My father who is 95 has asymptomatic metastatic castrate – resistant (hormone – refractory) prostate cancer. Apparently, Lupron Depot is no longer controlling his prostate cancer. His PSA has increased from 1.8 to 15.8 and the CT scan shows a spot on his right hip. The spot has been there since 2012 and was the initial reason for taking Lupron Depot. The scans did not show any new metastatic spots. However, there has been an interval change to the old spot.
His urologist is sending him to his group’s practice that treats advanced prostate cancer. They have called me up and said that he will be getting Provenge. There is no discussion. I asked about Radium 223. They told me that it is only used for pain management. Is the decision this cut and dry? Is Provenge the more effective treatment as compared to Radium 223? It seems to be complex for a 95 year old.
There is nothing cut and dry in the treatment of prostate cancer. Given his age his treatment decisions could be different then a younger man. What about is general health other than the prostate cancer?
In response to the use of Radium 223 it is usually held off until a man has multiple mets. It does provide pain control and it also does extend life. Now is not the time for it. If the hip is causing a problem it can very easily be targeted with external beam radiation.
Provenge is one of the few treatments that usually has minimal side effects, so for a man his age it is not a bad idea. Part of the decision process should factor in his expected life span (outside the prostate cancer). Provenge does not work as quickly as the other treatments, it takes time to have an effect, so if he has a lot of co-morbidity problems he might not live long enough to benefit.
What had been the drugs used for the hormone therapy? sometimes canging them or adding Casodex (bicaludamide) to the mix if it had not been used can also help.
My father is legally blind because of macular degeneration. His biggest threat is trip and fall which he has done in the past and he had to have burr holes to relieve the pressure from a subdural hematoma. His mind is still good – no dementia. He doesn't have any heart problems. He did have a bout of adult diabetes when his dermatologist put him on massive doses of steroids for eczema. His mother lived to 99. He still has the will to live.
In 2007, he was originally treated with radiation for prostate cancer. The adverse side-effects were proctitis and urinary incontinence. His rectal bleeding is mild and we can control the urinary incontinence (oxybutynin). He has only been treated with leuprolide (Lupron Depot) and he also takes Prosteon daily.
I will go back to his uroligist and play devil's advocate about trying another hormone therapy drug - Casodex (bicaludamide). I really appreciate your advice.
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Prosteon is calcium citrate and Vitamin D3(2000IU). These are available OTC.
I assume that people do blood tests to check the effect of supplements on blood levels. Some people I listen to recommend much higher does of D3 for higher levels of D in the blood - up to the levels that lifeguards at the beach have and that chimpanzees have. (well above 33)
Have you explored Xtandi or Zytaga with your doctor? Zytaga requires addional monitoring as it includes steroids so I would consider Xtandi first. Although I understand there is no set order for these drugs including Provenge they should be considered. I would suggest you discuss these alternatives with your Oncologist. If he won't discuss them get a 2nd opinion. This is just my opinion since I am not a Doctor but have talked to several who all agree Xtandi should be a good second line of defense. Given his relatively low PSA and lack of major metastasis it sounds reasonable to me. Actually, your father probably stands a greater chance of dying of something other than PCa. You should also discuss if watchful waiting might be an option at his age. Good luck.
I would be very careful since your father is 95 and every single treatment we went through caused my husband severe side effects. I realize many don't get so many but if he is not suffering much at this point, I would not rush into some of the new drugs. They can make you pretty sick. The radium 223 did not work for my husband and actually caused worsening pain. Provenge still haven't proven much to me when you consider the fact that the PSA rises and they don't really know what it does, just that it supposedly helps, but there have been several on here who did suffer some side effects that you should ask about. It also seems that your fathers cancer is a slow growing cancer and perhaps not rushing into anything until you have all the questions asked and answered.
I agree with others that radium-223 is probably inappropriate. It delivers radiation to building bone everywhere in the body and is a good treatment for men with many bone mets distributed everywhere. By killing the prostate cancer cells that develop in the bone, it can relieve bone pain. It can extend life if, and only if, the threat to life comes from bone disease. It sounds to me like your father has no widespread bone metastases, no bone pain from his one identified lesion in his hip, and no threat to his life from bone metastases. So I would think radium-223 is off the table.
