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Old 01-25-2011, 06:23 AM   #1
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pc gleason 9 with metastasis

Hello,my dad 68 years old, just found out that he has advanced pc.He has psa 14.5 and a gleason score of 9,with metastasis at the bones.We have see a lot of doctors with different opinions of treatment.
one doctor prescribed 150 mg casodex for one week and then shots every three months but also with casodex.The other doctor prescribed casodex 50 mg for two weeks and then shots every three months but he also said to continue casodex for a month and then only the shots.
I am confused.If any of you has the same experience i would be grateful if you could help me.
I am very sad is he going to be ok?what is the outcome of this therapy and what can i do for him?

Thank you very much

 
Old 01-25-2011, 02:27 PM   #2
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Re: pc gleason 9 with metastasis

Hi Bella

Both protocols recommended to your father are typical on hormonal treatment (HT). Both will do the job, but some doctors recommend a higher dose of the anti-androgen (150mg) to have a quicker reaction in lowering the testosterone in our body. Cancer cells survive by feeding on testosterone.
In short, HT (also called; Androgen Deprivation Therapy) aims in killing the cancer by blocking this feeding, starving the cells and inducing them to die.

The drugs recommended by your doctors (the shots) are LHRH agonists that will block (stop) the manufacture of the testosterone in the testis (chemical castration) and therefore lowering the testosterone circulating in our body. Casodex is an anti-agonist that will stop the feeding at the cells (blocking its mouth).

In HT these drugs can be taken separately (Single Blockade approach) or together (Double Blockade approach). Some protocols add still one more drug called 5-alfa reductase inhibitor (Triple Blockade approach) which blocks the manufacturing of dihydrotestosterone (DHT), a stronger type of testosterone.

LHRH shots cause initially an increase of the testosterone during the first 7 to 10 days after administration, known as “flare”. That in turn will cause an increase in the activity of the cancer which is an adverse condition for advanced cancer patients. To avoid this “flare”, anti-agonists (Casodex) is taken usually two weeks in advance of the shot (LHRH agonist). This answers one of your questions in your post.

LHRH agonists are available in several doses of effectiveness of 1, 3, 4, 6 and 12 months. These varieties in dosages permit a better scheduling of the protocols.
One doctor have advised your father a Double Blockade protocol of Casodex with a 3-months shot, and the other doctor advised a Single Blockade protocol of Casodex in the initial month with a 3-months shot.

Surgical castration (orchiectomy) is also a means to lower the testosterone, but it becomes permanent. With chemical castration the symptoms caused by the low testosterone can be stopped once we withdraw from the drugs. This also allows for an intermittent approach (In/Off the drugs).
In this forum you can read the experiences of a member with the acronym IADT3since2000, who has successfully been on HT-Triple Blockade intermittently (IADT3) for eleven years. His posts are very educative and I recommend you to read his explanations. Just click on his name.

Wishing the best to your father.
Baptista

 
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Old 02-01-2011, 05:32 PM   #3
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Re: pc gleason 9 with metastasis

Hi bella30,

Welcome to our board! (And thanks Baptista for your kind words.) I'm sorry your father has had to start this journey with a challenging case. Fortunately, these days, a lot can be done. We are far better off than patients were as recently as a decade ago, even five years ago.

Baptista has already covered the key facts. I'll add some thoughts in green to an excerpt of your post.


Quote:
Originally Posted by bella30 View Post
Hello,my dad 68 years old, just found out that he has advanced pc.He has psa 14.5 and a gleason score of 9,with metastasis at the bones.
That case picture rules out the more common options that are used for local and regional prostate cancer, including surgery, customary radiation, and cryo surgery. There is a strong consensus that hormonal therapy, also known as androgen deprivation therapy and hormonal blockade therapy, is appropriate at this point. Sometimes these days a short course of early chemotherapy is added to the hormonal therapy, but that is not standard practice and is uncommon.

Quote:
We have see a lot of doctors with different opinions of treatment.
one doctor prescribed 150 mg casodex for one week and then shots every three months but also with casodex.The other doctor prescribed casodex 50 mg for two weeks and then shots every three months but he also said to continue casodex for a month and then only the shots.
I was diagnosed with an advanced case in December 1999, and after a couple of false starts, I settled in on hormonal therapy as my only therapy. I am now doing very well at the 12th year point. I've learned a lot about hormonal therapy and have some firm opinions, but I am a layman with no enrolled medical education. I have posted about my own story a number of times.

