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Old 02-22-2011, 05:15 PM   #1
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Unhappy Is dad out of options?? (psa back to 95 after 2 years of remission)

If anyone can provide some kind of ideas as to whether my dad (77) is out of options or not, I would be very grateful.

I live in Sydney, my father is in the UK and therefore even having direct phone/email contact with doctors is great, but it doesn't stop you worrying yourself grey!

Will keep this short:

-In late 2008 Dad diagnosed with Prostate Cancer and a PSA of 100.
-Treatment given - hormone injections/medication pills... injections every 3 months, tablets everyday.
-After a month, PSA 0. No bone scan done.
-Regular checks to July 2010 show no increase in PSA.
-July 2010 PSA showed score of 6.
-October 2010 PSA: 32.
-Medication changed to Casodex.
-January 2011 PSA: 95.
-February 2011 Specialist orders Bone Scan and talks of possible Oestrogen therapy.

What, if any treatments are there possible for a man of 77 and a reading of 95 PSA? Not sure what the bone scan will reveal... but the hormone therapy he has received to date seems to be no longer working. A common thing I'm told. I don't think a radical prostatectomy is an option due to his age.

Any advice/help is so VERY gratefully received....

Thank you.

Ric

 
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Old 02-23-2011, 11:16 AM   #2
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Ric

Your dad is NOT out of options.
I wonder if in 2008 he has had any biopsy and given a pathological report on the grade of the cancer (Gleason score). This would help in considering treatments. I do not think that surgery would be an option because of his high PSA indicating a cancer that have probably spread out of the prostate. Surgery is a treatment for localized cases when cancer is considered still contained.
Radiation treatment would be better but again this is a treatment directional to a target localized.

The bone scan will check for metastasis in bones, and that will provide information for the next treatment. Many doctors do change hormonal drugs when the ones being taken stop doing its job (this is the case for your doctor move into Casodex).
After several months, some patients become refractory to the standard hormonal treatment and have to start a “second line” treatment with other combination drugs. In this second attempt, doctors use a mixing of chemo and hormonal drugs or even immunological drugs, before moving into “heavy” chemotherapy.
There are many cases were patients do fine for many years on this second line drugs.

Wishing your dad the best.
Baptista

 
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Old 02-23-2011, 01:43 PM   #3
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Hi Ric,

Welcome to the Board! I'm returning to your original post after reading Baptista's response which I hope helped you. I can identify with your dad's case as my PSA was over 100 (actually 113.6) when I was diagnosed, and other features were also challenging. I'm doing very well now during my third vacation period from the major drugs of triple hormonal blockade therapy. Hormonal blockade is the only therapy I have had - no surgery, radiation, etc. I'm in my twelfth year as a survivor.


Quote:
Originally Posted by RICSYDNEY View Post
If anyone can provide some kind of ideas as to whether my dad (77) is out of options or not, I would be very grateful.
I'll just reinforce what Baptista said: options with a good chance of being effective do exist for your dad. However, sometimes access is a problem.

Quote:
...

-In late 2008 Dad diagnosed with Prostate Cancer and a PSA of 100.
-Treatment given - hormone injections/medication pills... injections every 3 months, tablets everyday.
-After a month, PSA 0. No bone scan done.
If the injections and pills are the ones I'm thinking of, that's a pretty good program, but, though widely accepted, would not be optimal in my view, as I'll mention below. By the way, I have become savvy about prostate cancer but have had no enrolled medical education.

That was a fast response to a PSA of 0, but many doctors use a conventional PSA test that won't measure down to <0.05, or even better, <0.01 with an ultrasensitive test. If his real PSA was something like 0.09 but did not drop lower, that indicates that more should have been done, at least according to the doctors I regard as experts.

A bone scan is so often useless, even for high risk patients, that a leading medical group in the US has recommended against its routine use in low-risk patients. However, I'm quite surprised the scan was not done with someone who presented with a PSA of over 100. To me, that indicates one of the areas of sub-optimal care. The docs I follow would have ordered a bone scan up front as well as a CT scan or an MRI.


