Join Date: Nov 2007
Location: Annandale, VA, USA
Re: Orchiectomy Questions
The board is acting up tonight, stretching out posts on the screen way to the right so that you only see a single line or two. I figured out that I can drag my cursor over a post and then transfer it to a letter, so I'll work that way. I'll put "JIM HERE" in front of my replies.
Hi everyone. My husband's PCa recurred after IMRT with booster treatments and he has been using Avodart, oncologist-prescribed supplements, and diet to manage growth of the cancer.
JIM HERE: That's probably a good approach. However, a few patients have a genetic problem in making use of Avodart. Switching to finasteride solves the problem, from what I've read. Just a thought - it's probably not an issue at all for your husband. (Finasteride is generic and much less expensive than Avodart, but for many men it does not stop as much of the conversion of testosterone to DHT, which is the main purpose of taking these drugs.)
However, PSA velocity increased and he will need either chemical or surgical castration. While the CT and bone scans were clear, it is believed he has metastases in his lymph nodes.
JIM HERE: I was (maybe still am) in the same boat. My CT, bone and ProstaScint scans were essentially negative back in early 2000, but with a baseline PSA of 113.6, Gleason 4+3=7 and all cores positive, most 100%, micrometastases were suspected by all of the doctors I talked to. There is a way of checking the nodes that will now pick up even quite small metastases, but the only place that does it is in Belgium. The PCRI Insights newsletter published a couple of articles about that Combidex technology and Dr. Jelle Baerentz (spelling from memory) within the past year, as I recall. However, even knowing whether there are positive nodes would probably not make a difference in a decision to move to hormonal blockade at this point. Would you mind telling us how much the increase was and what the pattern of increase was?
His liver is very sensitive. He has had to cut his antidepressant to one-third its usual dose and stop his statin in order to bring his liver enzymes down to normal.
JIM HERE: Have your husband's doctors suggested a drug known as Ursodiol to control the liver enzymes? It, and I believe a similar drug, apparently are effective for many men. That might permit resuming the statin and restoring the antidepressant.
Because of this, we are concerned that chemical castration would endanger his liver or have to be terminated prematurely due to elevated liver enzymes.
JIM HERE: Liver is rarely an issue with stopping production of testosterone from the testes by either medical or surgical castration. However, if it is a dominating concern, the doctor might try a one month shot of Lupron or one month insertion of a Zoladex coil. In fact, the Zoladex slow-release coil could be removed if there were a problem with the liver, making me think that would be a better solution. Liver enzymes are occasionally an issue with the second class of hormonal blockade drug - the antiandrogen class, usually bicalutamide (the generic for Casodex) these days. Ursodiol sometimes solves the problem so that an antiandrogen can be taken. If it doesn't solve it, the antiandrogen can be stopped. Avodart and finasteride rarely raise liver enzymes. In a sort of summary, liver function tests are done routinely with antiandrogens (but not with the other drugs), at least until it's clear how the patient handles the drug.
In addition, we think it unlikely he will be able to continue in the highly-physical profession he's worked for most of his life, so finances are a factor, and orchiectomy is less expensive than drugs.
JIM HERE: Would you mind explaining what makes you believe he won't be able to continue? There is probably a very good reason (Is he a prize fighter?), but there is a myth about hormonal blockade therapy involving the lack of testosterone that says muscle mass decreases and men become weaker. Well, that is likely to happen unless we patients on blockade use countermeasures. What we need to do is both aerobic and strength exercise on a regular and frequent basis. A patient can actually build muscle, including upper body muscle, with virtually no testosterone. I'm not sure that's true of all patients, but I expect it's true for many of us. It has been true for me, though it hasn't been easy (though I'm not a gym rat - average probably once a week with physical work at home in addition). Your husband probably will get most of the exercise he needs from that highly physical profession. Also exercise is known to help us emotionally, decreasing depression, so that's a side bonus. Drs. Mark Scholz and Richard Lam have published a paper dealing with the side effects of blockade therapy and countermeasures. The PCRI Insights newsletter also published an excellent piece on them by the late Brad Guess two or three years ago
JIM HERE: Yes, orchiectomy would be much less expensive, but, to achieve a vacation from the castration, it would be necessary to take some testosterone as a drug, so that would be an expense. Also, Zoladex will probably come out in a generic version shortly as it's patent expires this year or has already expired. Casodex is now available as much cheaper generic bicalutamide, and Proscar has been available as generic finasteride for some time. What I'm highlighting is that the cost of medical castration has gone down substantially and will soon no doubt drop much more. That might make that option affordable.
We sold our home to finance the IMRT several years ago. Sorry for the long background info. My questions so far are these: Is orchiectomy as effective as chemical castration (Triple Blockade plus Avodart) at bringing PCa into remission (or as close to remission as possible)?
