ADT Treatment

[timwynn]

Doctors! I would appreciate opinions on a course of treatment with ADT. As you can see from my clinical history below, my PSA is now rising after RP in 2001 and salvage radiation in 2011. Thank you, Tim

PSA pre RP
Aug 14 2001 – 8.9

Biopsy August 14, 2001 – six cores. Three from right side of prostate are benign. Three from left side of prostate are involved with prostatic adenocarcinoma.
Gleason major pattern 4, Gleason minor pattern 3, pattern score 7.

Radical Prostatectomy 20 Sep 2001 at Walter Reed Army Hospital

Post surgery pathology report;
Multifocal carcinoma Gleason 3 and 4.
Stage pT (5) 3b Nx
Surgical Margin: Negative
Lymph nodes negative for malignancy
Oct 2006 - 0.02
Oct 2008 – 0.10
(PSAs on request from doctor for missing years)
Oct 2010 - 0.54
Oct 2010 - 0.62

Rising PSA detected in October 2010. Physical examination and follow up transrectal ultrasound showed a mass in the prostate bed (left anterior wall of the rectum). Biopsy performed on December 14, 2010. Pathology report showed a tumor with a growth pattern consistent with Gleason pattern 4+4=8.

Started radiation treatment on Feb 23. 2011.
Received 38 IMRT treatments using Calypso focusing.
Finished April 18, 2011.

August 2011 Nuclear Medicine bone imaging whole body – No definite metastatic lesions identified
August 2011 CT Abdomen pelvis with contrast – No solid organ lesions or evidence of osseous metastatic disease, mildly enlarged left perirectal lymph node, borderline enlarged presacral lymph node.

Post radiation PSA
July 2011 – 1.76
Aug 2011 – 2.53
Sep 2011 – 3.78

[Jan.M PCRI]

Tim - I hope you can find the help you are looking for, but there are no doctors on Blue Community who give answers to posts. Perhaps that will change at some point in the future.

You have given a lot of good info in your post. I have a couple of questions:
1) Did the bone scan recommend further imaging - X-ray or MRI? I'm just curious because you use the phrase "no definite" which makes it sound like they may have mentioned something suspicious? I certainly hope not, but I have seen follow up imaging recommended, that was not done. Just make sure you understand that report.
2) The 2 enlarged lymph nodes on August 2011 CT - were they targeted with Calypso?

I might look for a prostate MRI in your area - it may be more accurate than the CT, and give you additional imaging to use for follow-up. There is a good article on our website that might be helpful - Prostate MRI: Information for Patients and Families (http://prostate-cancer.org/pcricms/sites/default/files/PDFs/Is13-4_p8-13.pdf)

You may also be able to consider Intermittent ADT. There is a Member here on Blue Community that has used this regimen - his Member name is "IADT3only:Decade+". Perhaps you can email him directly for some discussion. The IADT "3" probably refers to 3 drugs - hormone therapy with Casodex & Proscar (or Avodart) added.

I hope that is helpful.
Jan Manarite - PCRI
Disclaimer: I am a prostate cancer researcher and advocate, not a medical professional. Information I share with you is to help expand your knowledge for discussion with your own physicians and should not be considered actual medical advice

[Nathan.R PCRI]

Doctors! I would appreciate opinions on a course of treatment with ADT. As you can see from my clinical history below, my PSA is now rising after RP in 2001 and salvage radiation in 2011. Thank you, Tim

PSA pre RP
Aug 14 2001 – 8.9

Biopsy August 14, 2001 – six cores. Three from right side of prostate are benign. Three from left side of prostate are involved with prostatic adenocarcinoma.
Gleason major pattern 4, Gleason minor pattern 3, pattern score 7.

Radical Prostatectomy 20 Sep 2001 at Walter Reed Army Hospital

Post surgery pathology report;
Multifocal carcinoma Gleason 3 and 4.
Stage pT (5) 3b Nx
Surgical Margin: Negative
Lymph nodes negative for malignancy
Oct 2006 - 0.02
Oct 2008 – 0.10
(PSAs on request from doctor for missing years)
Oct 2010 - 0.54
Oct 2010 - 0.62

Rising PSA detected in October 2010. Physical examination and follow up transrectal ultrasound showed a mass in the prostate bed (left anterior wall of the rectum). Biopsy performed on December 14, 2010. Pathology report showed a tumor with a growth pattern consistent with Gleason pattern 4+4=8.

