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treatment & prognosis for bone Rx


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Old 09-18-2017, 12:24 AM   #1
dale2035
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treatment & prognosis for bone Rx

I have a second appointment with an oncologist in a couple weeks. He will give me a report on a recent bone scan. He gave a short preliminary report that indicated cancer has spread outside prostate involving bone in pelvic area. A biopsy showed no cancer a year ago. Rapid rise of PSA (7 to 13( resulted in MRI and a biopsy of prostate. Sort of academic , I guess, but Gleason was 4 + 4. Cancer outside organ. Colonoscopy, I read some blog from a prostate cancer patient whose cancer spread to his bones and it did not sound as ominous as bone cancer that had not spread from prostate. I will get the recommendation re treatment. I was started on Lupron every 3 months and a daily oral ADT. Did I read bone cancer from prostate spreading gets a Zometa infusion every 3 or 4 weeks ...for 15-30 @. Have you had bone cancer spread from prostate? I had proton therapy 9 years ago. So I am doing pretty good for an 9ld guy (82 in Nov) I think some of my contact experts are super for their specialty (one robot surgeon and radiation expert). I like this UCLA oncologist and think he will help me. I wanted some input to know what to expect and what to ask. This board was very helpful 9 years ago. Jim and Daff were great! Gratitude for help like that can't be expressed adequately.

 
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Old 09-18-2017, 01:12 PM   #2
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Re: treatment & prognosis for bone Rx

Hi Dale,

I’m hoping you get good results from your bone scan. You raised a number of issues, so I will number my responses for convenience.

1. What kind of bone scan did you get? If it was done by UCLA, I’m thinking it was the NaF18 PET/CT scan which is outstanding at picking up bone metastases. A more common option is the technetium based bone scan which has been used for decades; unfortunately, it takes about 10% of bone involvement with the cancer at the affected area to be picked up by the scan, which means that some early bone tumors are missed. There are also other scans that can reveal both bone and soft tissue metastases, such as multiparametric MRI that is adjusted so it will focus on regional bone and soft tissue metastases and not just on the prostate itself. A very well known radiologist spoke about use of imaging in cases like yours at the Roundable case discussion session at last year’s 2016 Conference on Prostate Cancer in LA. His talk confirmed my high opinion of radiology at UCLA, so I expect you will benefit from leading-edge expertise.

2. Do you wish to share your detailed bone scan results now?

3. If you have bone mets but not soft tissue mets, my layman’s understanding is that the drug Xofigo® would probably be a good match for your needs. It seeks out bone mets and then delivers powerful but short range radiation to the mets. There has been a lot of excitement about this drug in the past few years.

4. Zometa® or a more recent and somewhat better drug, Xgeva®/denosumab, are mainly designed to help protect bone density for patients with metastatic prostate cancer. As I had no detectable mets (with one questionable soft tissue spot in an unlikely location shortly after diagnosis indicated by ProstaScint), I was able to use milder bisphosphonate drugs (Fosamax®/alendronate and later Boniva®/ibandronate) to successfully protect bone density. These might be options for you, as might another more leading-edge option advocated by a doctor we will call Snuffy, estradiol (estrogen) patches. I was on these patches for my fourth round of IADT3 because we were concerned that I had been on bisphosphonates for more than ten years and could be at increased risk of experiencing a break in the femur, per research. The main risk with Zometa® and Xgeva® is osteonecrosis of the jaw, which can be nasty; a key countermeasure is to have all your dental surgery work caught up and either avoid or go to an expert dentist for this circumstance if you need surgery while on these two drugs. There’s more on the estrogen option below.

5. Being on Lupron at age 82: What shape are you in? If you have not maintained an exercise program, and since you have diabetes, being 80 or older and on Lupron could be a rough combination. The doctor we will call Snuffy and the well-known oncologist MS who practices solely on prostate cancer in Marina del Rey have both expressed strong concern that Lupron and related drugs that sharply reduce testosterone can be quite debilitating for elderly patients. However, sometimes there isn’t much choice as the anti-cancer benefit is more important. What they prefer is to use just an antiandrogen, such as Casodex®/bicalutamide at 150 mg/day (or sometimes even more) along with other drugs such as Proscar®/finasteride or preferably Avodart®/dutasteride. Unfortunately, while that combo is a lot easier on the patient and has roughly 80% of the anti-cancer benefit, if you have metastases you may need that extra kick that you cannot get with this combination.

If you need a Lupron type drug, find out what you and your doctor can do to minimize side effects. There are some drugs that can address fatigue, for instance. There are also lifestyle tactics, including the exercise which you have so far avoided. Also, “Snuffy” believes that using the estrogen patches to build back up to a normal level of male estrogen (to replace the estrogen no longer synthesized from testosterone because it has been virtually eliminated) helps the patient’s energy level, mental sharpness, etc. However, use of the patches for bone density is somewhat controversial. Snuffy believes it is a safe way of getting estrogen (in contrast to getting it orally).

6. You might ask your doctor about the relatively new drugs Zytiga®/abiraterone and Xtandi®/enzalutamide (like a much more powerful Casodex®/bicalutamide). If you have metastases, you may qualify, and there is a lot of excitement about these powerful drugs. Unfortunately, some men will not benefit from them due to a genetic feature they have, but there is a test for that. One emerging issue is that men on these new drugs are at greater risk of having the cancer transform into a more dangerous version known as "small cell" prostate cancer. Apparently estrogen can prevent or even reverse this transformation, something Snuffy has noted in his practice.

