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Old 04-07-2013, 02:12 PM   #1
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IADT, 8 months on vacations

Eight months ago I posted in this forum, details of my recovery from the hormonal treatment, while stopping the mono-blockade of LHRH agonist Eligard. The HT treatment started in November 2010 and it was stopped after completing one year on PSA remission levels lower than 0.05 ng/ml.
You can read about my previous thread in this link;
http://www.healthboards.com/boards/cancer-prostate/916538-recovery-hormonal-therapy-my-latest-results.html

So far I managed to be on drugs vacation (off medication) for a period of 11 months. The last 6-month shot was administered in November 2011. The progress of the intermittent treatment has been followed with periodical PSA and Testosterone tests.

Particulars of this free from symptoms period have been great, specifically in respect to the nostalgic erections, which become constant and very effective. Other good feelings are described in my previous thread above.

I had a follow-up consultation with my uro-oncologist this month but I am not satisfied with his comments in regards to the progress of this Off-drugs and to the next phase of On-Drugs periods.
I expected to get maintenance drugs for extending the vacations before reaching the threshold of 2.5 ng/ml (defined previously by him) but instead he commented to “…let it increase without manipulations and start the next phase protocol when the PSA reaches the 10 point mark (about September)”. That will complete 22 months since the last Eligard shot and 16 since the end of the effectiveness of the drug.

In any case I was looking for a much longer period of vacations but he pointed out that I am a systemic patient. I will need “constant” control to pin down the bandit. His words; “Try learning to enjoy the moments without medication to the fullest. Think of it as a gift.”
Well ! I did not like that comment.

Regarding the protocol, he recommends to continue with Eligard 6-month shot preceded by two weeks on Bicalutamide, and continue with the antiandrogen daily (50 mg). This is the typical IADT2. I question about adding Avodart but he said that the biggest volume of DHT (dihydrotestosterone) is synsitized at the prostate gland, which is none existent in my case (RP in 2000 and SRT in 2006). A small portion is converted in the adrenal gland and testes; however, he wants to see if I manage to get “control” with lesser drugs. He also commented about the usefulness in future of alpha blockers. The periodical PSA and T tests, as well as the Dexa, ECG and lipids are to be continued. He does not see it necessary to have additional Bone scans or MRI for the moment. (I am not so sure about that.)

In conclusion; I am sceptical that this doctor is proper to continue assisting my progressive case. I know he is giving preferences to quality of life more than being more aggressive, but he seems to be much conservative and not in touch with the newer ways of seeing hormonal treatments.
I am not aware of any beneficial principle of using a PSA=10 as a threshold in IADT for guys with no prostate, particularly if the protocol is just double blockade. No comments about supplements or other means of added control, such as bisphosphonates.
I am not satisfied. It may be time to sail to other waters and look for a better oncologist.

Along this vacation period the PSA accompany the increase of the testosterone. I hope it does so again when castration is reached at the next phase.

Here is the chronology of the tests since the last Eligard shot;
Nov 2011: PSA=0.02, T=0.32 (last Eligard 6-month shot)
May 2012: PSA=0.02, T=<0.01 (End of Eligard’s effectiveness; Starting Off-Drug period
Aug 2012: PSA=0.02, T=0.11
Nov 2012: PSA=0.03, T=0.56
Jan 2013: PSA=0.13, T=2.52
Mar 2013: PSA=0.37, T=3.19 (319 ng/dl)

Regards to all.

Baptista

Last edited by Baptista; 04-15-2013 at 02:51 AM. Reason: add date of RP

 
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Old 04-08-2013, 11:59 AM   #2
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Re: IADT, 8 months on vacations

Congratulations on the vacation. From everything I've read, the kind of complete PSA response you are getting is the best indicator of continued response. In the US, Zytiga (abiraterone) is only approved for mCRPC, and Xtandi (enzalutamide) is only approved so far for mCRPC after docetaxel. Most clinical trials for the newer hormonal drugs require evidence of metastases, of castrate-resistance, or both.

My friend got Zometa based on his diminished bone density from ADT, even though his bone scan was clear.

