano, and "Beating Prostate Cancer: Hormonal Therapy & Diet," by Dr. Myers.
There's a new drug that is highly likely to be approved by the FDA in the next six months in the US for men in your father's condition. It is known as Provenge. It is given by epheresis. It is also very expensive, but hopefully for US patients, insurance should help. I have not heard anything concrete about its international availability, but I do know that Dendreon, the company that developed the drug, is working on that.
At present he has an urge to pass urine every after 1/2 an hour, but he cannot empty the bladder full. Every time during urination, a little stool also comes out.
It someone can help me to know, if there is any way to stop the PSA rising, and if frequent urination problem can be treated?
The 5-ARI drugs were originally approved by the FDA for treating benign enlargement of the prostate. It's quite possible that they might help with the urination problem, and it's also possible that the enhanced hormonal blockade therapy might reduce the cancer in a way that would help with urination.
I hope that your father finds something that works.
It gives me great relief after reading your immensely knowledgeable reply. It will serve me as a valuable advice. I have read your reply again and again many times to understand word by word. It appeared, I have made you to guess too many situations. Please pardon me for that.
After Orchiectomy, my father was taking Calutide 50, and Flotral (Alfusin D) 60 mg. During Chemotherapy (with Docetere 60 mg), all these medicines were stopped. After the 24th Chemotherapy, he was prescribed Calutide 50, which he had taken till May 09, thereafter all these medicines were stopped. From May 09 onward, X-trant (Natco Pharma) 140 mg, 2 tablets thrice daily along with Supradyn and Cap Biocumin were prescribed. X-trant did not show any improvement, rather made his digestive system weak and developed condition of constipation and red nipples; his SGOT and SGPT shot up to 101 and 107 (normal <38 and <41 respectively). Syp Sorbiline has helped to reduce it to 73 and 44 in 15 days.
I had taken my father to the doctor again, after writing my first post. The Doctor has stopped X-trant. He has now been given Lycogem. For urine control Urispas and Hytrin 2 mg. He has been advised to take these medicines along with Supradyn and Biocumin for one month, and observe. If condition still persists or deteriorates, then Chemotherapy will commence again from 04 Aug 09.
For bone thickening my father is given Blaztere 4 mg (I think, it is the same medicine under license and packed by Dr. Reddy’s Lab). He is also taking Calcium 500 mg daily one tablet. I will ask my doctor to prescribe him Vitamine D3.
My father is pure vegetarian, non smoker and non drinker. His lumbar spine is curved (‘positional short curve scoliosis of lumbar spine with convexity to right side’), Therefore, he cannot perform any exercise, but is able to walk in the lawn for around 10 minutes, but swelling develops in his legs if he walks, which lasts for about a week (his urine and blood test did not show any sign of presence of albumin and protein)
At 80 yrs of age, my fathers heart although is functioning exceptionally well. It may not indeed be as good as compared to someone younger person’s heart. I am therefore, writing at the end of my post, about the 2 D ECHO report and medicines he is taking for heart.
I will ask my doctor to assess changing the course of medicine and prescribing antiandrogen drug in combination with 5-ARI before commencing Chemotherapy. Maybe, I need to change the doctor.
My sincere thanks to you again, for an exceptionally wonderful advice. It is definitely more than what I expected. Especially, from someone knowledgeable, and someone whom I do not know personally. Lastly, would you also explain as to why Provenge is given?
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2D ECHO report:
1. Distal septum and Apex hypokinetic. LVEF is 50 %.
2. LVH is present. All cardiac chanber dimensions are normal.
3. Mild MR, Mild TR (PASP 35 mm Hg), No AR/PR.
4. Diastolic relaxation impairment ( A>E).
5. No intracardiac mass or thrombus seen.
6. No pericardial pathology seen
Medicines taken for heart: Seloken 25 mg, Aspisol 75 mg, TG-Tor 10 mg, Roza D, and Acanec for pain relief (sos)
It gives me great relief after reading your immensely knowledgeable reply. It will serve me as a valuable advice.
Your are very welcome. I'm glad I can help.
I have read your reply again and again many times to understand word by word.
That's what I did after asking many questions following my diagnosis. I learned slowly, gradually, but steadily.
It appeared, I have made you to guess too many situations. Please pardon me for that.
That's no problem at all. It is most difficult to know what is important when you are trying to learn about prostate cancer, especially about an advanced case.