JIM HERE: Very likely not as effective because surgical castration is just the equivalent of an LHRH-agonist drug (e.g., Lupron, Zoladex, Viadur, Trelstar) and triple blockade involves an antiandrogen (usually Casodex) as the second, medium weight drug in the triple combination, with Avodart being the light weight component, though still important. Thus, surgical castration plus Avodart would be leaving out Casodex, or more likely generic bicalutamide. However, adding bicalutamide as well as Avodart to surgical castration would be equivalent triple blockade. In fact, a comprehensive study of hormonal blockade in Japan suggests that surgical castration may be somewhat more effective than medical castration, especially in combination therapy. (That inferiority of medical castration could be due to issues of faulty drug administration or unusually rapid clearance of the drug, issues that would not arise with surgical castration.) My now savvy layman's estimate is that adding bicalutamide would be important for your husband, if his liver can tolerate it.
Because there will be no "drug holidays" with orchiectomy as there are with chemical castration, does this mean we lose the possible benefit of growing some hormone-sensitive cells during the "off" periods of Intermittent Triple Blockade thus making the cancer resurge after orchiectomy when it would not with Triple Blocade?
JIM HERE: Actually, provided your husband does not have detectable metastatic disease, there's a good chance he would be eligible for testosterone supplementation (yup!) after he had knocked his PSA down to below 0.05, hopefully down to below 0.01. (I've done that twice, and gotten down to 0.04 the third time recently, before taking a vacation from the Lupron and Casodex.) That would give him recovery of much of any function lost as a result of the castration. Obviously, with recurring prostate cancer patients, giving replacement testosterone needs to be done carefully and wisely. Dr. Robert "Dr. Bob" Leibowitz and colleagues have recently published a paper on this subject. Researchers still have some work to do before they have a firm grasp on the advantages of intermittent over continuous blockade; in fact, there are some staunch advocates of continuous blockade. However, I feel it's becoming clearer every year that intermittent blockade is superior if patients have a choice.
Why are some men still receiving chemical castration drugs when they have already had orchiectomy?
JIM HERE: If they have had a full "bilateral" orchiectomy, they don't need drugs like Lupron, Zoladex, etc. However, some testosterone is still produced indirectly via the adrenal glands, and for some men the adrenals sharply ramp up production when a shortage of testosterone is sensed. Lupron and like drugs don't do a thing to halt that indirect production. That's why antiandrogen drugs like bicalutamide are needed; they mainly block the cancer cells docking ports so that the testosterone can't link up and fuel the cancer. That recent Japanese study was not a clinical trial, but it was large, and I came away impressed that combined blockade (castration of either kind plus an antiandrogen) looked far superior to just castration (either kind) for cases with some challenging characteristics. I suggest you get a copy of the study and look over the survival charts.
I want to thank you all and especially Jim for the informative discussions of side effects and countermeasures.
JIM HERE: You're welcome. I'm very glad to be able to help.
My husband is faithful to his diet and supplements and uses policosanol in place of statin. He exercises even though his work days are long and arduous and will continue to walk and also add other exercise once he is no longer able to perform his job.
JIM HERE: You both may be pleasantly surprised at how well he is going to be able to do in maintaining strength and endurance. It can be done, but it does take work.
He is too thin right now.
JIM HERE: Thin is actually a good thing, provided it is not really thin. It's hard not to put on pounds once a man is on blockade therapy. Even with diet and exercise, putting on five to twenty pounds happens frequently. However, I know a really dedicated patient on blockade who has prevented weight gain. Your husband needs to try to avoid excessive carbohydrates - goes straight to the waist!
One more question: what are your experiences with work after orchiectomy or during triple hormonal therapy? What kinds of work are still possible for you? Are you able to work full-time? Have any of you been unable to work at all?
JIM HERE: When I was diagnosed in late 1999, and after starting blockade therapy and learning more in early 2000, I thought I would probably have to retire early from a mentally demanding job. As the months passed on blockade, I had to take some naps after work (early on hot flashes and sweats, as well as some initial joint and muscle soreness, interrupted my nights - tolerable, but not easy), especially in the first few months, but I realized I was doing quite well. I retired in January 2004, partly because I wanted to do more with prostate cancer education and have more time for exercise; I could have easily kept working. Many hormonal blockade patients keep working at jobs that are physically demanding, are mentally demanding, or both. There are a few men who have extremely bothersome flashes and sweats, or other side effects, such as anemia. These could interfere with doing a job, but there are countermeasures that are usually highly effective, as I understand it.
Thank you again and you are in my thoughts for your health and happiness.
JIM HERE: And you both are in mine. Take care and have faith!