As far as immunotherapy, there are clinical trials of Provenge for its use earlier in disease progression.

Stopping the "off" period at PSA=10 is arbitrary. On the one hand, you want as long a vacation as possible. But, on the other hand, you don't want the cancer to grow substantially. What level would you like to see as the target?

I think the vacation period might be a good opportunity for you to explore some of the advanced imaging options. They seem to be more available in Europe than the US. Dr. Fortuin at Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands has published comparative studies of C11 Choline PET and ferumoxtran-10 MRI, so he seems to be proficient in both. (Now is tulip season in Holland and may be a great time to visit.) They also have such capability at Inselspital University Hospital Bern, Switzerland. Many places in Europe offer C11 Choline PET scans: Milan, Bologna, Ulm, Munich, etc. The USPIO MRI is better for identifying lymph node mets, and can detect smaller mets.

My friend had a C11 Acetate PET scan that detected a suspicious node. He pre-treated with ADT and Leukine, to enhance the abscopal effect, and then received SBRT in an area around that node. We have to wait until he comes off his ADT cycle in September to see if it worked.

- Allen

 
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Old 04-13-2013, 04:20 AM   #3
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Re: IADT, 8 months on vacations

Allen

Thanks for the comments. Have been away and busy with other matters but the disappointment with the last consultation is persistent in my mind.
You have given me good insights and I appreciate it very much. I am trying to get details about the image studies done at Radboud University Nijmegen Medical Centre, in The Netherlands. I agree that it could at least provide me with a different way of analysing my status.
I cannot find any reference about Dr. Fortuin. Is the name correct?

I wonder how choline works to identify PCa. I think that PET alone is a 2-dimension image test which may make it difficult to pinpoint the location of small metastases. I thought it useful if used in cross-reference with a CT or MRI.

I recall discussions between us and Jim in regards to the meaning and benefits of the period free from hormonal medication. Jim believes in “vacations” done with maintenance drugs, like Dutasteride or Finasteride, and he even suggest to add supplements (vitamin B) and Thalidomide. But by doing so one cannot verify for how far a “natural” vacation can last.

I agree and believe that a longer period free from hypogonadism is better to everything particularly in terms of response of the cancer to medication administered later, but I am clueless on the minimal length a vacation period should be to still consider IADT as a good treatment.
What minimum length should be considered still ideal?

Surely shorter periods closer to this minimum could be extended with maintenance drugs and, therefore, justifying the use (or usefulness) of the maintenance drugs.

In my lay opinion the arbitrary threshold to trigger the RE-START of the hormonal therapy depends much on the histology of past events (& treatments). Cases with a history of failure therapies and shorter PSADT before HT should be regarded as aggressive, independently of the Gleason type/pattern diagnosed initially. Those could restart IADT immediately if the increase is speedy. For the ones with longer PSADT, maintenance should be avoided and the PSA tests should be unmasked.

All prognoses should be judged in accordance with the levels of T (hypogonadism status). Like in my case, if the drugs’ effectiveness is confirmed with T values and the PSA increases in parallel to the increases of T, then one may try to extend the period with maintenance drugs so that it manages to achieve the longest vacation.

What worries me is the meaning of the “speedy” increases (vPSA) of my case. I came from an initial low Gleason score of 5 and a not so bad PSADT (9.5 months)at SRT failure, with negative image studies (traditional MRI and bone scan). I would think of my cancer to be sort of slow growing but the fast pace is telling me otherwise. My case might be due to a cancer colony resting in a lymph node(s) with free access to the circulatory system. It may be at a location feasible for spread to distant places.
If the colony is set at bone I would think it lesser active so that a longer period of PSADT (now at 1.9 month).

Accordingly, I think that the threshold PSA=2.5 initially defined by my doctor is reasonable in my IADT. I am naïve of any androgen like bio structures “glued” to cancer cells’ ARs. That may also justify the shorter period on remission once the testes started to function.

Can you opinion on my thoughts?

Another question, are you aware of the malaria pill named Artemisinin used in Chinese herbs medication for the past 2000 years?

