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Hormone Therapy Question


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Old 01-13-2018, 11:28 AM   #1
Milos14
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Hormone Therapy Question

I was diagnosed in June 2016 after biopsy...10 of 12 positive; Gleason of 4 + 3. I opted for surgery based on 2 opinions that cancer was confined to my prostate, but was aggressive. Had MRI & bone scan in Aug 2016 and both were negative. Post surgery pathology showed 1 lymph node positive as well as seminal duct. In hopes that the cancer had only recently spread outside the capsule, my Urologist recommended radiation & ADT to, hopefully, get any remaining cancer. I had 8 weeks (39 treatments) of external beam radiation in Dec 2016-Jan 2017. I also started Eligard in late Sept 2016. I had a second shot in Dec 2016 and a third in April 2017. My PSA has been undetectable since surgery. I was checked in Oct 2017 and it remained undetectable. I go back this week to be rechecked. I'm, of course, hoping that it will still be undetectable, but, am concerned that it won't be. I don't know what's next if the PSA has risen...more Eligard, or something else. I had a lot of trouble with hot flashes and 0 desire or ability for sex during the Eligard treatment. I feel much better after being off the Eligard. Just wonder if anyone might have other options for me to consider if the PSA does go back up. BTW, I'm 61 and in otherwise good health. Thanks for any help.

 
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Old 01-13-2018, 01:33 PM   #2
IADT3since2000
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Re: Hormone Therapy Question

Hi Milos,

It looks like you are doing very well, but I can empathize completely with your concern about a rising PSA. My own lab test is due later this month, and if it's good, it will be nearly five years of extremely low PSAs following my IMRT supported by ADT3, a course pretty similar to yours. I feel pretty relaxed about the lab, especially after great labs for more than four years, but it's hard to put it totally out of mind. I had considerably more anxiety in the earlier years after radiation.

First, what do you mean exactly by "undetectable." If you are using an ultrasensitive PSA test with a really low threshold, or even one like my doctor uses with a looser but still low threshold of less than 0.05, your results are quite reassuring. If your doctor is using the old but still often used tests with thresholds of less than 0.1, then there is a lot more play and a lot less clarity in what the results mean. My own results have been remarkably and unusually low at less than 0.05, the lower limit of the test my doctor is now using. Often results for patients like us who are on a reassuring path are somewhat higher, but not a lot.

Are you doing anything that amounts to a safety net to help minimize recurrence? The program I like involves a favorable diet (such as Mediterranean), strength and aerobic exercise, stress reduction if possible, and a few supportive medications. The main ones that are advocated by experts I follow and supported by research are: Avodart®/dutasteride (or Proscar®/finasteride for men who do not respond well to Avodart®) - sharply reduces DHT conversion from testosterone, thereby sharply reducing the potency of androgen fuel for any remaining prostate cancer; a statin drug (reduces the bad cholesterol that is used to make testosterone, plus other helpful effects, I believe); and metformin, (with the dose adjusted to avoid side effects; this is an old and now very inexpensive drug for diabetes that has proven to have some impressive effects for a number of types of cancer, including prostate cancer, with some dramatically favorable effects for prostate cancer patients who were taking it while having their radiation treatments). If my own PSA goes up from its current level of less than 0.05, then the first thing I will do is add metformin to my safety net. I do all the other elements already. I will then wait to see the effect on my PSA.

As I understand the options for someone like you should your cancer recur, as of 2018, I believe that resuming hormonal blockade (after the initial safety net attempt described just above), resuming hormonal blockade in some form would be the logical next step. It could be with a more potent drug, Firmagon®/degarelix, but, if so, be sure your doctor understands the steps to minimize discomfort at the injection site. I'm personally fond of adding an antiandrogen (such as Casodex/bicalutamide) and a 5-alpha reductase inhibitor (such as Avodart®/dutasteride or Proscar/finasteride), plus a bone density protector (I favor estradiol patches to restore estrogen to the normal male level, but I've also been on Fosamax® and Boniva®, both now generic, with other options available.). If you do need to resume hormonal blockade, be sure you understand the countermeasures to each of the commonly encountered side effects so you can minimize them; countermeasures can make a big difference in quality of life. Unfortunately, many doctors do not know much about countermeasures, and sometimes not much about side effects of ADT, so be sure to get advice from someone who does understand these areas.

