Finished 39 radiotherapy for tumor growing out of my prostate 5 weeks ago. Been on Degarelix for 3 years and the tumor grew during the year I was supplementing with Cosudex. Last visit to oncologist 2 weeks ago discussed docetaxel plus predisnone. Sent me for scans and further blood tests. Had the bone scan Tuesday and blood tests Wednesday. Had CT scan this afternoon. Due to scheduling I met with the Radiation Oncologist before the CT scan (meeting Oncologist next Tuesday). Results of bone scan and blood tests better than good. Most metasticizes gone! PSA down from 1.9 to 1.3. All other blood tests fine. So, the only unknown variable is the CT scan.
If that is okay, I am wondering why I would need to go on chemo? Wouldn't watchful waiting be the best option? Of course the Degarelix will continue each month.
Would appreciate some input to assist me in my deliberations.
Thanks
Chris
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Christor13
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I am not completely familiar with your case nor am I the Doc in charge but yes, I am wondering why the rush to start chemo now with such a low psa, but the bad news is that the psa will probably rise at some point and then chemo is required, but whats the rush other than they want to hit it while it is low and be able to give you a lower dose which would be nice, I just finished my third cycle of chemo and I feel sick at the moment
I expect to feel better in a couple days, I have bone mets and the chemo actually reduced my bone pain and I was feeling good in between chemo cycles and my psa has gone down from 45 to 4.9 in two months, so I am going to continue to ride this horse as long as it works.
Having chemo at this stage is not the normal protocol. I am wondering if the docs thinking is that since early chemo is effective in newly diagnosed men with aggressive disease that it might be a positive for you.
If this is the thinking, I don't believe that there is any evidence that would either support or not support this approach.
Normally I would expect either Zytiga or Xtandi as your next drug.
Prostate cancer is not homogeneous. It is heterogeneous. That means there are different varieties of cancer cells in the tumor even at the time of diagnosis. Majority of these cancer cells are hormone sensitive ( Depends on hormones for their growth ) but there is a minority - most dangerous - they are hormone insensitive ( Do not depend on any hormone ) and they progress very silently. Therefore any of the hormone therapies/drugs/treatments are totally irrelevant to them. These are the cancer cells which start causing havoc during CRPC ( castration resistant ) stage. Even the hormone sensitive type, sooner or later may become resistant to hormone therapy ( hormone refractive ) like various viruses against antibiotics. Therefore all types of hormone therapies/drugs/treatments can only suppress the growth and progression of prostate cancer only up to a limited period of time. Some individuals respond to hormone therapy over a long period of time depending on their pathological risk factors before they become CRPC. Hormone therapy is considered as a palliative treatment ( not curative ) but has the advantage of being systemic ( whole body ) treatment. During hormone treatments some of the cancer cells - hormone sensitive - may undergo apoptosis ( death ) but majority will remain dormant and will start growing again.
Then how to destroy/kill all types of PCa cells becomes the key issue. Only antimetabolites or cytotoxic ( cell killing ) drugs can do the job. Strong radiation beams also can destroy any type of cancer cells but the treatment is focal and cannot be used as a whole body treatment. Now research is being done to develop radio active isotopes to be used in systemic treatments as well. Already Radium-223 ( Xofigo ) is used to treat bone metastasis.
Now I will come to chemotherapy. This treatment protocol uses antimetabolites or cytotoxic pharmaceuticals which can kill cancer cells as has been explained above. They are strong drugs such as Docetaxel, Cabacitaxel etc. and often associated with significant side effects. But they can be tolerated with pre-planning and preparedness. Early use of Docetaxel, synergized with appropriate combination of other drugs will give more tangible results whereas, when given too late at CRPC stage may not bring any favourable results.
Hope the above information will help you to make your decision whether to continue with palliative treatments ( hormone therapy ) and buy more time or use a cytotoxic treatment ( Chemo ) which is also a systemic ( whole body ) treatment. Certainly, pros and cons you have to discuss with your oncologist.
Thank you Sisira that's the most comprehensible account of my treatment over the psst two years plus my projected treatment once Zytiga gets tired. I now understand why my PSA has gone from 200 to 0.15 and why my drugs have changed rather than having increased doses. We're hunting mutating cells constantly.
Why would Docetaxel at CRPC be "too late"? Wouldn't this drug stop rapidly dividing cells any time? Here is the dilemma for those with a rising PSA after the "cure" attempts. Is it a drug by drug "dance" approach or a "throw everything at it from the start" approach?
In the conventional approach in treating PCa, CRPC is the stage for the use of chemotherapy ( Using drugs such as Docetaxel, Cabacitaxel etc. ) as the standard treatment protocol and it is not considered as too late. Any how at this stage the cancer is not curable but only treatable although the drugs used are cytotoxic. You are right when you say these drugs are used to stop the rapidly dividing cells including both cancer cells as well as normal cells. That is why the side effects are so significant.
