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Old 12-27-2011, 10:15 AM   #1
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Triple Androgen Therapy

After failed RRP in 2007 subsequent failed SRT in 2009. I started with Casodex 150mg monotherapy in April this year, which initially brought my psa down to 0.1. By October my psa had risen to 0.6.
I have now completed my first month of Lupron.
After reading these boards I have come to the conclusion that the path for me is triple androgen blockade (Lupron, Casodex Avodart). However I have a question can I now use Casodex as part of the triple blockade as it appears I failed on Casodex.
If Casodex cannot be used what could be used in it's place.
I'm not sure if my doctor would support triple androgen therapy, I live in Norway and the doctors here are very conservative and not open to any deviation from the standard protocol.
If I decide to go ahead with triple blockade I will be self medicating without the approval of my doctor.

 
Old 12-27-2011, 12:32 PM   #2
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Re: Triple Androgen Therapy

Quote:
Originally Posted by landcrab47 View Post
After failed RRP in 2007 subsequent failed SRT in 2009. I started with Casodex 150mg monotherapy in April this year, which initially brought my psa down to 0.1. By October my psa had risen to 0.6.
I have now completed my first month of Lupron.
After reading these boards I have come to the conclusion that the path for me is triple androgen blockade (Lupron, Casodex Avodart). However I have a question can I now use Casodex as part of the triple blockade as it appears I failed on Casodex.
If Casodex cannot be used what could be used in it's place.
I'm not sure if my doctor would support triple androgen therapy, I live in Norway and the doctors here are very conservative and not open to any deviation from the standard protocol.
If I decide to go ahead with triple blockade I will be self medicating without the approval of my doctor.
Landcrab

Welcome to the board.
Being from Norway you can consult oncologists residents in other European countries, using your health social security card. Germany and Sweden may be not so “conservative” in treatments of ADT3 protocols. Hormonal treatments in fact can be followed by a distant doctor with periodical visits (every 6-month).

You have not shared details on you and your present diagnosis which may influence the opinions from the survivors in this forum.

What are your age and other health status?
What was your PSA level before starting Casodex?
Have you done any image studies after SRT?
Is your doctor an oncologist? Who did recommend you Casodex and the Lupron?

In your previous single blockade protocol with casodex, the increase in PSA from 0.1 to 0.6 may not represent that the drug has failed yet. Casodex is an antiandrogen which effects are greater on the cancerous cells androgen receptors. Lupron is the “heavy-duty” drug that will surely knock down the cancer, depriving it from high levels of testosterone. The combination of the two drugs complements each other and may show better benefits when taken together. You should try that before given up with Casodex. Avodart (5-ARI) will still reinforce the blockade (ADT3) by lowering the levels of dihydrotestosterone.

The first thing I recommend you is to find an oncologist that you can trust and that is knowledgeable with the advances in prostate cancer care and newer drugs. You may then discuss with him about the several protocols including the one you believe in. You should also consider that some drugs may interact with other medications for separate illness which may prohibit some protocols.

It is typical practice from oncologists, when antiandrogens (hormonal) drugs stop being effective, to change first the drugs’ dosage (ex; 150mg to 200mg) and check for results. If negative, then they usually substitute the drug with another of the same category (ex; Casodex to Cyproterone).
If the change is still not effective, then oncologists move to different protocols with what it is called as second-line hormonal drugs (ex; ketoconazole, abiraterone, etc.).
In any event you will always need some doctor to follow your treatment progress.

Before starting ADT, during and after, you should consider a series of tests important in the follow up. Such as:
Testosterone and DHT tests; to check for drugs effectiveness.
Bone densitometry test (DEXA); to check for any bone loss (osteoporosis). Hormonal drugs affect the bone and you may need to add a bisphosphonate drug.
Lipids tests; to check for any increase in liver and kidney function, and heart health, etc, etc.

You should also get started with a diet program and physical fitness which will help in counter the side effects from the treatment.

I hope you find that doctor and peace of mind.

Baptista

 
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Old 12-27-2011, 08:03 PM   #3
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Re: Triple Androgen Therapy

Hi landcrab47,

I'll add my welcome to the Board!

Baptista has already provided important information about treatment and triple blockade in particular. I'll just add a short note at this time. Androgen deprivation therapy, which soon became triple androgen deprivation for me, has been my only therapy, on an intermittent basis, since late 1999 for a challenging case. I'm now in my third vacation period off the heavy duty drugs (Lupron and bicalutamide (Casodex's generic version) for me).