Quote:
-Regular checks to July 2010 show no increase in PSA.
-July 2010 PSA showed score of 6.
-October 2010 PSA: 32.
-Medication changed to Casodex.
-January 2011 PSA: 95.
-February 2011 Specialist orders Bone Scan and talks of possible Oestrogen therapy.
Your dad enjoyed short term success of somewhat more than a year with two-drug blockade. To me, the critical flaw is that a "5-alpha reductase inhibitor" drug, either finasteride or Avodart, was not used. These drugs greatly reduce the conversion of any remaining testosterone into the far more potent cancer fuel known as DHT (dihydrotestosterone). However, your dad could still start taking one of those drugs - Avodart is generally preferred though many of us (me) do fine on one or two of the less expensive finasteride pills. Do you know if your dad's DHT level, and his testosterone level, were measured? They should have been, though many doctors neglect this part of managing hormonal blockade. If the testosterone is not around a level of below 20, and if the DHT is not lower than around 5, then the therapy is not being adequately implemented and changes are needed. In addition to adding the 5-ARI drug, the experts would probably want the Casodex dose to be 150 or even higher. Unfortunately, there is not much published research on this approach, and that inhibits many doctors who stick to the published standard of care. That may sound wise, but such standard care often does not include the insights from recent research, and it is often less than the best. In prostate cancer, I'm convinced it is often far less than the best. The three books that do a good job explaining superior approaches are:

"A Primer on Prostate Cancer -- The Empowered Patient's Guide," Strum and Pogliano, 2005 rev. ed.

"Beating Prostate Cancer: Hormonal Therapy & Diet," Myers, 2006.

"Invasion of the Prostate Snatchers," Blum and Scholz, 2010.

The non-profit group known as The Prostate Cancer Research Institute (PCRI) has a number of publications available that make some of the same points as are found in the books. All three of the medical authors of the above books have been associated with PCRI.


Quote:
What, if any treatments are there possible for a man of 77 and a reading of 95 PSA? Not sure what the bone scan will reveal... but the hormone therapy he has received to date seems to be no longer working. A common thing I'm told.
So many doctors tell their patients that who have challenging cases, and, unfortunately, it indicates the doctors do not realize what is possible. I was basically told that too; fortunately, I realized within months that it probably was not true. Well done hormonal blockade, with the support of drugs like Zometa to preserve bone density while on hormonal blockade while also helping to counter bone mets, often has a considerably better outcome. There are also a number of drugs that often help, such as Leukine. The very expensive drug Provenge (a vaccine) for the immune system is also a possibility, but it won't be covered by insurance in the US unless the patient already has mild bone metastasis and is no longer responding to hormonal therapy.

Estrogen therapy is reported to be highly effective for some patients. In the US, the oral form of estrogen, known as DES, is cheap, but it comes with an undesirable package of potential cardiovascular side effects. On the other hand, transdermal estrogen, delivered through the skin via patches, is reported to be effective and without the cardiovascular risk. While Casodex, now available as much less expensive generic bicalutamide, may still play an important role in conjunction with a 5-ARI drug or at a higher dose, another option is to substitute ketoconazole plus high-dose hydrocortisone to counter a side effect. However, ketoconazole is not used up front because it is a fairly tricky drug to manage - substantial interactions known with certain other common drugs, attention needed in timely administration throughout the day, and a likely serious problem if tylenol (or its key ingredient) are used. (All this is what I've heard and read; I lack any authoritative medical knowledge.)


Quote:
I don't think a radical prostatectomy is an option due to his age.
No, as Baptista said, I'll join his choir here, but yes to possible radiation, as Baptista also indicated.

Quote:
Any advice/help is so VERY gratefully received....

Thank you.

Ric


Nutrition, diet, supplements, exercise and stress reduction also appear to be quite helpful. They do not appear to have heavy-duty impact on the disease, but it looks like they provide valuable support if employed, and the lack of employment may lead to problems. I had a friend who got on hormonal therapy for a recurrence after more than a decade of no problems since his initial treatment. However, unlike the rest of us, he paid little or no attention to diet and continued to enjoy big portions of red meat, as just one instance of risky nutrition. Two years ago he suddenly and surprisingly stopped responding to hormonal therapy and went down hill fast to his death. I would bet that his poor diet undermined his chances. If your dad is not following wise lifestyle tactics, now it the time for him to change his ways. I've come to like my healthy diet very much. (Among other treats, most fish, almonds, red wine, and high-cocoa content dark chocolate (in moderation) are all recommended! Basically the diet I follow is a Meditteranean diet.)

In the US, 95% of even high-risk patients are alive at the ten year mark. My impression is that prostate cancer patients in the US are doing better than their counterparts in most other countries, but that is probably more due to medical practice and the standard of care than to the lack of existence of effective treatments. Even in the US it is not that easy to get the triple therapy I've been describing. That said, I did it and so have numerous others. It is possible for your dad too, I think.