Now I would like to highlight your statement "throw everything at it from the start". All depends on what your starting point is. If at the time of diagnosis your pathological findings are too bad such as the cancer has already spread, your PSA is high and the Gleason score is 8,9 or 10 ( very aggressive cancer ) , this is a very bad start, causing panic to most of the people and aggressive treatment protocols will start. One may interpret this situation also as a kind of "throwing everything at the cancer from the start"
On the other hand, it is an obvious fact that the cancer burden ( or volume of cancer ) is very high at the CRPC stage and some cancer cells most aggressive and dangerous ones are hiding in places difficult to reach for treatment, marking their time for a catastrophic attack. Usually, we spend a good number of years trusting too much on the hormone therapies where as this treatment approach has not changed fundamentally for the last 50 years. ADT can only suppress the progression of only one type of cancer cells ie. hormone sensitive ( hormone dependent ) type. That means during these so many years we are allowing the nasty, most dangerous type ( hormone insensitive ) to grow silently and finally take our life. That is why having spent so many years, when all HTs fail and the CRPC stage is reached, application of Docetaxel is very unlikely to bring about the desired results.
Therefore, for high risk prostate cancer ( Gleason 8,9 and 10 ) Docetaxel will prove its worth when used at an early stage when the cancer burden is low ( Lesser number of cells to be destroyed and also the cancer cells have not yet become monstrous ). Used along with early ADT the protocol has proved to be more effective. It is easier to kill the enemy when it is sleeping. If the monster gets up when all hormone therapies fail ( CRPC ) there is no place for us to run!
Whether you should use chemotherapy or not is a different question. It depends on other important factors too such as your age, overall health status, quality of life concerns etc. There is no doubt, it is a very aggressive treatment associated with significant side effects because the drugs used are toxic.
I am very happy. This is what you should be able to do.
First understand what type of PCa you are having at the time of diagnosis and its status according to the pathological findings including Gleason Score, PSA and the TNM staging.
In your own situation how far Hormone Therapy can help you to manage the disease and its limitations. ( Not curative, only palliative ). What are the drugs used in HT ( first line, second line etc. ) and their action and side effects.
Don't forget the fact that PCa is heterogeneous and ask the oncologist what he is going to do about the nasty cancer cells which don't give a damn to hormonal treatment, which can survive with various other growth factors. They can synthesize their own food! Even if you have started your HT ten years ago these dangerous cells were working in their laboratories silently even before your diagnosis.
It is a pity that our oncologists don't do sufficient work to catch these nasty cells early enough and destroy them. Instead they use HT to suppress the growth and progression of the other type of cancer cells ( hormone dependent ). The sad part is, actually it is the suppression of our knowledge that some lethal cells are still growing silently to overpower all types of treatment at one stage and take our life.
I am not quite sure when our oncologists will pay sufficient attention to this stark truth.
Hope, Success and Well being!
Sisira
"Watchful waiting" is a strategy that is used after diagnosis and prior to any treatment. While it is true that there may be "waiting" post diagnosis, and one may be "watchful" as well, it probably is not too good to extend the use of that phrase to this time period. It can only give false assurances, and actually reduce the "watchfulness" of the "waiting" involved.
Chemo is often given every three weeks. After one treatment, a person has to wait for three weeks for the next one, but no one calls this interval "watchful waiting", even if they may watch during this time.
My 2 cents, i went on docetaxel shortly after my diagnoses. My psa was 850 with 3 mets and extensive lymph node involvement. Fast forward 18 months, my psa is now 0.08 and holding steady. Once it rises to double digits, I'm going right back to another course of docetaxel while remaining on lupron. I'm saving Xtandi for the day when docetaxel no longer does the job. I see Cabacitaxel as my 3rd round of chemo.
I did 6 cycles of docetaxel spaced 3 weeks apart. I took a total of 3 predisnone tabs per cycle. If I remember correctly, 1 the night before, 1 the morning of, and 1 the night of. the entire thing was breeze. I did get a tad fatigued about the 4th cycle but never vomited, etc. I feel it was the best move I ever made. Of course this is just my experience, however it was recommended by Maha Hussain who is a world renown prostate cancer specialist. She was at the university of Michigan at the time.
Nameless, I am reminded of the great poet William Shakspere who said "What is in a name that which we call a Rose by any other name would smell as sweet". If you can give any name!
I am very much motivated by your reply which says how much you "enjoy" the Docetaxel treatment whereas for many "chemo" means yet another monster! This is because the doctors fail to explain the scientific principles involved in these treatments. If one knows, then it would be easier to assess the risks and benefits and make a rational decision.
My PSA has remained at 0.00ng/ml for the last 21 months. RP in March 2015, adjuvant IMRT ( 36 sessions - 74Gy ) with concurrent ADT2 ( Zoladex+Calutide ) going for 2 years. Staged T2cNoMx, Gleason 4+5=9 with positive surgical margins. Asymptomatic .