Started radiation treatment on Feb 23. 2011.
Received 38 IMRT treatments using Calypso focusing.
Finished April 18, 2011.

August 2011 Nuclear Medicine bone imaging whole body – No definite metastatic lesions identified
August 2011 CT Abdomen pelvis with contrast – No solid organ lesions or evidence of osseous metastatic disease, mildly enlarged left perirectal lymph node, borderline enlarged presacral lymph node.

Post radiation PSA
July 2011 – 1.76
Aug 2011 – 2.53
Sep 2011 – 3.78

********* ADT *************************
Hello TimWynn: Yours is a serious situation with biopsy confirmed Gleason 8, failed surgery and salvage radiation, and PSA doubled in only two months from 1.76 to 3.78.

I strongly recommend you seek out a medical oncologist who is a specialist in treating high-risk, recurrent prostate cancer. see http://www.prostate-cancer.org/pcricms/node/38

Perhaps the Standard Of Care is at some point to begin 'Lupron' (LH-RH Agonist drugs), also called hormone blockade or androgen deprivation.

Other doctors believe a man with high risk, recurrent cancer should do everything possible, early, to immediately kill as much of the cancer as possible and try to get the cancer in remission. http://compassionateoncology.org/pdfs/3-pronged-111908.pdf

Is there still a chance of long remission with radiation therapy? With the bone scan clear and a couple of lymph nodes enlarged, watch the videos by Dr. Snuffy Myers about treating Oligometastatic disease. http://askdrmyers.wordpress.com/category/ogliometastatic-disease/ He uses radiation by Dr. Dattoli in Sarasota Fl.

CLINICAL TRIALS There are many new prostate cancer drugs just coming on the market or beginning clinical trials. http://www.prostate-cancer.org/pcricms/node/37

There are some small steps to be considered;

Proscar or Avodart - although not FDA approved for treating men with recurrent prostate cancer (it has never been tested by randomized clinical trial), it is legal to use these drugs in men with PC. Lacking clinical trial "proof", we do have lots of "evidence" that finasteride (Proscar) and Avocart have powerful anti-prostate cancer effects. They are proven to reduce the occurrence of prostate cancer http://www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is13-3_p3-5.pdf. And in men on intermittent hormone blockade, Proscar increases the time off therapy. They have low side effects that may include reduced libido, breast tenderness, and low blood pressure. The side effects subside when stopping the drugs.

Note that these drugs change the way prostate cells produce PSA, and will drive PSA down about 50%. One must re-calibrate the PSA graphs looking for progression.


http://www.prostateoncology.com/resources/?pg=patient_education&id=24

http://www.compassionateoncology.org/pdfs/proscargreet.062508.pdf

This paper showed lengthened the time to progression (seemed to slow down the cancer) for men on Active Surveillance. http://www.europeanurology.com/article/S0302-2838%2811%2900049-2/fulltext

Proscar (finasteride) and Avodart (dutasteride) have demonstrated activity against prostate cancer for some individuals. In 2011, Fleshner, et al. presented a Canadian study, “302 men with early-stage prostate cancer received either dutasteride or a placebo for three years. Researchers found that cancer grew in 38% of men taking dutasteride compared with 49% of men taking the placebo”.
And this by Dr. Strum Part 2 –http://www.prostate-cancer.org/pcricms/node/131

statin drugs may help reduce the risk of dying of PC http://www.ncbi.nlm.nih.gov/pubmed?term=prostate%20cancer%20statin

Vitamin D blood level can be testedhttp://www.vitamindcouncil.org/

pomegranate - See From The Editor in March 2011 Insights http://www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is14-1.pdf

nutrition - Maintain a "heart healthy" diet. Diet, Vitamins & Exercise for Prostate Cancer PCRI Pamphlet 2010 http://www.prostate-cancer.org/pcricms/node/429


If you need any assistance with any of the above, or want to discuss your situation, please call my direct line at 805 642 2297 or the PCRI Helpline at 800-641-PCRI or 310-743-2110.

