Another western diet male

[efsculpt]

Hi. My PC is in high risk category. Had RP and later, radiation. Have slow rise of PSA less than one year later. So, am researching ADT options. Leaning towards ADT3, intermittent, maybe docetaxel, maybe lukine. got to research.

[Dan59]

Sounds like you are on the right track. However you do not give any stats like Gleason score, Current psa and how much the rise is. Recent studies do show increases survival with Docetaxol early when adt is started, knock it back hard and put it in remission! Leukine has long been a favorite add on by Dr. Myers, ever since Dr Eric Small in San Franscisco showed a benefit.

[efsculpt in reply to Dan59]

I think my Gleason is 8 with two 4+4 needle biopsies out of 12, PSA 6.3 , that was 10/2012. At 9 months after salvage radiation, I am at PSA .2 (up from <.1). The trend is upward. Vegan, exercise, relaxation, pomegranate, turmeric, capsacin, D3 4000/day. Next PSA test is in December- if still rising then I see my radiologist. It will also be the time I book a medical oncologist. Meyers in VA is "no new patients" but DANA his PA is available, and there is Dr Eshaghian with Compassionate Oncology (Leibowitz in Los Angeles). Would like to stay with Stanford but not if it's lupron monotherapy forever.

[JEKNY in reply to efsculpt]

I had similar numbers before surgery, I had surgery in 2008, followed up by salvage radiation in 2014 when my PSA hit .25, my PSA rose steadily for 2 years reaching a high of 0.9 in May of this year, I was ready to go to MSKCC in NYC when I hit the 1.0 mark but the oncologist said to wait and hold the Hormone Therapy Card for later when numbers were higher, and other issues developed. I had another PSA in August down to 0.4, and again this week 0.3 a downward trend more than 2 years post salvage radiation. Your Gleason score is higher than mine was I was at 7 (4+3), so you may want to be a little more aggressive.

My oncologist explained that hormone therapy could effect my quality of life, which at the time is excellent I am able to do everything a 64 year old guy can typically do.

Good luck with your travels through this disease.

[Dan59 in reply to efsculpt]

I was dxed in 2006 gs 10 bpsa 148.6, lowest it went was 3, I am always amazed at men who can compare .1 to .2, for me if it only goes up or down a full five points it is stable, often it will vary 5 points if I even have a psa done on two consecutive days, that being said , I have always been interested in Dr Bobs compassionate Oncology, THough I have chosen to be treated at a Hospital that is affiliated with a major learnig center, wherever that would be. current psa 41, down form 63 2 months ago. I wish you the best

Dan

[Hidden]

There are two schools of thought for high risk category PCA which shows recurrence right after primary therapy - in your case, rising PSA less than one year later. One is to try to kill it right away with aggressive chemotherapy such as docetaxel, as you suggest or taxotere. The other is to go ADT. The latter is not curative but you can be lucky and have lengthy remission. I was in the same situation as you and I elected intermittent ADT for 14 years. Still alive and kicking. Quality of life was good for the 14 years. Am now castrate resistant so I am in a new phase and a different ball game.

Good luck in making your decision.

Fred

[JoelT in reply to Hidden]

FYI- Docetaxel and taxotere are the same drug, generic vs. trade name

Also early chemotherapy is still coupled along with hormone therapy.

[efsculpt in reply to Hidden]

Dear Fred:

Did you do ADT3? And- steady hormone therapy or intermittent?

Thanks,

Craig

[Hidden in reply to efsculpt]

HI Craig. I did intermittent ADT. Three months of Zoladex and daily Casodex. After PSA reached undetectable, I monitored PSA rise. Some practitioners of intermittent ADT wait till PSA gets to 10 but I decided to resume at 1.5. Also kept track of doubling time, which got shorter and shorter. Finally, after 14 years, it would no longer go down so my med onc put me on ketoconazole. 1200 mg a day (400 mg 3x) I don't care much for the side effects so I was prescribed hydrocortisone, which has its own unpleasant side effects. If I have a choice, I'd rather have just the ketoconazole and try to tolerate its side effects. As a rule, the less medication, the better, right?