Pubmed writes about the drug indicating its benefit to control angiogenesis and its ability against cancer. In the article they say that Artemisinin and its derivatives have shown to induce growth arrest and apoptosis, as well as inhibit angiogenesis by down-regulation of the vascular endothelial growth factor vascular epidermal growth factor and its cellular receptor KDR/flk-1.

I am not sure what this is about, but they also found that
the highly stable artemisinin has shown to inhibit the growth of and selectively kill several human cancer cell lines without inducing cytotoxic effects on normal neighboring cells. This is just fantastic.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629082/


Best regards.

Baptista

Last edited by Baptista; 04-14-2013 at 03:29 AM. Reason: Error in drug; edited Bicalutamide with Dutasteride

 
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Old 04-13-2013, 12:01 PM   #4
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Re: IADT, 8 months on vacations

Hi Baptista,

Quote:
I am trying to get details about the image studies done at Radboud University Nijmegen Medical Centre, in The Netherlands. I agree that it could at least provide me with a different way of analysing my status.mI cannot find any reference about Dr. Fortuin. Is the name correct?
Here's a reference about a study he authored that shows his name and email on the second line:
http://www.ncbi.nlm.nih.gov/pubmed/22417806

Quote:
I wonder how choline works to identify PCa.
It's preferentially uptaken by the the cancer.

Quote:
I think that PET alone is a 2-dimension image test which may make it difficult to pinpoint the location of small metastases. I thought it useful if used in cross-reference with a CT or MRI.
The "T" in PET stands for tomography, which means it takes pictures in 2D slices as the person moves through the positron detector. The slices are then merged into a 3D picture in the same way that CT scans or MRIs are. But you are quite right that the resolution is not all that good, and the PET image is almost always fused with a CT image taken at the same time.

Quote:
Jim believes in “vacations” done with maintenance drugs, like Bicalutamide or Finasteride
Finasteride is very mild, bicalutamide is a powerful anti-androgen. A vacation on bicalutamide isn't much of a vacation.

Quote:
...but I am clueless on the minimal length a vacation period should be to still consider IADT as a good treatment. What minimum length should be considered still ideal?...Accordingly, I think that the threshold PSA=2.5 initially defined by my doctor is reasonable in my IADT. I am naïve of any androgen like bio structures “glued” to cancer cells’ ARs. That may also justify the shorter period on remission once the testes started to function. Can you opinion on my thoughts?
Every doctor seems to have his own protocol, and maybe it has to be approached on a case by case basis. Clearly, you want full recovery of testosterone baseline levels during the vacation period -- otherwise, what would be the point of having a vacation? So that would seem to set the minimum duration of the vacation period. Then, how long after testosterone recovery is achieved should the vacation be allowed to proceed? I don't know that anyone has found the optimal triggers to end the vacation. I think that you are quite right that it must take into account the PSADT as well as the absolute PSA level, and how quickly testosterone and PSA responded to ADT on the previous "on" cycle.

My friend, who is treated by Dr. Scholz and Lam, takes Avodart during the "off" cycle. He continues to take metformin, tocotrienols, statins, aspirin, soy isoflavones, pomegranate extract, celecoxib, aspirin, apigenin. He also takes Prolia and Vitamin D with extended-release calcium for his bones. He also follows the usual dietary and exercise programs. With that, and a PSADT of two months, his last vacation lasted for about 6 months.

Quote:
Another question, are you aware of the malaria pill named Artemisinin used in Chinese herbs medication for the past 2000 years?
Based on that lab and animal model study, it certainly looks promising. I hope this one fulfills its promise. Are you taking it as a supplement? Now that absinthe is coming back in vogue, what can an occasional glass hurt? Interestingly, another anti-malarial, chloroquine, may work synergistically with ADT. However, it may cause psychosis in some people, so I would wait for the results of controlled clinical trials before rushing out to try it.
http://www.ncbi.nlm.nih.gov/pubmed/22819840

- Allen

 
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Old 04-14-2013, 11:34 AM   #5
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Re: IADT, 8 months on vacations

Allen

Thanks again for the comments and correcting my mistake. I meant to write dutasteride (5-ARI) instead of Bicalutamide (antiandrogen).