Nathan Roundy, PCRI Helpline Associate

Disclaimer: I am a prostate cancer survivor, researcher and advocate, not a medical professional. Information I share with you is to help expand your knowledge for discussion with your own physicians and should not be considered actual medical advice.

[timwynn]

Thank you, Jan, for your reply.

1) Reference the bone imaging: No follow up test were recommended. Details on the report are noted below.
Normal physiologic distribution of tracer is noted. There is a focus of relatively intense radiotracer uptake abutting the superior endplate of S1. This correlates on the CT exam with a focus of sclerosis, contiguous with the superior endplate, where there is severe degenerative disc disease. Areas of moderate uptake are seen within the lower cervical leel, consistent with spondylosis. Areas of mild uptake are seen at multiple joints of the wrists, knees, feet, right AC joint, and ankles, consistent with degenerative joint disease.

2) The two lymph nodes were not targeted with the Calypso. A tumor 1 cm in diameter in the prostate bed was the focus. Complete report reads: Mildly enlarge left perirectal lymph node, measuring 1.0 cm short axis dimension. Borderline enlarged presacral lymph node, just to the left of midline, measuring 0.9 cm short axis dimension. The patient is status post radical prostatectomy. The prostatectomy bed demonstrates scattered vessels, however o recurrent mass is seen in this area. The urinary bladder and rectum are unremarkable. The remainder of the solid organs demonstate no suspicious lesions ...

Thank you for the link on the Prostate MRI. I will share it with my doctor as the next steps for my treatment are decided. My current age is 62 years.

Tim

[Jan.M PCRI]

One of the issues with CT scan is that is has a low "sensitivity" for finding prostate cancer in lymph nodes. That means it can give false negatives. One reason for this is that CT's strength is anatomy - it can visualize something too large, or a mass that doesn't belong there. It doesn't have uptake designed to light up because of cancer. This is why lymph nodes are actually measured to define cancer involvment - because they are enlarged, and that's about all a CT scan can see. Hopefully this understanding can lead you to more clarity in your research, and your discussion with your physicians. And this is one reason I mentioned prostate MRI. Honestly, though, another type of whole body imaging might be valuable - either FDG18 PET, or something else. I'm not sure of the exact fit here. Try calling AdMeTech (see www.admetech.org ) and see if they can help you locate a lymph node imaging that would be helpful.

Nathan pointed out a PSA doubling time that is 2 months. Although it is probably better to measure doubling time over a longer period of time, I would agree the doubling time is of concern - especially in light of the imaging that shows irradication of the prostate bed mass + 2 enlarged lymph nodes + the poor sensitivity of the CT scan.

If you decide to undergo ADT, I would consider taking Casodex 1st (beofre the hormone injection) to prevent flare. Some experts recommend 1 week of Casodex before the hormone injection.

Also, if you tell us where you live, we may have a local resource for you - support group, etc.
Hope this is helpful,

[timwynn]

Thank you for the imaging quidelines. Will discuss with physician tomorrow. My wife and I purchased Dr. Myers' book two weeks ago. Excellent resource. Our home is near the Canadian border, 90 miles from Seattle, WA. Tim

[Jan.M PCRI]

Although all support groups are different, UsTOO International has some excellent groups - they call them Chapters. It looks like there is one in Bellingham that meets the 2nd Tuesday of each month - Is that close to you? Check www.USTOO.org. Click on "Find a Support Group Chapter Near You". Questions about local physicians, local imaging, and treatment side effects are usually good questions for a local support group. Maybe this can give you some direction....

[timwynn]

Good Morning!

An update on my progress. Latest PSA was somewhat encouraging to us as the rise seemed less dramatic yet still of major concern. November PSA to be taken soon.

Post radiation PSA
July 2011 – 1.76
Aug 2011 – 2.53
Sep 2011 – 3.78
Oct 2011 - 4.33

09 Oct 2011 Fluoride bone scan identified spot on sacral spine
10 Oct 2011 ProstaScint scan Negative

22 Oct 2011 Started Casodex
07 Nov 2011 MRI to further define spot found on fluoride scan
Tumor found near sacral spine. Consulted many doctors about Cyberknife for tumor.
Going forward with Cyberknife

08 Nov 2011 First Lupron shot

Best to all, Tim