I am eagerly waiting to use Docetaxel upfront no sooner I come out of my ADT cycle and see any indication of a PSA rise. No more watchful waiting and buying time with hormonal treatments including second line drugs such as Zytiga and Xtandi. I prefer to use the killer metabolites.
Do you think my line of thinking is correct or can it be detrimental?
I wish I had an answer for you regarding your timing involving Docetaxel. As one world famous oncologist once stated, "all cancers can be cured however the cure will kill the patient". In my case I was advised to be treated with Docetaxel very early due to the results of the CHAARTED study which showed that I had a 50% chance of living for at least 5 years. Because my cancer was found in the stage 4 phase, I took those odds.
Several weeks ago I posted here that a friend, 4 star general Robert Cone died after a 5 year battle with prostate cancer. He went through 60 cycles of Docetaxel before his body gave out. Yes, 60. At one point, his entire skeletal system was one big cancer mass. They quit counting mets at 200. He should have been dead in one year but chemo keep him going.
I'm very happy that I jumped on the chemo bandwagon as soon as possible. However, I'm just about the furthest thing from being an advisor as anyone can get. I needed something besides Lupron and casodex to knock my cancer back and chemo did just that. Bottom line, only you can decide what to do with your body, as I did with mine. good luck to you.
I was on ADT, my PSA was 1.2, there were no bad blood markers. I was constipated and finally a n oncologist ignored the "good" readings and sent me for a scan. Apparently the biggest tumor the radiation onc had seen growing out of prostate and invading the bowel!!! You are right it is heterogeneous, silent and slow growing!
Sisira, thanks for your informative posts. I was wondering about how aggressive treatment should be for someone like me with stage 2, supposedly still confined to prostate. I had HIFU surgery a couple of months ago and I will get my first PSA reading in a couple of months. I was Gleason 8 (5 of 12 positive, one 8, one 6, and three 7's). I was planning to discontinue ADT and see if the surgery did the job. Or should I insist on more aggressive treatment? I don't like ADT and being chemically castrated. I am 66.
Hope you are choosing your treatments intelligently. Your PCa is T2 organ contained is supposed to have been destroyed by the HIFU treatment. But HIFU is a focal therapy and not Systemic ( Whole body ).
GS 8 and above are aggressive PCas and microscopic PCa cells would have leaked into your blood Vascular system and lymphatic system even before your diagnosis. This micrometastasis can eventually develop as CRPC ( Castration Resistant Prostate Cancer ) unless treated In time properly to achieve a cure or stable long term remission. Because of this potential risk, obviously a systemic treatment is necessary.
As I have explained earlier ADT is a systemic treatment but it is only palliative and not curative. Sooner or later the cancer will come back and start to spread rapidly.
Going for a kill of the cancer is to use systemic cytotoxic treatments not caring for the side effects. ( I don't mean over treatment ).
You have to be realistic. Our likes and dislikes cannot be counted in treating PCa. What Is important is to give the right treatment at the right time. In general all PCa treatments have significant side effects and more aggressive PCa needs equally aggressive treatment. It is an important decision one has to make whether to accept suffering/tolerating the side effects and live or die without being treated. But the treatment plan must have a clear objective.
IF you have anything not clear in this reply, please feel free to ask.
Sisira, my New Year's resolution is to find an oncologist. That seems scarier than finding a urologist or even a surgeon. I don't think my urologist will be of much help -- he didn't like me getting HIFU from outside his practice.
I didn't want to touch on this disappointing aspect of finding a good Urologist or an Oncologist. Realistically, our battle is not with the cancer but with these doctors!
Anyway work hard and get hold of a good and reliable Oncologist who specializes in treating PCa.
Good luck Merry Christmas and Happy New Year!
Sisira
Hi Chris,
I was in the same type of situation. My new uro was gung-ho to start me on Xofigo (Radium-223) for the bone mets I have. He said to get 'em before they get worse. Well, I didn't/don't have any bone pain. My new Onc said no way, and instead put me on Xgeva.
I'm curious as to why you're on a monthly injection, as opposed to 3 or 6 month depot injection. You know, co-pays add up.
I agree with everyone about the chemo, not a good time to jump into that can o' worms. I don't know how things work down under, except that toilets flush the other way, but is Lupron or another long term drug available. I get a shot every six months. I'm in nj, usa, don't want to say it to loud. I didn't vote for him.
Hi, I'm at Exit 4. My current uro docs are out of Somers Point. They have an office in Voorhees, a lot closer to me. My onc is in Mt. Holly. Enjoy these last days of indian summer. I hope your Dad is well.
Some of the other replies say it all. ask your doctor why the rush to chemo with a low PSA? It seems like a very aggressive move. Why not go on Aboraterone or xtandi. Once you go on chemo you won't be eligible for some trials.
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Lytic bone metastases?
Bad News. Would appreciate input. 
Chemo 18 dripping now. Good news on response.
WHAT'S NEXT? I am posting this for "Running-on-Empty" (with his permission). 
Good News fora Change