Good luck, and I hope the Board can continue to help. Please let us know how the tests turn out.

Take care,

Jim

 
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Old 02-25-2011, 05:08 PM   #4
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Only just logged back (sat) as I couldn't find my p/w.. but I am reading through both posts now... thank you both in advance, a lot to take it here. I am grateful for your knowledge. I have little confidence in the doctors where my dad lives as they missed spotting mum's cancer in time and she passed away last year from bowel cancer. A lot in my family - my own diet needs attention methinks. Anyway - I must get on and read through all of your advice here guys, THANK YOU. Will keep you updated - so far been a week since the bone scan - not sure if the 'no news is good news' thing applies with bone scans though. . . RIC

 
Old 03-04-2011, 04:03 PM   #5
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Ric,

I met several Australians and a couple of Brits receiving treatment at Loma Linda during my treatment at Loma Linda Dec 2009 and Jan 2010. I would say that from my point of view that Proton is your Dad's best hope. A Proton clinic began operation treating prostate cancer in Munich in July 2010.

Best of luck, Bob

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Old 03-04-2011, 08:28 PM   #6
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Hi RIC and Bob,

Bob, you wrote in the previous post:

Quote:
Originally Posted by harpman View Post
...I would say that from my point of view that Proton is your Dad's best hope....
One key point in RIC's dad's case is that there's a good chance the cancer is spread around the body. It may still be generally in the pelvic area, but not tightly packed. I'm wondering if proton therapy would be well suited to such a case. Proton therapy seems sort of like a very precise rifle, where other kinds of radiation would be more capable of a shotgun like impact that would cope with a spread out cancer. Are some doctors using proton beam for spread out prostate cancer?

The Prostate Cancer Results Study Group has compared quality research studies of various therapies. Proton beam is arguably respectable for low risk and intermediate risk cases, with results around the 80% success for no recurrence around the four to five year point for both risk levels, but their study had no proton results for high risk cases.

How did you do with the proton beam therapy for your own case, and was your case classed as "low risk"?

Take care,

Jim

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Old 03-04-2011, 09:53 PM   #7
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Re: Is dad out of options?? (psa back to 95 after 2 years of remission)

Jim,
Any possible cure is predicated on the cancer being localized and not metastasized to the bone or elsewhere in the body. I know in some cases they use half proton and half photon if the cancer has invaded the lymph nodes. As for proton it is a rifle shot as you say but it has the ability to be focused in a 3-D zone which is layered with beams covering the treatment area. The protons enter the body at lower energy than photons causing less damage and stop at the treatment site instead of continuing past the treatment site and causing more damage as they exit the body. Protons can be programmed to stop in living tissue at a precise spot where they give off an energy burst. This is called the Bragg Peak Effect and is used to deliver the radiation dose to within one millimeter. At the present time proton is able to treat one area but they told me that they will be able to treat several areas at the same time in the near future.

Loma Linda claimed a 95% "control rate" after ten years for prostate cancer. As you know all studies claim five year, ten year survival rates, and none guarantee a certain cure.

In my case I had a radical prostatectomy in Sept 2001 and cancer recurrence in April 2003. I read a study that found for patients with positive margins after surgery the rate of metastasis was 50% after 8 years and 67% after 10 years. My PSA had risen to the 0.5 range in 2009 and I was getting nervous. My doctor advised me not to seek more treatment but to concentrate on quality of life and offered me a hormone shot. I immediately phoned a proton center and arranged to travel to the USA to have tests and treatment. It turned out that I had incomplete surgery in 2001. Jan 31/11 was the one year anniversary of my last treatment and my PSA was 0.03. I am very lucky in that I have gone through two different prostate cancer treatments without side effects such as impotence and incontinence. As for low risk or high risk I would say that Proton Treatment is the 21st Century Gold Standard for Prostate Cancer.

The body can tolerate a higher dose of proton radiation.
The radical prostatectomy was a major surgery and success is so dependent on the skill of your surgeon.
I met several DaVinci patients during treatment who were to a man impotent, incontinent, unhappy, and were in a Proton Center for salvage a few months after surgery.
I didn't want the side effects of photon radiation and my doctor gave me 5 - 13 years in 2001 if I chose the radiation route.
I didn't trust the Canadian medical system and especially my local hospital.

Hope some of this helps, Bob

 
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