I was just watching a lecture given by Dr. Scholz on October, 2010 in which he mentions the above drugs. The combination of these drugs, will, apparently, increase holiday periods between hormone therapy.
I'm also wondering where Avodart fits into all of this.
Looking forward to your feedback.
The Following User Says Thank You to honda50 For This Useful Post: IADT3since2000 (01-18-2011)
I have not seen that talk, but the combination looks interesting, and potent. Thanks for letting us and especially me know about it.
Celebrex appears to have some activity against prostate cancer, especially at higher doses, but I've heard that patients need to have a good cardiovascular profile to avoid heart risk while on Celebrex. I was on it for a while for prostate cancer, but at a lower dose than the experts were recommending. My oncologist was concerned about the risk, and when my insurer said they would no longer cover it (because of risk - remember the Vioxx and Bextra recalls), in the absence of clear benefit for me, we dropped it. I liked the drug; it helped a lot with those little aches and pains.
Revlimid is a kind of like second generation thalidomide. Basically, these drugs help cut down the blood supply to the tumor. I have been on low dose thalidomide (with 300 mg vitamin B6 to help prevent peripheral neuropathy while on the drug) twice, starting when my PSA reached about 10 toward the end of my vacation period. Both times the thalidomide knocked the PSA down two or three points and kept it down for a while, allowing me to extend the vacation, I believe about eight months both times, but I would need to check.
However, while I avoided the side effects from full triple therapy, I did not care for the morning drowsiness that is characteristic of thalidomide. (I did sleep great every night! ) I have read that Revlimid has a better side effect profile, including less drowsiness. However, in the US Revlimid is extremely expensive. Frankly, I would not want to burden my insurer for that extra cost just to extend my off therapy period when lower cost thalidomide is available. (If it were not available, I would probably just go back to full blockade sooner.) The Canadian system may make Revlimid available on a more reasonable basis. I feel that the thalidomide has bought me extra time, time for the researchers to make progress that may benefit me.
The experts I follow are all enthusiastic about Leukine. While it is quite expensive, in a way it is a poor man's version of Provenge, the three-treatment similar immune system drug that costs at least $93,000. Both are based on GMCSF. Both boost the immune system. Provenge is only available at present to late-stage patients, but Leukine is fairly widely available.
I believe Cytoxan is a chemo drug, but I'm not familiar with it.
It doesn't surprise me that this combo would extend an off-therapy period because Leukine and Revlimid would probably due that by themselves, making the combo even more potent. I'll bet that Dr. Scholz continues the Avodart (or finasteride) during that off-therapy period while adding these other drugs. He has been one of the leading pioneers of using the 5-ARI drugs for maintenance as well as for the third leg of triple blockade.
Wow, Jim...I'm letting YOU know something? Impossible!
Well, I've been researching a lot. I also just watched a lecture by Dr. Myers which I also found very interesting. There was something he said that was of particular interest to me.
He talked about a clinical trial, whereby high risk cancer patients, all who had had a prostatectomy were subjected to one of two conditions. Half of the patients had no therapy after surgery and the other half received half-dose radiation to the pelvic lymph nodes.
At 5 years, 77% of those how had the radiation were cancer free, and of those who didn't have the radiation, those who didn't have any BCR at that point was only in the low 30 percent.
He went on to say that it used to be thought that once the cancer left the prostate, it went everywhere but that isn't true. He said that it first remains in the prostate bed and then moves to the lymph nodes and then into the blood stream. He also said that, at that point, the cancer in the prostate bed is very responsive to the radiation even at half dose.
Jim, we can never be sure that the surgical route was the best choice for Irv but we can't go back. At the support group he went to tonight, men were talking about all of their side effects....radiation proctitis, permanent incontinence, feeling horrible with hormone therapy...and on and on.... Irv concluded that he didn't want radiation. But, the question is, would half dose radiation have a reduction in side effects??
This is getting all too confusing and Irv is starting to feel the emotional effects of this. Still can't quite grasp that this is happening.