In regards to the thresholds, I still do not understand your point about the timing in the control for the intermittent modality. I wonder if Dr. Scholz and Lam uses the T marker as a threshold minimum to consider “vacations”. Do they take T level as a goal in the intermittent modality? Are there any principle(s) to suggest IADT with intent to recover fully the testosterone?

In the Primer they write about the return to the “Libido world” more than any reference to a benefit of having T for other body functions.
There may be a certain ambiguity if T is used as a "marker" because of those that take longer (or never) to get to normal levels of Testosterone (typically above 250 ng/dl), or it would cause confusion when diagnosing refractory PCa.

My view on the matter leads me to think or to take in account the “good feeling” one starts to experience once the drugs lose its effect. In my case the T level tested low at 11 ng/dl when I started to experience erections again. I was still in castration, far from what could be considered a “good amount” of T for other body functions. One should also expect to get low PSAs in such circumstances of castration.

You have written about your friend progress in my other threads, and I appreciated that very much. His case has a different start from mine but I like to know about his experiences. It helps me to understand my case and my experiences. Thanks for doing that.
I image his treatment as part of the “brew” cocktail you written before. Can you say what have been is T levels (chronology) in regards to the PSA and the reason for the threshold attributed to him while in the control of treatment?

Regarding Artemisinin, I am not taking it or any other supplement. However, I am considering this drug for its capability as an inhibitor of angiogenesis.

I come across its name from a reply in another forum. I have been reading everything about its effects but do not know much about its “biochemical works” within cells. The only reference I got is that it works by selectively attacking cells with huge amounts of ferrous (cancer) and subsequently super oxidizing the so-called "active" iron (ferrous form) inside these cells. In other words it poisons the cells promoting apoptosis. Cells with normal amounts of ferrous are not affected.

In my lay anecdote opinion, this behaviour regarding the accumulation of iron in cancerous cells, contrast with what is known about Feraheme (iron) used as contrast agent in MRI studies, to locate prostate cancer (cells infested with iron). In fact, if PCa got the “ability” of absorbing abnormaly amounts of iron then it may suggest that Artemisinin can be highly toxic to prostate cancer.

Allen, You are an expert in cellular studies. Can you give any explanation about the above? Can you enlighten the facts?

Another point is related to Artemisinin side effects. They seem to be minimum in healthy man resuming to nausea, some fatigue, dizziness and few cases of cognitive fogging. The drug does not interact for the worse with medicines used to treat PCa, if the dose is “correct” (approximately 3 x 100mg per day for short periods up to three months, and 2 x 100mg per day for continuous use, as a common supplement).
By the contrary, hormonal drugs seem to affect the metabolism of Artemisinin. At high doses the drug may cause psychosis.

Dieticians recommend to use common sense and avoid any supplemental antioxidant within 12 hours of taking Artemisinin, including vitamins C, D, E, A, etc., and any food-based antioxidant like blueberries. They also recommend on the importance of taking the Artemisinin with fat-containing food (eg; a glass of whole milk) because it helps in the drugs metabolism but they recommend caution when eating foods with high ferrous/based contents, such as cereals or pastries or bread or processed foods, etc.

The half-life is 2 to 4 hours so that one may expect to returns to normalcy very quick, once the drug is stopped. The control on the effects can be done through regular blood tests such as the usual tests on liver enzymes, iron levels, renal function, anemia, etc.

Accordingly, I do not know if by taking Artemisinin as a supplement, I would lose the opportunity of getting a C11 choline PET/CT image study to locate cancer. I also do not think that Dr. Fortuin would give me an answer to such a question.
Still another “pitfall” to consider is where to get “real” Artemisinin. Several products on sale in the net are known to be modified substances.

I have been giving much thought to your super suggestion regarding the Advanced Image Options I may try.
The systemic diagnosis comes from the numerous negative image studies done along my 12 years as a PCa survivor, which have "confirmed" the initial diagnoses of micrometastases. This was sentenced to me by three PCa specialists at three different institutions; MSKCC, JH and TH (Japan) after my failed prostatectomy in 2000 and after the failed RT in 2006. I never thought that choline could reverse my status.