Based on this experience, I like what the first doctor said, though I'm convinced more is needed, but I'm convinced that the program the second doctor offers is simply inadequate and will shortly lead to progression of the cancer. We have a handful of doctors in the US, all medical oncologists (rather than surgeons or radiation oncologists), who have focused on hormonal therapy. They all have practices dedicated virtually solely to prostate cancer, and they see a great many patients, giving them a broad and deep base of experience. They also communicate well with each other. All of them feel that Casodex, now available in an equally effective but less expensive generic version as bicalutamide, should be used up front, as Baptista described, but then continued with the LHRH-agonist that is delivered by a shot (usually; there's an implant version also). While some of them prefer a dose of 50 mg of bicalutamide for a non-metastatic patient, they all routinely use a dose of 150 mg for a patient with detected metastases. One of them will even use higher doses under careful observation. I have always been on the 50 mg dose when I've been on the two heavier duty drugs and not on a vacation from the drugs under my intermittent therapy program. As for the beginning of therapy, either 150 mg of bicalutamide for one week or 50 mg of bicalutamide for two weeks should be sufficient, as I understand it; the objective here is to prevent what is known as "flare" from the first days on the shot. That's very important with a patient who is metastatic.

However, all of the experts also add a third drug from the 5-alpha reductase inhibitor class that Baptista mentioned. There are now two drugs in the class: finasteride (also available as no more effective but more expensive brand-name Proscar) or Avodart (technically known as dutasteride, but not available as a generic). While published medical research literature on the benefits of adding the third drug is scant, the experts are convinced of its value. Adding the third drug certainly worked for me. Also, the third drug is quite mild and fairly inexpensive, especially generic finasteride.

These drugs often cause some typical side effects, which have been described before on this board. (I can give you some leads to the posts if you have trouble finding them.) However, it is very important to understand that all of these side effects can be countered to some extent, usually enough to make them quite tolerable if not eliminating them altogether. Those important countermeasures have also been described on the board. Unfortunately, many doctors who prescribe these medications often are unaware of the countermeasures and do not counsel their patients about them. One of the best sources of information on hormonal therapy, its side effects, and countermeasures is a new book entitled "Invasion of the Prostate Snatchers" by Ralph Blum and Dr. Mark Scholz, MD, the latter being one of the leading experts in hormonal therapy. Another outstanding book, by another expert, is "Beating Prostate Cancer: Hormonal Therapy & Diet," by Dr. Charles "Snuffy" Myers, MD. Among other things, Dr. Myers serves up a healthy dose of optimism, which you and your dad could use at this time.

Your dad may need to ask the doctor (the first one) to add the 5-ARI drug under a procedure that in the US is called "open-label" prescribing. The patient acknowledges that the drug is not yet considered standard therapy, and the doctor informs him of what is known about any risks and benefits. I was explaining that to srhonda51 in a post a couple of days ago, a post you could look at.

The experts have led the way toward recognition that men on hormonal therapy with an LHRH-agonist (the shot type drugs) need to be assessed for bone mineral density, and probably treated with the kind of drug that helps prevent osteoporosis. Most of these drugs are known as bisphosphonates, though there is one new one that is a monoclonal antibody. They differ in power and side effects. I have done very well with two of the milder types, first Fosamax (now generically available as alendronate) and more recently Boniva. For patients with existing bone mets, the powerful drug Zometa is often prescribed. It can cause a rare but serious side effect known as osteonecrosis of the jaw. On the good side, it can not only strengthen the bone but also help slow, stabilize, or even eliminate bone metastases from prostate cancer! The patient takes supplements for calcium and vitamin D3 while on these drugs. A prescription version, calcitriol, is also available.


Quote:
I am confused.If any of you has the same experience i would be grateful if you could help me.
I am very sad is he going to be ok?what is the outcome of this therapy and what can i do for him?

Thank you very much
I wrote about this in an earlier post today that you would probably find interesting (about Dr. Crawford's research back in 1989) Based on advances since that time, hormonal therapy should work much longer. In the meantime, while it is working, new advances will surely be made. Another study indicates that even after hormonal therapy no longer controls the cancer, men with metastases in the bones survive for an average of 40 months, which, added to the initial period of effectiveness of hormonal blockad prior to failure, is encouraging to many of us. Moreover, that study was also done with men treated a long time ago, mainly in the 1990s. There have been many great advances since then, so such a study done on men treated in the just past decade would no doubt result in much longer survival.

Almost all of us are very discouraged when we first learn we have prostate cancer. The reality is that many of us have many years of good quality life ahead of us, even those of us with challenging cases.

I hope you, your dad and family will feel better soon. I hope he finds something that works well. I think he will.

Take care,

Jim

 
Old 02-07-2011, 01:46 PM   #4
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Re: pc gleason 9 with metastasis

Hello,

Thank you very much Baptista and IADT3since2000 ,you really helped me understand some things. I am wishing you the best from the bottom of my heart!

My father takes 50 mg casodex every day and one shot every three months.I will ask the doc about avodart because he didn’t prescribed this, and from what I read I think he should take it.

I ve read that with intermittent hormonal therapy it is good to stop the drugs when psa goes to 0,01-0,05 .Do you know how difficult that is or if it is possible for someone with advanced metastatic cancer to approach this number?