Radiation is not a treatment to be done as “brush-sweeping” the pelvic area. It is done directional to targets based on model plans previously defined according to your husband status. Half doses even theoretically enough are not recommended as it avoids the main principles of salvage radiation therapy. If you do it, do it fully aiming at cure, not half-way to treat the wound.
The side effects of SRT can be minimal if it is done at proper experienced clinics with the latest modern machinery with IGRT for live realignments of the gantry delivering the rays.
Nowadays adjuvant hormonal treatment given together with SRT is common, and the outcomes have demonstrated to have a higher successful rate (35% vz 47%) in the long term.
Your husband’s case is in recurrence status and he needs to gain some confidence on the new methodology of radiation. It would be convincing if you get him to visit one of those modern IMRT clinics and gets some information directly from a professional (it may be easier to him to identify it professionally as he is an electrician himself).
Thanks, Baptista. Admittedly, I'm not aware of the type of radiation the PMH radiation oncologist is planning. However, I will say that the man who complained of radiation proctitis had his radiation done by the same oncologist. Apparently he was working at a tradeshow and, as he was standing, he felt the blood drip from his rectum down his leg.
Irv suffered through colitis at one point in his life so that account of the man's experience did not sit well with Irv at all.
I wish we could wake up one day and this was no longer a part of our reality. It really seems like we're about to live a nightmare. I'm sure we can get some sort of lesson in coping with this from some of you on this forum. Right now, it just seems so surreal.
I wanted to second Baptista's advice. SBRT, usually known as CyberKnife, is available at the Juravinski Cancer Centre in Hamilton. It gives a VERY small dose to the rectum, bladder and pelvic bones, and a curative dose to the prostate bed in only 5 treatments. You can further limit rectal toxicity with the topical application of Amifostine in the rectum prior to each treatment. Side effects of treatment are non-existent to minimal.
I notice the PMH has a set of clinical trials going on now with RT for 4 wks or 6.5 wks and with no hormone therapy,6 months of hormone therapy or 24 months of hormone therapy.(hormone therapy begins 2 months before RT) Oddly, they do not give bicalutamide to Canadians on the trial.
Thanks Allen. I wasn't aware that Cyberknife can be done after a prostatectomy. I didn't even think it was an option.
We weren't told about any trials when we were at PMH but I can ask if any of them apply to Irv.
We're also going for a 2nd opinion at Sunnybrook Hospital which also has a good reputation.
The half-dose radiation I mentioned was with regards to a clinical trial that Dr. Snuffy (Charles) Myers mentioned at one of his conferences which I saw online. He said that, even with half-does radiation to the pelvic lymph nodes after surgery, the results were excellent as compared to those who just had the surgery.
The million dollar question is whether the PC is still localized in areas not excised by the RP. Usually it is. It would be an experimental use of CyberKnife, but it seems to be indicated fror Irv. They usually want to irradiate the entire pelvic area just to be sure, but with Irv's history of colitis, and with no mets found, there seems to be more danger in total pelvic irradiation than in treating whatever they didn't cut out with the RP. New visualization techniques like the DCE-MRI, which may be available at PMH, can help determine if it is localized and where it is.
I just wanted to add some research where hypofractionated radiation (IMRT) was given post-prostatectomy to the prostate bed. In each case, they found the curative results to be similar to whole pelvic radiation without the danger of side-effects.
It seems to me that CyberKnife, a more exact hypofractionation technique than those used in these studies, would be even better. But if you can't talk his doctors into using it, at least hypofractionation - fewer doses- seems to offer as good a chance at cure as the long course of radiation treatment.
Thanks, Allen. I'm definitely going to ask the ROs about this. I think, with Cyberknife, something is implanted in the prostate, and, of course, if there's no prostate, that would be impossible. I might be wrong, but I believe I read something to that effect.
Your information, however, is very helpful and gives me something to ask about. I'm not ready to give up on the idea of radiation for Irv. I just don't want him to take a huge chance at causing himself more problems when the chance of a cure might still be minimal.