That initial decline in PSA after Casodex as a single drug and subsequent rise to 0.6 suggests that Casodex "monotherapy" failed you. I suspect your body sensed shortages caused by Casodex and responded in ways that caused the single drug approach to fail. Among other things, DHT (dihydrotestosterone) is more effective at binding to the cancer cell fuel docking sites than is Casodex, so often Casodex is not able to block it sufficiently, even at 150 mg daily, as I understand it. However, adding Avodart will greatly reduce DHT for most men, thereby enabling Casodex to do its work of blocking the fuel ports. Casodex is better than testosterone at binding to those ports (technically called "androgen receptors"). Also taking Lupron will of course stop testosterone production from the testes, leaving just a small amount of testosterone from other sources. This is a long way of saying that I see this as Baptista does: Casodex will likely still work for you in a triple blockade combination.

There are alternatives to Casodex, but my now somewhat savvy layman's impression is that it would be premature for you to use them. One is an earlier antiandrogen drug than Casodex, known generically as flutamide. It is much less convenient - needing consumption every eight hours around the clock - and has somewhat greater risk of side effects than Casodex, but it does work. A much more effective drug than either is ketoconazole (taken with hydrocortisone), but that drug interacts with many others, requiring careful administration (acid stomach, careful timing, etc.) and management for many of us, and is often reserved for second line work after the first line antiandrogens no longer are effective.

Finding an oncologist to work with you could be difficult in Norway. You might want to check www.pubmed.gov, a site we can use on this board because it is Government sponsored, and search for Norwegian institutions or researchers who are doing work with androgen deprivation for prostate cancer. I can help with search ideas if you wish, but you may want to see what you can do on your own with the help PubMed provides, such as its "Limits" feature to filter your search results. Based on the high incidence of cancer in northern lattitudes, it's quite possible Norway has research activity in that area. While such researcher/physicians might not practice triple androgen deprivation therapy, it might be more credible to them.

Take care,

Jim

 
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Old 12-28-2011, 02:33 AM   #4
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Re: Triple Androgen Therapy

Baptisa and Jim thank you very much for your time to answer and your detailed and comprehensive replies, I appreciate them very much. I do envy you guys in the US who seem to have so many good prostate cancer onco's.
I have updated my profile and added some more information.
I'm 67 years old semi retired and I spend six months of the year in Spain (May - Nov) where I have a house. I believe my health is very good I run three times a week, swim every day when I'm in Spain and train on a multi gym twice a week. Diet wise I have cut out as much red meat as possible along with diary produce. I take pomegranate extract tablets daily and eat fresh pomegranates when they are in season. Additional vitamins D3, selenium, calcium and fish oil capsules
The doctor I deal with is an urologist it was he who put me on Casodex when my psa reached 1.3 in April this year. Unfortunately he forgot to send me for radiation of my breast tissue and I have now developed quite significant enlargement of the breasts. I'm due to have an operation some time in February to remove the mammary tissue.
It was the same doctor who prescribed Procren (which is the same as Lupron) with a three monthly injection in November, when I asked about possible side effects he said about the same as Casodex which I knew at the time was incorrect.
To say I have no trust in the doctor is putting it mildly, he does not inspire confidence does not impart any information even when asked. For example when he prescribed Procren I asked if that was the same as Lupron and he said he didn't know.
Whilst I was on Casodex (which I know raises the testosterone levels) I monitored my own psa and testosterone levels at my GP's at one stage my testosterone reached 35, which I believe to be quite high for someone of my age. When I pointed this out to my urologist he didn't seem interested.
I'm reaching the conclusion that to be a long time survivor of pca my treatment will possibly have to be outside Norway. As I spend six months of the year in Spain I have contacted an onco there and have an appointment with him in March to discuss treatment options.

Thanks again and good health for 2012.

 
Old 12-28-2011, 01:42 PM   #5
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Re: Triple Androgen Therapy

Landcrab

I am sorry for your disappointment with the urologist. You are not alone. Many guys report on similar “encounters” with unpleasant doctors that do not speak nor listen to their patients’ inquires.
You should try to find someone that satisfies you and that can follow your case during a long period of time (many years).

Spain has the European oldest oncology society. SEOM (Sociedad Espanola de Oncologia Medica, aka Spanish Society of Medical Oncology), is very up-to-date in oncologic practice and deliver Guidelines with similar standards of ASCO. They are in pair with American standards in terms of FDA approvals, etc. Their recommendations on hormonal treatment include total blockade and the intermittent modality which is not so accepted by the European Association of Urology (EAU).
You could contact them and request for a referral to a doctor (medical oncologist) in Malaga.