Good luck with your test this week!

 
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Old 01-13-2018, 02:12 PM   #3
Milos14
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Re: Hormone Therapy Question

Thanks for the reply and the great info. My PSA has been .02 or .03 every time it's been check post surgery.
As far as the safety net question...I am on Simvastatin and have been for 5 years. My Urologist told me to take a calcium supplement while on ADT, which I did, but no other meds.
I exercise regularly, 5-6 times per week, but my diet could probably be better...eat lots of nuts and fruit, but also some meat (mostly chicken).
Again, thanks for the info, which I will keep and look into. Best wishes and good luck!

 
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Old 01-16-2018, 11:35 AM   #4
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Re: Hormone Therapy Question

Hi again Milos,

I'm really glad your doctor is using ultrasensitive PSA tests to monitor your case.

I'm going to intersperse some comments in the text of your last post. Overall, it looks to me like you are on an encouraging course but not yet free of concern.

You wrote:
Quote:
Originally Posted by Milos14 View Post
Thanks for the reply and the great info. My PSA has been .02 or .03 every time it's been check post surgery.
Those results look pretty good to me, and I'm thinking the odds are fairly good that you have been cured. For guys like me who still have an intact, but well radiated prostate, those results would be outstanding; many patients treated just with radiation, perhaps with hormonal therapy in support, will have a PSA in the tenths after the effects of hormonal therapy have disappeared.

For guys who have had surgery but no radiation, those results would be somewhat concerning if the trend is upward and not stable or up-and-down, as results at the 0.04 level suggest a fair chance of a recurrence at the early stage, and a result of 0.05 is strongly suggestive of a recurrence at the early stage, unless that level is stable (Stability at that level suggests some unremoved healthy prostate tissue is responsible; PSA can be even higher in that situation.).

For a patient like you, with both surgery and then thorough follow-up radiation, I'm not sure, but my gut feel is that the odds are in your favor as you near the two year point. Actually, it is known that PSAs after radiation tend to continue to decline, often for up to two years, and, as you probably know, they can bounce upward for a brief time before again declining, and sometimes it is many months - even beyond two years - before that worrisome but harmless bounce occurs. I found one older paper (PMID: 21514736), where patients received a considerably lower dose of salvage radiation, that said significantly more distant metastases developed in men with a post-radiation PSA greater than 0.05, and you are well below that and had superior radiation (plus ADT) compared to men in the study. I found another paper that indicated excellent survival at ten years for patients who had had both surgery and radiation, though the devil is usually in the details.



Quote:
Originally Posted by Milos14 View Post
As far as the safety net question...I am on Simvastatin and have been for 5 years. My Urologist told me to take a calcium supplement while on ADT, which I did, but no other meds.
I exercise regularly, 5-6 times per week, but my diet could probably be better...eat lots of nuts and fruit, but also some meat (mostly chicken).
Again, thanks for the info, which I will keep and look into. Best wishes and good luck!
Five or more years of simvastatin is associated with significantly superior survival of prostate cancer per research. That's the drug I have been on for many years now, and I remember looking forward to the time I would have at least five years under my belt.

If your testosterone is now okay, your bone density is now being protected. That said, you might want to have a DEXA bone density scan (or a qCT scan, which is much less available and less familiar to many doctors).

My Mediterranean diet is mostly plant based but with a lot of fish and some chicken. That's pretty standard. The trick is to avoid processed meat, and also, to hedge your bet, to avoid red meat including beef, pork and lamb.

If your PSA tests become a concern, adding Avodart® (generically available as dutasteride) and metformin might be all you would need to do.

Good luck!

 
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