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Old 12-19-2012, 02:59 AM   #1
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Rising PSA Level - Options to Control?

Hi,

I've been following this Message Board in HealthBoards for last couple of months (including the posts by Jim) and would seek your advice on the below:

I'm taking care of my dad (aged 72) who was diagnosed with Metastatic PCa during July 2010 with a PSA of 7144 ng/ml and is on treatment since then. Biopsy revealed Gleason Rating of 7. He underwent Orchiectomy (removal of testes) immediately following diagnosis to control testostrone levels in the body (which is prime contributor for Androgen which spreads the disease). Post this his PSA level dropped down to 63.12 during Sep 2010.

In addition, he is on following medication as part of Hormone Therapy through Medication.

1. Eritel 40mg (Tablet) - (1-0-0)
2. Cobadex CZS (Tablet) - (1-0-0)
3. Folvite (Tablet) - (1-0-0)
4. Calutide 50 mg (Tablet) - (0-1-0)
5. Clopitorva 75 mg (Tablet) - (0-0-1)
6. Tamdura (Capsule) - (0-0-1)
7. Neurobion (Tablet) - (0-0-1)
8. Stamlo (Tablet) - (0-0-1)

[Note that my dad underwent CABG By-Pass Surgery during Apr 2010. Some of the above medication are relevant to that as well.]

His progress on PSA Levels are as below:

10.Jul.2010 - 7144 ng/ml
02.Sep.2010 - 63.12 ng/mL
08.Dec.2010 - 0.19 ng/mL
11.Mar.2011 - 0.10 ng/mL
27.Jun.2011 - 0.14 ng/mL
20.Oct.2011 - 0.13 ng/mL
17.Feb.2012 - 0.30 ng/mL
25.May.2012 - 0.74 ng/mL
20.Sep.2012 - 1.98 ng/mL
18.Dec.2012 - 4.91 ng/mL

We did notice that there was drastic improvement after starting with Harmonal Therapy with medication. I beleive Calutide (Bicalutamide) really helped control Androgen levels which must have helped lower the PSA levels between Dec 2010 and Oct 2011.

For some reason, the PSA level has started to increase during the last few months and is now increased beyond the normal value of 4 ng/mL which is causing me a bit of concern. We take the PSA samples and tests are performed at the same lab to ensure consistency.

While the whole body bone scan performed during Sep 2010 showed several areas of bone mets, a whole body bone scan which was done during last month i.e. Nov 2012 (after noticing increase in PSA level) revealed NO Bone Mets and the scan was completely normal and the report said there was significant response to the treatment.

He does not have any noticable side effects due to the infection (thanks to Lord Almighty) and is able to continue with his normal life.

I would really like to have your advice on the direction of further treatment based on your experience. Have you come across cases where the PCa stops responding to Hormone Therapy (Bicalutamide)? If yes, are there any suggestions on how to overcome the same?

Praying to Lord Almighty for his recovery.

Regards
Gatt.

 
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Old 12-19-2012, 10:40 AM   #2
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Re: Rising PSA Level - Options to Control?

Hi Gatt,
I'm sorry to hear your father and you have so much to contend with. I think maybe you're in Europe, because I do not recognize the names of the medications you listed. They may have different brand names in the US.

What your father is experiencing now - rising PSA in spite of castration is known as "castrate resistant prostate cancer." It means that the cancer has figured out ways to keep growing in spite of the castration. Fortunately, there are several new drugs recently approved for this purpose. I don't know if they are available where you are, but they are worth asking his oncologist about.

The bicalutamide may be hurting him rather than helping him at this point. Ask his doctor to take him off it and see if his PSA goes down.

The hormone therapy shrinks the bone mets, and as long as the PSA is low, they may be undetectable. However, they will show up again as PSA rises. For the bone mets, Zometa (zoledronic acid) and Xgeva (denosumab) may prevent bone mets and skeletal-related events. Alpharadin may be able to destroy bone mets that are already there. It is now available for expanded use through clinical trials. Cometriq (cabozantanib) has been approved for thyroid cancer, but has displayed amazing efficacy at clearing metastases in prostate cancer. Perhaps his doctor can prescribe it off label.

The best new hormone therapy is called Xtandi (enzalutamide) but Zytiga (abiraterone) is very good too. Either will keep the cancer hormone responsive even after castration has failed.

There are immunotherapies that may work along with the other therapies. Provenge (sipuleucil-T) has already been approved for prostate cancer. Yervoy (ipilimumab) was approved for melanoma but may be approved for PC soon. Both are already available.

Depending on his other health concerns, his doctor may allow him to take a chemo medication called Taxotere (docetaxel). A similar medication, Jevtana (cabazitaxel) is usually reserved for after Taxotere stops working.

I hope some or all of these are available where you are. There are many other drugs in clinical trials, but there is usually no guaranty he will get the drug rather than a placebo in a clinical trial. All of these have to be considered carefully, given his other health concerns.

Diet, exercise, and supplements may also help. I recently read that a 20% carb diet may be the best for cancer. Metformin, aspirin, statins and celecoxib may be good too, if they fit in with his other medications and health concerns.