[Spitzz]

I pose a question. So often after a RP people stay with a Urologist when they should be seeing an Oncologist, hopefully one who specialize in PC, don't know if that is your situation,

I'll take you down my road: 2001 Gleeson 6, had Brachytherapy and shortly after (6 months) it was obvious that it failed,

Immediately went on 3HT - Lupron, Casodex, Avodart intermittently off / on for 14 years, in some instances off drugs for 4 years. As my PSA started to rise (2015) my oncologist put me on Zimiga (abiraterone), still taking Lupron and Avodart, been on it for 14 months, PSA < 0.01..

Best of luck to you,

Arnie

[Sisira]

In the absence of key pathological features of your case it is difficult to frame a good and meaningful reply. Besides all, at least your age! I don't know how to assume accurately.Battle against PCa should be viewed more seriously.

However, I have a feeling that your case is very much similar to mine. So let me give my own case with the key factors and tell you how I have made my treatment choices.

I was diagnosed for high grade PCa in March 2015 at the age of 68. Since my cancer was organ contained ( Confirmed by DRE, and MRI ) but my Gleason Score was 4+5=9 ( high risk ), cancer in 6 cores out of 12 core needle biopsy, I underwent RP in March. Post surgery pathology report indicated : No seminal vesicle involvement, no lymph node involvement, no extraprostatic extensions but positive surgical margins (Some cancerous tissues left by the surgeon after his job ). My cancer staging : T2cNoMx . My PSA before surgery was 7.9ng/ml and 3 weeks after surgery went down to undetectable ( 0.07 ) before any further treatment could start.

I fell into the high risk category mainly because of the Gleason scorebeing 9 ( 8,9,10 - high risk ) and also with the added risk factor - Positive Surgical Margins.

I believe "knowledge on PCa" is foremost important in making right treatment choices.

In a high risk case like mine, after allowing for about 3 weeks for healing post surgery, adjuvant radiation is needed to the prostate bed to kill the residual cancer cells mainly caused by positive surgical margins. It has been found that radiation is most effective when given along with ADT. To avoid side effects as much as possible I used IG-IMRT ( image guided intensity modulated ) - 76Gy - 36 sessions. I used ADT2 ( Zoladex 10.8 plus Bicalutamide 50mg). Uptodate ( 21 months I am on the ADT2 protocol and my PSA is remaining at 0.00ng/ml. The only side effects, I am 100% impotent ( should be obvious ) but fortunately, fully continent. I will be completing my planned 2 years on ADT in April 2016.

My next move, treatment strategy is going to be very critical and my choice is purely based on knowledge factors ( I always believe "knowledge is power" ). The same knowledge may be useful to you as well in your decision making ( What you are seeking now ). Some useful facts thus : Prostate tumor does not contain all homogeneous cancer cells. They are different types, mainly Hormone Sensitive ( Hormone dependent ) and Hormone Insensitive ( Hormone independent ). PCa treatments are two types. Curative ( That kill or destroy cancer cells and try to cure ) and Palliative ( That suppresses the growth and progression of the cancer ). Palliative treatment cannot cure PCa although some hormone dependent cancer cells may undergo apoptosis ( cell death ) for not having androgen for their growth, whilst the majority will remain dormant only. The hormone insensitive cells relatively in smaller number at the early stages don't care at all for any kind of hormonal therapy and grow slowly and silently until they take full control of the situation and cause disaster. Only treatment protocols that use cytotoxic ( killing cells ) drugs and other killing procedures can deal with these nasty cells. Radiation can kill cancer cells but it is focal and not a whole body ( systemic ) treatment. Salvage radiation can be less effective. Chemotherapy is a cytotoxic ( killing cells ) and also a whole boy treatment. All these aggressive treatments are associated with significant side effects that affect the quality of life. The Hormone Therapy which is widely practiced even today has not changed fundamentally for the last fifty years whereas prostate surgery and specially radiation techniques have seen vast developments and innovative changes.