Provenge might help. I don't know. I read a few reports of men whose cancer went into remission after a combination of Provenge and Lupron. I've read other reports from men who were unable to see any clear benefit.
My inexpert inclination is to agree with KidKotch and go for a more advanced hormone therapy like Zytiga or Xtandi. Your father already showed a good response to hormone therapy in the past. When HT stops working, it's usually not because HT can't work any more, but because even low the levels of testosterone present under the older forms of HT (Lupron, etc.) may now be enough to stimulate the growth of the cancer. Zytiga or Xtandi will lower testosterone levels significantly lower than Lupron does. They may work for many months or conceivably even longer, and with hopefully manageable side effects.
I also want to say that the best person to help your father at this stage is probably not a urologist or even a general purpose medical oncologist. Ideally, he should see a medical oncologist who specialized in prostate cancer and keeps up with developments and has a lot of experience in hormone therapy and other treatments.
for information about teaching and research centers in the U.S. where expert specialists can often be found. If you tell use where your father lives, others in the group may also know some good experts in his geographic area.
My best wishes to your Dad. I hope I, and all of us, can do as well as he has done.
I visited Dr Charles Myers in Charlottesville, Virginia (American Institute of Diseases of the Prostate) in 2011 and 2012 from Perth in Western Australia and I can say it was well worth the trip - both times. He is a Prostate Cancer specialist of high repute with vast experience. Many of his patients come form Interstate and many from overseas. He would be a good option if it works geographically.
There was a guy with all kinds of mets who went to zero PSA with Lupron and had a 5 year zero PSA remission. Cancer (PSA) came back and he swears that Provenge saved his life, a true believer. That part I don't get, but the point is that hormone therapy can be magical in some (how many??) cases.
Apparently PSA can be driven lower after nadir by the XZ hormone drugs, but these do mess with the adrenals and possibly with the liver. hmm.
Don't neglect statins and heart healthy behavior. Maybe metformin for sugar modulation. Your basic "system support" if you go that way.
I will be going Joel and hope to attend another of your meetings, have enjoyed them. I Doctor with Dr. Lam with Dr. Scholtz
I want to thank you all for your help and support. Your feedback gets me up to speed and will enable me to focus my questions to my father's caregivers.
The notion that Radium 223 is for pain is false, and I would not trust those doctors with making my lunch. The ALSYMPCA trial is clear. Radium is a calcium look-alike and goes, like calcium, to bone deposition, including deposition of prostate cancer mets. It is an alpha radiation which means the breakdown product is the nucleus of a helium atom. This is a powerful but very short range product that they think breaks both strands of any DNA it hits.
What I think the problem might be is that the radium is distributed to all bones sites that having deposits, and not only the cancerous sites. Still, the radiation is limited to the bones only, and so that is helpful.
However, an alternative to internal radiation is external radiation. Why have you excluded that? If you can get an unambiguous visualization of the bone met, there should be many ways to direct energy to that location to kill that bone met. The more aggressive the treatment the more risk, and conversely, the less aggressive the treatment the less risk.
I do agree with many of the other comments. The first question to be asked and answered is what is the threat to life and to quality of life from the the "spot on his right hip". You do not indicate the PSA doubling rate; just that the PSA has gone up significantly since 2012. I am guessing that the PSA in January 2015 was 3, and when you wrote in January 2016 it was 15. This is a doubling rate of just under 5 months - pretty aggressive. The first question is where is this coming from. If you feel that there is good evidence that there is (only!!) one spot, it makes sense to me to go after it. Conservatively at first (cyberknife?) and if the effect on the PSA is dramatic, then reevaluate. You have good fortune in that the PSA is still working as a warning system for cancer progression in your dad's case.
Provenge is slow acting, and often does not show an effect on PSA. It is not a bad idea, but may do little for the indicator that you are tracking.
Curious as to how things are going now that it is six months out....
I have become more skeptical of provenge (even though I have had it). The explanation of how it works is - well there isn't one. Radium 223 is pretty straight forward. My choice would lean strongly to radium, between the two.
So what did you end up doing and how did it work out??
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