So far I am excited about the possibility but do not see a breakthrough to cure.
How does it work? Do we first locate the cancer and then apply focal radiation?
What about if the cancer is detected in several distant places, is there still hope for a treatment?

Nevertheless I should firstly find out about the limitations of choline to “work” properly. I read studies on choline applied in prostate cancer research in three forms; C11, Acetate and F18, in two areas; bone images and at lymph nodes staging. It seems that choline in all forms do better in PSAs above 4 and tumour sizes/lesions above 5mm. Is this correct?

I found a place in Germany doing C11-Choline in a sophisticated Siemens PET/DW-MRI machine. This uses the latest technology in scanning with 3 Tesla capabilities; however, I do not know if the equipment and C11 contrast can detect cancer “producing” low PSA levels.
Again may I ask you if you have any suggestion on how far low can the PSA be so that it will assure proper results? Could I try to get tested before reaching the 2.5 ng/ml?
This is the threshold I believe to be proper in my case to restart the hormonal therapy.


I am looking forward to your reply.

Sincerely
Baptista

 
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Old 04-17-2013, 12:34 AM   #6
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Re: IADT, 8 months on vacations

Hi Baptista,

I'll try to address your questions as far as I know.

Quote:
Can you say what have been is T levels (chronology) in regards to the PSA and the reason for the threshold attributed to him while in the control of treatment?
He is now on his second "on" cycle, not counting the adjuvant ADT he had with his salvage radiation. He expects to be on ADT for 9 months (his PSADT is 2 months). I don't know his exact T levels, but he did say that Dr. Scholz was looking for his T to get over 250 during the "off" cycle. In his case, he's given up on erections, but looks forward to the psychological relief from ADT. He stopped his last vacation when his PSA reached 2 because that's what was needed to detect the cancer in the lymph nodes, and immediately afterwards he re-started ADT (+Leukine) as neoadjuvant therapy prior to SBRT to the affected nodes.

Quote:
I imagine his treatment as part of the “brew” cocktail you've written about before.
We're waiting until the end of this ADT cycle to see if he needs any further therapy. We've talked to Scholz and Lam about a cocktail, and they're amenable. Right now, his ADT consists of Lupron, Zytiga & Avodart. He also takes a host of supplements, and has made diet and lifestyle changes.

Quote:
Allen, You are an expert in cellular studies. Can you give any explanation about the above? Can you enlighten the facts?
Thanks for your faith in me, but I am not an expert and you certainly know a lot more about Artemesinin than I do. Artesunate is not available as an anti-malarial in the US. From what I read, it is given intravenously as an anti-malarial. I don't know to what extent it is absorbed if taken by mouth. I haven't seen any studies of its use in humans for PC.

Quote:
In my lay anecdote opinion, this behaviour regarding the accumulation of iron in cancerous cells, contrast with what is known about Feraheme (iron) used as contrast agent in MRI studies, to locate prostate cancer (cells infested with iron). In fact, if PCa got the “ability” of absorbing abnormaly amounts of iron then it may suggest that Artemisinin can be highly toxic to prostate cancer.
I think it's the other way around -- the iron (feraheme or feromoxtran) is absorbed in healthy lymph nodes but not in cancerous ones, so healthy nodes look black on the MRI while cancerous nodes remain white.

Quote:
Accordingly, I do not know if by taking Artemisinin as a supplement, I would lose the opportunity of getting a C11 choline PET/CT image study to locate cancer. I also do not think that Dr. Fortuin would give me an answer to such a question.
I think you meant to say the feromoxtran MRI, rather than the C11 Choline PET. But if it affects iron absorption, I agree that you are probably better off waiting until after the MRI.

Quote:
So far I am excited about the possibility but do not see a breakthrough to cure. How does it work? Do we first locate the cancer and then apply focal radiation? What about if the cancer is detected in several distant places, is there still hope for a treatment?
I agree that it is only a small possibility of a cure, but it seems to me better than no possibility. It depends on being able to find at least one and no more than five metastatic sites. SBRT (5 treatments) are used on the sites found.