Therefore from the above you can see, Hormone Therapy and its modalities ADT, ADT2( With bicalutamide ), ADT3 ( With bicalutamide+Avodart ) ; Continuous therapy or Intermittent, First line hormone drugs, Second line hormone drugs, Third line hormone drugs ..........all Hormone! Hormone! can only buy time without destroying the cancer cells. True enough some individuals can enjoy long years with their response to hormone therapy but the nasty hormone insensitive cells don't give a damn to these treatments and silently progress to create a catastrophic situation with a deadly blow. In some cases, even the hormone dependent cancer cells become castration resistant sooner or later. Even chemotherapy drugs being cytotoxic cannot kill all the PCa cells in the body when advanced metastatic stage is reached.

So, I have decided to take a short break after completing my 2 years on ADT2, and then go straight away for the "kill" by using Docetaxel ( chemo ) taking the earliest opportunity without buying any more time with further ADT. This will be the ideal time when the cancer burden is very low and the cells are sleeping whilst I am strong enough to better tolerate the associated side effects.

Some individuals, depending on their age and priority interests may take a different route but I am asking from myself what else is more important than "life" if one likes to live it.

I also appreciate the valuable inputs contained in the replies of all the others who wanted to help you and I am proud of them.

Good luck and Good Health!

Sisira

[efsculpt in reply to Sisira]

Thanks, Sisira. I'm 71 and share much of the same numbers. I'm considering docetaxel. Have you looked into Lukine as an immune system stimulant while the cancer is "down"?

[efsculpt in reply to efsculpt]

I think your choice of Docetaxel is good. The more the cancer is hit from different angles (Docetaxel inhibits rapidly dividing cells from dividing) the longer it will take for the cancer to get "up and rolling" again.

Another "angle" is angiogenesis. Inhibiting the growth of new blood vessels to the tumor (s). Leibowitz in LA uses Thalidomide to do this (side effect peripheral neuropathy). Here is a write up on angiogenesis- jhoonline.biomedcentral.com.... So, pounding cancer without over pounding yourself. A delicate balance.

[Sisira in reply to efsculpt]

Well, Leukine which is the brand name for the hormone GM-CSF or granulocyte macrophage colony-stimulating factor is normally used to reverse low white blood counts caused by chemotherapy and it also improves host immune response to cancer. Nutropenia ( Abnormally low white blood count ) can increase the risk for infections during chemotherapy. Prednisone (steroid) used invariably with Docetaxel also adds to the immunity and also improves the lost energy levels to a considerable extent. There are other drugs also to treat neutropenia.

All these drugs cannot be included in one single treatment regimen but combinations should be worked out according to each individual's pathological condition of the cancer. This is no easy job. We have to discuss with a good medical oncologist before execution of any treatment plan and your proposals based on sound knowledge will be very useful.

I have in my mind all sorts of ammunition but the tragedy is in my small country ( Sri Lanka ) I can't find a single Oncologist who is specializing in treating prostate cancer. This is a serious issue, but I am sure "knowledge" can conquer anything you need, if you have a will.

Cheers,

Sisira

[Hidden in reply to Sisira]

I see GM-CSF used in apheresis. It does help mobilize bone marrow stem cells for collection. Dr Pienta in Johns Hopkins uses it (plus plerixifor) to mobilize not only stem cells but bone mets.

I wonder of GM-CSF also causes the mobilization out of the bone of bone mets...?? I think at least a little, it has to. This could also be one mechanism for the value of Provenge - just the aphersis phase alone could be helping.

[Hidden]

Question: are the guys with rising PSA trying to get better imaging to help decide on targets for local/focal treatments? Like PSMA scans?

And, if so, would you consider taking testosterone before the imaging to activate the cancer cells so that they can be seen more easily?