- Allen

 
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Old 12-19-2012, 09:27 PM   #3
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Re: Rising PSA Level - Options to Control?

Hi Gatt,
Sorry to hear that your father has to face these challenges.
My husband is in a similar situation to your Dad, and his doc has put him on 2mg Diethystilbestrol , plus 2mg Warfarin, this has lowered his PSA plus his PSADT has gone from 3.7months to 2.26 years. The Diethystilbestrol thickens the blood, hence the warfarin. These might not be appropriate with your Dad's heart concerns.
Hugs,
Ann

 
Old 12-20-2012, 02:13 AM   #4
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Re: Rising PSA Level - Options to Control?

Thank you so much. It is truly heart whelming to receive your responses.

While it has been a bit of struggle, we have learnt that life indeed presents us with lots of such challenges and that's exactly when we start to truly understand the value our lives and relationships.

With the best efforts and a spirit of positive energy, I trust and strongly believe things will get better.

We have an appointment with the doctor this weekend and will find some time to post on the outcomes.

During our previous visist, the doctor was also of similar opinion that after some period, the PCa might start building resistance to Bicalutamide. How does this happen? During this situation when PCa stops responding to Bicalutamide and instead starts to use it as an catalyst to spread the disease, is there a known way to reverse this adverse reaction?

Regards,
Gatt.

 
Old 12-20-2012, 12:18 PM   #5
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Re: Rising PSA Level - Options to Control?

You asked:
Quote:
How does this happen? During this situation when PCa stops responding to Bicalutamide and instead starts to use it as an catalyst to spread the disease, is there a known way to reverse this adverse reaction?
It's an adaptation by the androgen receptor and the way the cancer cell uses it. We don't reverse it, but the new drugs Xtandi (enzalutamide) and Zytiga (abiraterone), and several more in clinical trials, get around it for a time.

- Allen

 
Old 12-22-2012, 03:28 AM   #6
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Re: Rising PSA Level - Options to Control?

Hi

Today we met the doctor and he suggested taking off Bicalutamide from the daily prescription and study the condition in next two months. He did not want to hurry up with follow-up medications as he wanted to keep the options open and give further treatment based on symptoms.

We are planning to go for another PSA test after two months.

Any recommendation on duration to consider to study the PSA effect after taking off Bicalutamide from the medication (i.e.) before performing the next PSA test?

Regards
Gatt.

 
Old 12-22-2012, 08:26 AM   #7
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Re: Rising PSA Level - Options to Control?

It's not a fixed time. As long as PSA goes down, it's OK. When it starts going up again, he'll require one of the newer medications.

They won't affect his PSA, but taking Zometa or Xgeva now may prevent further bone mets, and Alpharadin will treat existing ones. I can't see why he wouldn't take them now.

I also think that starting immunotherapy and chemotherapy sooner, while he is healthier and better able to cope with them, is better than waiting until later.

- Allen

 
Old 12-22-2012, 07:12 PM   #8
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Re: Rising PSA Level - Options to Control?

Dear Allen,

Thank you so much for your advice. I've put my response in blue.

Quote:
Originally Posted by Tall Allen View Post
It's not a fixed time. As long as PSA goes down, it's OK. When it starts going up again, he'll require one of the newer medications.

Thanks. I've seen some posts on reducing the PSADT by lifestyle and dietary modifications. I've also read about Green Tea and Pomogrenate Juice helping on the same as powerful anti-oxidants. Do anti-oxidants always work in bringing down the Cancer growth? What's considered as an effective diet for the same?

They won't affect his PSA, but taking Zometa or Xgeva now may prevent further bone mets, and Alpharadin will treat existing ones. I can't see why he wouldn't take them now.

I also think that starting immunotherapy and chemotherapy sooner, while he is healthier and better able to cope with them, is better than waiting until later.

Thank you for reminding. I forgot to mention that he is indeed taking Blaztere (Zoledronic Acid 4mg) on a regular basis (every two months). The next dose is already scheduled for 1st week of Jan 2013.

- Allen

 
Old 12-22-2012, 09:57 PM   #9
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Re: Rising PSA Level - Options to Control?

Quote:
Thanks. I've seen some posts on reducing the PSADT by lifestyle and dietary modifications. I've also read about Green Tea and Pomogrenate Juice helping on the same as powerful anti-oxidants. Do anti-oxidants always work in bringing down the Cancer growth?
Not every anti-oxidant, just some particular ones.You might want to try the more concentrated extracts. EGCG is green tea extract. Broccoli sprout extract or sulfurophane may be helpful. Also: soy isoflavones, gamma-tocotrienol (but NOT Vitamin E), apigenin, red yeast rice (or statins), milk thistle extract (silymarin). The evidence is suggestive for these.

Quote:
What's considered as an effective diet for the same?
20% carbohydrates. Also include colorful fruits and vegetables (e.g., raspberries, currants, beets). Cruciferous vegetables. Limit dairy and red meat intake.

At least 3 hours per week of vigorous cardiovascular exercise is important, under his doctor's advice. It is associated with increased survival and better quality of life among men with PC. It improves his immune defense, fights cancer-related fatigue and improves mood from hormone therapy. Weight-bearing exercise will help preserve his bones and muscle.

- Allen

 
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