Quote:
Nevertheless I should firstly find out about the limitations of choline to “work” properly. I read studies on choline applied in prostate cancer research in three forms; C11, Acetate and F18, in two areas; bone images and at lymph nodes staging. It seems that choline in all forms do better in PSAs above 4 and tumour sizes/lesions above 5mm. Is this correct?
Since you are lucky enough to be able to get the ferumoxtran MRI in Europe, I would certainly try that first. Ferumoxtran and feraheme are just different varieties of a class of MRI contrast agents known as Ultra-Small Paramagnetic Iron Oxides (USPIO). It is able to detect tumors that are about half the size of what C11 Choline or Acetate PETs can detect. (F18 is not nearly as good as C11). Choline or Acetate PETs often miss lymph node mets that feraheme MRI can find, as you read in Dr. Fortuin's research. They are the primary investigators of this kind of imaging in the world.You will want your PSA to get up to the 2-3 range for detection to be possible.

Fortuin compared C11 Choline PET to ferumoxtran MRI. The MRI detected tumors as small as 4.9mm, whereas the PET minimum size was almost twice as big -- 8.4mm. The MRI detected cancerous nodes in 61% of patients, whereas the PET only detected 31%.
http://www.ncbi.nlm.nih.gov/pubmed/22417806

- Allen

 
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Old 04-17-2013, 05:11 PM   #7
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Re: IADT, 8 months on vacations

I should have added that I know of two places in Italy that have experience treating mets with SBRT. Dr. N. Di Muzio, Radiation Therapy, at San Raffaele Scientific Institute in Milan, Italy, and Dr. Giancarlo Beltramo, University of Milan. There may be others.

 
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Old 04-21-2013, 05:38 AM   #8
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Re: IADT, 8 months on vacations

Allen
Thanks for the info again.

So far I have e-mailed to the places in Germany, Holland, Spain and Italy but haven't received yet a reply. Probably because I addressed and commented about the researchers involved in the studies and procedures.

In any case I met the radiologist who did the radiosurgery in 2006, to obtain details of his work and to check about possibilities of irradiating the same areas done back then.
His comments were that; there is still a limitation by the irradiated tissues in absorbing more grays for the short period of 6 years (since RT). However, the radiation field of 2006 included the lymph nodes in the pelvic and iliac. He does not think that recurrence is from localized areas but he does not rule it out too. I need firstly to localize the cancer before making a decision.

In any case, he also commented (and I think it logical) that the diagnosis of micro-metastases of my case would not free me from future recurrences again. Meaning that the newer ways (contrast agents used in MRI) of imaging are also limited in detecting micro-tumours. The image study could be positive to some small sized tumours but still negative in detecting existing micro-tumours of millimetric sizes.

The above tells me that I could be facing still false negatives, and in such case I could undermine the possibility of future spot radiation in some areas.
Confusing but a point to think about.

It seems that radiologists suggest radiation to advanced patients with wider purposes. They look for localized control (such as in metastases in lungs) and pain.
The consensus of the doctors here is sequential. This is what has been done traditionally to treat PCa (RP/RT/HT/Immuno/Chemo/others).

What an adventure. But I am ready for it.
I hope to get an answer from the places using the newer contrast agents.

Regards.
Baptista

 
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Old 04-21-2013, 11:28 AM   #9
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Re: IADT, 8 months on vacations

Hi Baptista,

If your previous SRT already irradiated the pelvic nodes with sufficient dosage, I agree that there is no point to looking there for the cancer. In my friend's case, his SRT was mostly to the prostate bed, but he did not receive adequate dosage to his iliac lymph nodes to kill cancer. His radiologist reviewed the dose volume histogram of his previous SRT and felt that after 5 years it would be safe to use SBRT on the suspicious nodes. While one would not want to have IMRT on top of IMRT, there is a clinical trial now for using SBRT on top of previously irradiated IMRT. I've heard that early results are going well, with little urinary or rectal toxicity.