With minimal side effects, it seems a no brainer....but we'll have to ask about it.
You're right that gold fiducial markers have to be placed with any IGRT to track movement of the prostate during treatment. Since Irv has no moving prostate, I don't know how that would be used. They can place them in the urethral and bladder walls, if need be (they're tiny -- the size of rice grains, and they only need 3 of them). They also track the entire pelvis by continuously by CAT scan during treatment.
With no prostate in place, there is no need for fiducial markers as the irradiation isodoses plan is directional to areas in the pelvic and prostate fossa. Tattoos in the skin are used instead to centralize the gantry. The target accuracy in real-time is done with CT or trans-abdominal ultrasound.
Proton beam radiation may be the best choice in cases where inverse application is required, such as rectum colitis (your husband case), because it permits a more precise localization of the radiation dose. That means to give the “blow” of the ionizing radiation at a certain distance (from the linear accelerator) and no further propagation (3 millimeters of tolerance). This is called the “Bragg peak” where the ray loses its energy at a certain point.
Photon beam are not as precise in terms of depth irradiation and its rays energy continuous the path, which may cause damage to the tissue after the target in its path. However, proton beam may cause more damage to the tissue it passes through before reaching its target.
This application is possible but it may be difficult to be accepted at a proton clinic for treatment. You can try to discuss the matter with a Radiologist specialized in the treatment of prostate cancer. Just try, nothing to lose and it may be conformal to your husband.
I'm so glad you found that video by Dr. Myers. I had intended to send you a lead to the information he discussed, and I'm glad you have it. I'm also glad you have had responses about advanced radiation techniques that could help. I hope you find someone who is confident about avoiding colitis problems while delivering the radiation. I'm encouraged by SBRT (often delivered with CyberKnife, but possible with other systems), especially by the report delivered with five year average follow-up. I'm not so keen on proton because of the failure to update earlier findings with longer follow-up. Proton does look great in theory, but the proton researchers are still concerned about practical problems in delivering the doses. In brief, the main problem, as it appears to me, is that the carefully aimed radiation gets messed up a bit when it goes through body material with different densities. Up until recently, proton radiation entered the body through the bone, and it's easy to see how that could throw it off. Recently, IMRT radiation has been proposed, and I think that involves different delivery ports. I wish Loma Linda would update its published reports and extend the success of its earlier reports published years ago. Frankly, I feel they owe us that!
However, one-time or intermittent triple hormonal therapy with Avodart or finasteride maintenance is also an option, and it could gain time to research the radiation or to wait for improvements in that therapy, without losing ground. The blockade would lay the groundwork for radiation if you both decided that was the way to go. (By the way, I continue to do well in my ninth month of my third vacation from the heavy duty drugs; I'm at the 11 year 1 month point since diagnosis now.)
YES, you definitely helped me learn something! Thanks again.
Thanks, Jim. I guess my diligent and persistent research has some benefit.
I hope that the Canadian Radiation oncologists don't look at me as though I'm from a different planet when I mention hypofractionated radiotherapy. In other words, I really hope this is something that they do so it can be discussed. I like the fact that it seems it isn't as toxic as standard fractionated radiotherapy.
Oh my goodness, would you just listen to me? I actually sound like I know what I'm talking about. LOL
I hope this feeling of empowerment translates into getting the best possible treatment for Irv.
Actually, as you mentioned, I have thought about the idea that he go on hormone therapy for awhile to try and reverse some of the effects of the surgery before jumping into radiation. The main thing is that we get the remaining cancer under control. This stage of doing nothing is disturbing to me. I am so eager to get another PSA result for him.....albeit, frightened too.
Should we expect some rise? I'm hoping it's the same. Is that too much to hope for? His last PSA test was done on Jan. 4 and we'd like to do another one at the one month mark. Does that make sense at this point? We have the requisition slip ready to go from our family doctor. We're just waiting for the right time.