7. Metformin. This is getting really long, so I’ll close by asking if you are on the diabetic drug metformin. There is a lot of excitement about the value of metformin for prostate cancer patients, especially those who are diabetic. For instance, in a study the post-radiation survival difference was awesome between patients on metformin (who had outstanding survival ) and diabetic patients not on metformin (whose survival was not that encouraging. ) Snuffy talked extensively about metformin for prostate cancer during his presentation at the 2016 Conference on Prostate Cancer (which is available as a DVD).

Ok, one more thing: since you are in the LA area, have you ever attended a prostate cancer education and support group?

Good luck!

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Old 09-27-2017, 12:47 PM   #3
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Re: treatment & prognosis for bone Rx

I had the second appointment and first after bone scan. I think he said he was going to order another scan in a few weeks. The NaF18 PET/CT that you mentioned. The scan showed cancer had spread to the lower back...he pointed to the spine a few inches up. The PSA was at .8 and he was pleased. No pain. He is going to start chemotherapy in a few weeks: Taxdare infusion. He was very optimistic. I am extremely pleased with receiving such high quality care at a tiny outpost with two doctors. One may focus on breast cancer ...and P.C. must focus on prostate cancer. He is better than other experts who have helped me.
Thanks for your help. It was a big help. P.C. thought I was doing great and did not need to ad Avodart or increase the Metformin. He thinks I take the max dose (2000 mg)

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Old 09-27-2017, 02:46 PM   #4
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Re: treatment & prognosis for bone Rx

Hi again Dale,

It's always nice when you are pleased with your doctor and have a good relationship. It strikes me that the doctor is managing your case well.

These days combining chemo (the taxotere you mentioned) with androgen deprivation therapy (ADT - the Lupron and probably Casodex/bicalutamide as a pill) is well accepted for patients with metastases who are starting ADT. Several trials have indicated an advantage for adding chemo early like this, but it's recent, just the past couple of years or so.

How are you doing with fatigue, hot flashes/sweats, sleep, energy, and joint soreness? Some patients do very well, but most of us have some issues. As I mentioned earlier about your age and ADT, if you have major issues, you need to work with the doctor so that the treatment does not put you in a nursing type facility. I'm assuming you are doing liver function tests (LFT) just to make sure that your liver is able to handle the Casodex/bicalutamide or similar drug well. Most patients are fine - I was, but some cannot avoid injuring their liver if they stay on the drug. Usually you are tested for the first few months to make sure all is well. If you have not been tested or discussed this area with your doctor, be sure to do that. Also, if your LFTs do indicate a problem, there are a number of drugs that can solve the problem or at least minimize it so that you could probably continue on the Casodex/bicalutamide type drug.

I'm glad to hear that you are taking 2,000 mg of metformin. Yes, that's the max dose, and it's probably has done and is doing you a lot of good. I believe in adding Avodart, but the medical research evidence for it is weak, and it's not surprising that your doctor did not want to add it.

Did the doctor tell or show you how many metastatic spots you had? If it's three or fewer, or even, pushing it, up to five, and in places accessible to surgical removal or radiation, it's known as "oligometastatic" (meaning "few" metastases) cancer, and it may be curable. If you have more than five spots, research has shown that chances of a cure are small. However, pushing the cancer back to where it is "chronic" rather than deadly, or gaining enough years so that it is something else that does you in, are worthy goals for you and the doctor.

Of course, all this is with technology as it has been proven as of now. While far from a sure thing, there is a realistic basis for hope that an emerging technology will help you a lot, similar to what happened for President Carter with his brain cancer. In addition to the Xofigo that I mentioned earlier, an isotope of the element lutetium as the cancer killer, hooked to an antibody that seeks out the PSMA (prostate specific membrane antigen) that is on most prostate cancer cells, has already generated excitement in increasingly mature clinical trials. This is just one example. It strikes me that your doctor is keeping abreast of technology, which is easier in the LA area because of the fine oncology community there.

Will you be going on Zometa or Xgeva (denosumab) for protecting bone density while on ADT? I expect the doctor would want to do something to protect your bone density.

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Old 11-29-2017, 01:57 PM   #5
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Re: treatment & prognosis for bone Rx

tHANKS FOR YOUR reply....Great. I heard from from nobody else....but what great help from you....again.

I am so lucky. With your input....I get a thorough consultation....He tolerates my inquiry....my other experts might not have been so patient. I test out his flexibility...in case it seems I am not doing well. I said I read (did not say where...thatbicalutamide sometimes has dosage of 100 or 150 or even more. He says 50 is the :standard"...no comment when non-standard is indicated. I timidly ask if we may be acing x or y for bone density....not needed....Avodart...not needed.... He is okay. Your helop will helpo him be even better....I get my second chemo on Tuesday......I am doing fine.....I need to beef up my exercise. I love tennis...and love my grandkids....hope to be able to get in condition to play... not there yet....thanks for your advise that an increase in exercise would be helpful.. If I did not have you ...I would be alone. Your help is all I need. + UCLA....Have a good day...and holiday..
Dale

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