I'm sorry to hear that you have not yet heard back from the doctors you contacted. Perhaps you will have better luck contacting the radiation oncology departments of those hospitals. I am curious as to how to best communicate. Do you assume they all speak English? use Google Translate? find someone who knows Dutch?

If you are still interested in pursuing advanced imaging, I should also mention the F18-FACBC PET scan. They did a clinical trial of it at Emory University in Atlanta, and I recently saw that at the University of Bologna they found it to be significantly better than the C-11 Choline. Perhaps it is almost as good as the USPIO MRI. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/23591953

I think your doctor is right that the most likely scenario, for both you and my friend, is that there are micrometastases that no imaging technique will ever locate until much later when they establish and grow. Those bone metastases can be palliatively treated with SBRT, but with Alpharadin about to be FDA approved, I think that will soon become the standard of care.

Most of the clinical trials are reserved for men who have known metastases and/or are castration-resistant. But there are some that are being tried earlier. My friend was able to get Zytiga even though his cancer is still hormone sensitive. I would love to see him get immunotherapy now in the hope of slowing down the micrometastases. Dr. Scholz is running a clinical trial of a combination of Provenge and Yervoy, which I think is an excellent combination immunotherapy. There are many newer immunotherapies being tried alone and in combination: Prostvac-VF, anti-PD-1 antibodies, sargramostim, low-dose cyclophosphamide, IL-2, etc. I expect these will become widely available over the next few years.

- Allen

 
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Old 04-25-2013, 01:27 AM   #10
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Re: IADT, 8 months on vacations

Hi Baptista and Allen,

I've just read over this thread and I'll jump on the bandwagon. Irv is in the same situation. After a failed prostatectomy in November, 2010, Irv went on his first round of IADT3 in February, 2011, for one year. His PSA reached a nadir of <.02. His PSA remained undetectable for 11 months in his first "off cycle". However, in January, his PSA came back at .05. One month later, it was .13, and then .22 and his last one this month was .4. We realize this is an aggressive case of cancer and his oncologist told him that statistically, patients with a fast doubling time, don't do as well over time. With that, and a combination of other stuff going on at home, I've been feeling rather sad at times.

Irv and I have been seriously considering the C-11 Choline PET scan at the Mayo Clinic. However, what you are saying in this threat has definitely been a question in our mind too. Dr. Myers also said to Irv that with such a short doubling time, the chance that the cancer is oligometastatic is very slim and unlikely. I find myself revisiting the question of prognosis here.

At any rate, we are running out of time to consider imaging this time as we quickly approach the need to restart the "on cycle". Also, Irv was on a double dose of Avodart while in the "off cycle" and it did nothing towards lowering his DHT...That was a mystery.

So, from what I'm reading here, the C-11 Choline PET scan or any other effective imaging, for that matter, might very likely be a waste for somebody such as Irv, since his doubling time is just about every 5 or 6 weeks.

I'd appreciate feedback on this and also on the expected prognosis for a man with a very short doubling time.

Very much appreciated,
Many Regards, Rhonda

 
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Old 04-25-2013, 12:42 PM   #11
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Re: IADT, 8 months on vacations

Hi Rhonda,

From everything I've read, the biggest prognostic indicator is how complete the early response is to ADT, and how quickly that happens. I'm not minimizing the adverse impact of PSADT, but it is only one of several prognostic factors. You might be comforted by the following study abstract, which has a link to the full study:

http://www.ncbi.nlm.nih.gov/pubmed/17315162

The study tracked men who received ADT after RP or RT failure, and found that shorter time to undetectable PSA (undetectable defined as <.2 ng/ml) was associated with longer prostate cancer survival. As you can see in Figure 1, among men with PSADT<6 months and G7-10, all of those who had a faster time to PSA nadir following ADT survived prostate cancer at least 7 years (when tracking ended).

My friend, who has a PSADT of 3 months, GS9 & failed SRT after RP, was told by Dr. Lam that he estimated a 10% chance that the cancer was oligometastatic rather than micrometastatic and disseminated. We thought it was worth the chance, even if it just slowed it down and allows longer ADT vacations. But it may have been a waste of time and money. We'll know in the fall when he comes off ADT.