I am afraid that if he takes all the drugs together his pc will be refractory sooner, and then what? I would be very grateful If anyone has advice on the best possible treatment of advanced pc with bone metastasis.

Thanks again

 
Old 02-07-2011, 08:40 PM   #5
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Re: pc gleason 9 with metastasis

Hi bella30,

I'll insert some thoughts below.


Quote:
Originally Posted by bella30 View Post
Hello,

Thank you very much Baptista and IADT3since2000 ,you really helped me understand some things. I am wishing you the best from the bottom of my heart!

You're welcome, and thank you!

My father takes 50 mg casodex every day and one shot every three months.I will ask the doc about avodart because he didnít prescribed this, and from what I read I think he should take it.

I ve read that with intermittent hormonal therapy it is good to stop the drugs when psa goes to 0,01-0,05 .Do you know how difficult that is or if it is possible for someone with advanced metastatic cancer to approach this number?

My impression is that it's best to stay on the drugs to reach <0.01 (0,01 for Europe, I believe, following your post), and to stay on the drugs for at least nine months, probably for at least a year. If the metastasis is wide spread and painful, it may be very difficult to reach those levels without additional intervention. I've read and heard that some men with metastases have been able to take a vacation from the hormonal blockade drugs. I'm not sure how likely it is for triple therapy patients who are metastatic.



Quote:
I am afraid that if he takes all the drugs together his pc will be refractory sooner, and then what?
The evidence I see for triple blockade suggests that the refractory state will be delayed, and I haven't seen anything indicating it will be hastened. Moreover, while the Avodart is pretty weak on its own, though having some activity, there is evidence that it works much more effectively as part of a combination.
I would be very grateful If anyone has advice on the best possible treatment of advanced pc with bone metastasis.

Thanks again[/QUOTE]

The powerful bisphosphonate Zometa (zoledronic acid) is often prescribed both to preserve bone density and help counter bone metastasis. There are some potential side effects. Is he taking Zometa or another bisphosphonate drug?

If there are five or fewer metastatic spots, radiation that targets and kills cancer in just those spots may be an option.

Take care,

Jim

 
Old 02-08-2011, 04:38 AM   #6
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Re: pc gleason 9 with metastasis

Quote:
Originally Posted by bella30 View Post
Hello,

Thank you very much Baptista and IADT3since2000 ,you really helped me understand some things. I am wishing you the best from the bottom of my heart!

My father takes 50 mg casodex every day and one shot every three months.I will ask the doc about avodart because he didn’t prescribed this, and from what I read I think he should take it.

I ve read that with intermittent hormonal therapy it is good to stop the drugs when psa goes to 0,01-0,05 .Do you know how difficult that is or if it is possible for someone with advanced metastatic cancer to approach this number?

I am afraid that if he takes all the drugs together his pc will be refractory sooner, and then what? I would be very grateful If anyone has advice on the best possible treatment of advanced pc with bone metastasis.

Thanks again
Hi Bella

There is no substantiated prove in the “net market” yet that taking HT drugs intermittently would delay the refractory process. There are many articles indicating that double blockade (LHRH agonist plus anti-agonist) work better in lowering the testosterone and therefore in controlling the advance of the cancer.
In the intermittent modality, the so called “vacation from drugs”, starts on the day established by the protocol of the oncologist regarding to each individual case. The PSA threshold of 0.01 to 0.05 is not a marker of “stop”. It refers usually to the status of “remission”, a term indicating the success of the HT treatment. Some oncologist use still higher thresholds like 1.0 to 5.0.
An example is Dr. Myers principle that will keep his patient on the drugs or even increase the “power” of the drugs (shortening the effectiveness period of the agonist and/or increasing the mg taken), until such threshold value of remission of <0.01 is reached, and kept.

Your father’s case (PSA 14.5 and a Gleason score of 9, with metastasis at the bones) is consistent with advanced cases, and hormonal therapy has successfully controlled the cancer in that group of patients. The double blockade HT is probably more effective. Hormone-refractory prostate cancer (HRPC) is an event mostly regarded as a sequence of hormonal treatment during long periods (continuous as well as intermittent). That is connected to the way our cells behave (get resistant to drugs), and that is difficult to stop.

HRPC patients have a choice of treatments of the so called “second line” hormonal therapy which incorporates Ketoconazole or an estrogen (DES) with immunologic therapy drugs or with chemo drugs. There is now a very “nice” drug (I have fallen in love with) named Abiraterone acetate, which results from phase III have shown to be better than Ketoconazole, and it has less side effects.
Your father and I will have the benefits from these new drugs on the pipeline.

I wish good results in course of your father’s treatment.
Baptista

Last edited by Baptista; 02-08-2011 at 04:51 AM.

 
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