There is also the Hospital Quirón Málaga, with an oncologist department treating prostate cancer.
Try finding their contacts using a net search engine.

While waiting for your next meeting with the doctor (in Spain or Norway), you could continue the treatment with Lupron plus Casodex and Avodart. I recommend you to get the tests indicated in my above post now so that you have basic data for comparison and for discussion with your future doctor.
The typical range of normal testosterone levels fall between 250 to 800 ng/dl (2.5 to 8.0 ng/ml). In your age (67) a level of 3.5 ng/ml, is not high, it is just at the normal range. You should check for any decimal place in the results or for the units used at your laboratory, to ascertain for errors.

I wonder if you have any image study done already (CT, MRI, Bone scan, etc.).

Good luck in your journey.

Baptista

 
Old 12-28-2011, 01:44 PM   #6
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Re: Triple Androgen Therapy

Hi landcrab47,

Here are a few more comments. It looks to me like you have a good lifestyle program, though you might want to make some adjustments after reading the books. Selenium is in a gray area these days; some forms do no good at all, but early research is suggesting that some of us will get substantial benefit provided we have a certain gene set up. (This is the research being done by the Kantoff team in the Boston area, US.) I'm envious of your Malaga address! You wrote:


Quote:
Originally Posted by landcrab47 View Post
...
Whilst I was on Casodex (which I know raises the testosterone levels)
I have never heard that Casodex raises testosterone; and I don't understand how that would work. Would you mind double checking your information? If it is so, it will be news to me. Both finasteride and Avodart, the two drugs in the 5-alpha reductase inhibitor class, are known to increase testosterone because they act in large part by preventing the conversion of testosterone to the much more potent and dangerous DHT, prevention which results in more testosterone than if some were converted.

Quote:
I monitored my own psa and testosterone levels at my GP's at one stage my testosterone reached 35, which I believe to be quite high for someone of my age. When I pointed this out to my urologist he didn't seem interested.
Actually, in the units used in the US, a level of 35 is quite low, considered by many doctors in the recent past to be in the castrate range, though the doctors who seem to know the most insist that the T level be around 20, preferably below 20. The US uses ng/dl as the unit for testosterone. I've seen the normal range indicated as 400 ng/dl - 700 ng/dl, with some variation around those numbers depending on the source.

The level could be important. If those are the same units for your score of 35 as in the US, and if you had such a low level before being diagnosed, then the prostate cancer is growing without the need for a lot of testosterone, and androgen deprivation sometimes does not work as well in such circumstances. However, based on your impression that 35 is a high level, and based on your impressive level of physical activity, it seems likely that different units are used in your scale. Just shifting the ng to the next larger unit or shifting the dl down to cl would, if I've got it right, boost that 35 to 350, about in the normal range.


Quote:
I'm reaching the conclusion that to be a long time survivor of pca my treatment will possibly have to be outside Norway. As I spend six months of the year in Spain I have contacted an onco there and have an appointment with him in March to discuss treatment options.

Thanks again and good health for 2012.
I did this search in PubMed to pick up researchers in Norway who were publishing in medical research journals on prostate cancer and androgen deprivation therapy (quotes just to set off the search string here):
" prostate cancer AND androgen deprivation therapy AND (Norway OR Norwegian) "

That yielded 20 hits. By clicking on the blue hypertext you can read the short description ("abstract") of the study if there is one. A quick look suggested most of the activity was around Oslo. Dr. Fossa (with a small circle over the a) was involved in ten of the hits, more than any other researcher, and for five he was the first or last author, the two key positions in medical research author listings. Drs. Lilleby and Dahl also appeared a number of times, but not nearly so often. You might want to broach triple blockade to these doctors or their staffs. It's possible you will find them open minded and willing to try something that is not familiar. On the other hand, judging from my experience in the US, many doctors will reject what they do not know already from their own experience, and researchers at universities are often hungry for fresh patients for their own studies.

I did a similar search in PubMed for Spanish activity:
" prostate cancer AND androgen deprivation therapy AND Spain ". The result was 31 hits.

I'm curious why you spend the coldest months in Norway rather than the other way around. I'm guessing you like the winter sports.

Good luck with your quest.

Take care,

Jim

 
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