As for detection, my understanding is that Mayo charges quite a lot for their C11 Choline PET scan. C11 Acetate may be available for quite a bit less, about $3000 I think, at several places in the US. Dr. David Schuster is running a clinical trial of a novel tracer called F18-FACBC at Emory University in Atlanta. Dr. Mukesh G. Harisinghani studies USPIO MRIs for lymph node detection at Mass. General.

- Allen

 
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Old 09-18-2013, 11:02 PM   #12
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Re: IADT, 8 months on vacations

Hi Allen,

I'd be curious to see how your friend is doing, now that we are into the fall.

As for Irv, a lot has happened since my last post in April. His PSA back then was at .4.

We went to see Dr. Myers in May and even he said he was worried. During the time we were away, Irv's ulcerative colitis flared up badly and he also ended up with gastritis and duodenitis and, within a few days after our return from Virginia, he spent 10 days in the hospital trying to recover.

In May, his PSA shot up to a scary 1.33 from .4 the month before. But then, while on prednisone, his PSA continued to rise but at a much slower rate. It was 1.47 in June, 1.58 in July, 1.77 in August and at his last check, after having completely tapered off of the prednisone, it jumped to 2.10.

I'm wondering, first of all, if you have heard of low dose prednisone to control growth of cancer in the off cycle. Irv's PSA is a little all over the place but, then again, so has been his health and that might be a factor.

There is a clinical trial in London, Ontario with new imaging that he is qualified for and scheduled for late October or early November. He had to come off of the Avodart to qualify. We are also considering Dr. Almeida's C-11 Acetate scan in Arizona. We want to move fast as we never really know what's going to happen with Irv's PSA from month to month.

Any input is appreciated as we decide upon our next plan of action.

Rhonda

 
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Old 09-19-2013, 06:28 AM   #13
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Re: IADT, 8 months on vacations

Hi Rhonda

I am sorry for the news about Irv's progressive PSA.

Just a note about my experience, as commented above, initially the PSA raised steadily on an average PSADT of 20 days. I was concerned that the Off-drug period would be shorter than expected but for my surprise the following PSA tests shown a decline on aggressivity with much longer doubling periods. The last PSA (Sep) was 0.88 (up from 0.73) representing now an average doubling of 14 months.

I also want to get the C11 PET/CT scan or USPIO but must wait until the PSA gets higher. I found that all those tests are done in several places in Portugal too.
In any case, I want to get a positive picture of the bandit so that we can check if radiation is in fact still a possibility. I have discussed the resent progress with the radiologist of my SRT because I wanted to know details of the isodoseplanning done by him back in 2006. He said that they are also doing the C11 tests and that they request higher PSAs. However, he commented that when the PSA increases fast in short periods it may be a cause from inflammation of a certain node (s) in which case it would also be detected by the PET scan even in lower PSA levels.

So far I am off medication for a period of 17 months. The last Eligard 6-month shot was administered in November 2011. I hope to this period to extend still for several months before I will have which ever test.

Allen is no more posting in this forum. You may find him at the HW.

Best wishes for Irv and peace of mind to you.

Baptista

Last edited by Baptista; 09-19-2013 at 06:31 AM. Reason: edit spell

 
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Old 09-19-2013, 10:56 PM   #14
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Re: IADT, 8 months on vacations

Thank you for your encouragement, Baptista. However, Irv's last Zoladex injection was in February, 2012 and his last PSA came back at 2.10, .33 up from one month ago.

For some reason, this jump has made me feel anxious.

 
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Old 09-20-2013, 12:44 AM   #15
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Re: IADT, 8 months on vacations

My opinion is that the time is right for a series of tests to access Irv's present status. Image studies (even the traditional ones) could be done to look for any metastases. Often they occur in bone so that a bone scan would provide some bases.
If my radiologist's opinion is correct then, with such fast rising PSA, a sort of inflammation is occurring which may provide a location.

Best wishes.

Baptista

Last edited by mod85; 09-20-2013 at 07:44 PM.

 
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