After Orchiectomy, my father was taking Calutide 50,
I just checked and confirmed that Calutide is generic Casodex, known scientifically as bicalutamide. "50" most likely means the dose is 50 mg (the dose I take). Using this drug after an orchiectomy strikes me as very good practice - basically your father is getting "combined hormonal blockade", but the doctors I consider leading experts in hormonal blockade therapy would use a dose of 150 instead for a very advanced case like your father's, if it could be tolerated without causing liver problems (rare). The reason is that Calutide blocks the "androgen receptors" (ARs), the docking sites on the cancer cells for the testosterone and dihydrotestosterone that are the main fuels for the cancer; in metastatic and very advanced patients, there may simply be too many docking sites to be covered adequately by just 50 mg, as I understand it. Because it is an expensive drug, sometimes doctors will try just 100 mg - two pills daily - for their high-risk patients and see if their PSA and other responses indicate that 100 mg is enough to achieve success.
Sometimes the cancer mutates and is able to start using the Calutide as fuel. That's known as an "Androgen Receptor Mutation" (ARM). There is a workup that can be done to determine whether an ARM is causing rising PSA or whether the cancer is no longer controllable with the Casodex. If so, second line hormonal therapy tactics can be used.
and Flotral (Alfusin D) 60 mg. During Chemotherapy (with Docetere 60 mg), all these medicines were stopped.
I'm fairly sure that hormonal blockade drugs are usually continued during chemotherapy in the US.
After the 24th Chemotherapy, he was prescribed Calutide 50, which he had taken till May 09, thereafter all these medicines were stopped. From May 09 onward, X-trant (Natco Pharma) 140 mg, 2 tablets thrice daily
I believe X-trant is not marketed in the US. It is a "phosphorylated combination of estradiol and mechlorethamine (nitrogen mustard)." Estradiol, a form of estrogen, is getting much attention in the US when regular hormonal blockade is not enough to control the cancer. However, there is concern here that estrogen taken orally involves an uncomfortable level of risk for cardiac complications; the form now getting great attention is "transdermal estrogen, in other words, estrogen delivered through the skin via skin patches. That form seems to be both safe and effective.
Nitrogen mustard, which I believe is known as estramustine (?), is sometimes used as part of a chemotherapy program.
along with ...in 15 days.
I had taken my father to the doctor again, after writing my first post. The Doctor has stopped X-trant. He has now been given Lycogem a lycopene supplement plus minor amounts of other vitamins]. For urine control Urispas and Hytrin 2 mg. He has been advised to take these medicines along with Supradyn
This multivitamin has some elements in it that look good for prostate cancer patients, but some of the amounts do not line up with research. For instance, it appears that the daily dose of selenium that helps is about 200 mcg vice 28 mcg in Supradyn. Dr. Myers has written a couple of excellent, easy-to-read books about nutrition for prostate cancer patients. The more recent one is "Beating Prostate Cancer: Hormonal Therapy & Diet."
and Biocumin for one month, and observe. If condition still persists or deteriorates, then Chemotherapy will commence again from 04 Aug 09.
For bone thickening my father is given Blaztere 4 mg (I think, it is the same medicine under license and packed by Dr. Reddy’s Lab). He is also taking Calcium 500 mg daily one tablet. I will ask my doctor to prescribe him Vitamine D3.
Blaztere appears to be the Indian version of Zometa (zoledronic acid), delivered by infusion. If so, that is a very powerful bisphosphonate drug and is the one that would be most likely used in cases like your father's by the experts I follow. I noticed that the recommended calcium supplement dosage while on the drug was only 500 mg. I believe that the recommendation would be higher in the US, but that would be worth checking. I have been on less potent oral bisphosphonates since the fall of 2000, first Fosamax for several years, and for the last two years or so on Boniva. I've been getting about 1,000 to 1,200 of calcium per day and about 2,000 IU of vitamin D3. The dosing of D3 is best tailored to the individual; in the US that would be done using the 25-hydroxy vitamin D blood test, with the goal for prostate cancer patients of keeping the level in the range from 50 to about 80, or perhaps up to 100.
My father is pure vegetarian,
That is consistent with a diet that helps us cope with the cancer.
non smoker and non drinker.
Of course not smoking is good, though it does not seem to influence prostate cancer. Regarding drinking, the resveratrol in red wine appears to be helpful to prostate cancer patients. I think that grape juice also has some resveratrol. I'll admit I enjoy a couple of glasses of red wine a day - for my health.
His lumbar spine is curved (‘positional short curve scoliosis of lumbar spine with convexity to right side’), Therefore, he cannot perform any exercise,
I'm wondering if he could still do some weight bearing exercises that were limited to the arm muscles, perhaps rotating from an elbow resting on a surface, or leg muscles, from a seated position - resistance exercise against weight would be good, but a reclining bike might also provide aerobic exercise.
but is able to walk in the lawn for around 10 minutes, but swelling develops in his legs if he walks, which lasts for about a week (his urine and blood test did not show any sign of presence of albumin and protein)
A concern for prostate cancer patients is deep vein thrombosis, and swelling is one of the clues for that. I'm not real knowledgeable about the workup for it, and maybe that is what the albumin and protein tests were for. That's really too bad. I hope your dad's leg condition improves. Keep up hope!
At 80 yrs of age, my fathers heart although is functioning exceptionally well. It may not indeed be as good as compared to someone younger person’s heart. I am therefore, writing at the end of my post, about the 2 D ECHO report and medicines he is taking for heart.
Good for him! I'm not very knowledgeable about heart medications, other than for cholesterol, but maybe someone else can comment, though it looks like you are including the information just to give a complete picture.
I will ask my doctor to assess changing the course of medicine and prescribing antiandrogen drug in combination with 5-ARI before commencing Chemotherapy. Maybe, I need to change the doctor.
Maybe, but my overall impression is that the doctor is giving your father some good and thoughful care. The doctors I follow closely for prostate cancer - those I consider true experts, specialize virtually exclusively in prostate cancer, though in the context of overall health. It would be hard for a doctor who does not so specialize to have such an extremely high level of expertise, but a doctor may be doing a fine job even though he is not a highly expert specialist. My own oncologist does not specialize in prostate cancer, but he is open-minded, thoughful and talented. He and I have workded together to follow recommendations from the experts.
My sincere thanks to you again, for an exceptionally wonderful advice. It is definitely more than what I expected. Especially, from someone knowledgeable, and someone whom I do not know personally. Lastly, would you also explain as to why Provenge is given?
Provenge has not yet been approved by the American Food and Drug Administration (FDA), but based on a strongly successful clinical trial, following two earlier smaller but apparently successful trials (lower level of statistical confidence in the results), FDA approval is highly likely, probably within about the next half year. The company, Dendreon, does plan to market the drug internationally, but it is not clear how long that will take.
The clinical trials aimed at proving the drug for hormone refractory, metastatic prostate cancer patients. It is given by epheresis: blood is drawn from the patient; the blood is combined with the drug and specially processed at the company's factory; then this processed blood is infused back into the patient. This is done three times. While the median (average) survival benefit was about four months, as I recall, as is typical, that average included patients with no response or minimal response as well as those who responded strongly. While average survival of patients in the trial, without the drug, was projected to be about 20 months, as I recall, at the end of three years, three times as many patients treated with Provenge were alive as those not getting the drug up-front. (A "cross-over" experimental design was used, so patients not getting the drug up-front had the option of getting a frozen version of the drug after their cancer was seen to progress.) As you may know, once oncologists start working with such a drug and using it in combination, survival often improves well beyond what is seen in trials that are the basis for FDA approval. (It already appears that survival is substantially better with a combination of Provenge and docetaxel. In sum, the drug looks very promising for late-stage prostate cancer patients. It also has a remarkably benign side-effect profile - far superior to the profile for chemotherapy. Provenge is not chemotherapy; rather, it is an immune system drug. Unfortunately, it will probably turn out to be quite expensive; a couple of years ago, a full course of treatment was tentatively projected to cost between $40,000 and $60,000. For most US patients, that will make insurance coverage vital. (There is at least one thread on Provenge on this board. You could use the search function to check for threads and posts on Provenge.)
I'm glad I could help. What I have learned is not the kind of knowledge any of us laymen wants to have to learn, but it is wonderful that the knowledge is there to be acquired if we need it.
Take care,
Jim
-------------------
2D ECHO report:
1. Distal septum and Apex hypokinetic. LVEF is 50 %.
2. LVH is present. All cardiac chanber dimensions are normal.
3. Mild MR, Mild TR (PASP 35 mm Hg), No AR/PR.
4. Diastolic relaxation impairment ( A>E).
5. No intracardiac mass or thrombus seen.
6. No pericardial pathology seen
Medicines taken for heart: Seloken 25 mg, Aspisol 75 mg, TG-Tor 10 mg, Roza D, and Acanec for pain relief (sos)
I have faced a challenging case of prostate cancer myself, and that has led me to learn a lot about hormonal therapy and a fair bit about chemotherapy. I'll insert some comments in green.
That's known as an "Androgen Receptor Mutation" (ARM). There is a workup that can be done to determine whether an ARM is causing rising PSA or whether the cancer is no longer controllable with the Casodex. If so, second line hormonal therapy tactics can be used.
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