Initial diagnosis: August 2014 Stage 4 PSA 700 with Bone metastasis, Gleason 4+5
Treatment: Injections of Androcur for 6 months, bilateral orchiectomy in winter 2015 (the lowest PSA was 1.37), he cut down on meat, sugar and animal fats, supplements - reversetol, green barley.
Now: PSA has been rising for the last 2 years, now it is 5.5, testosterone is 0,14 ng/ml. Two oncologysts suggested chemo as the next step.
Questions: His testosterone is low enough, but testosterone production from adrenal glands has never been suppressed. Can any hormone therapy or something that suppresses testosterone or dihydrotestosterone (casodex, ketonazole, avodart...) help him or is his PC castrate - resistant? Zytiga and Xtandi are not possibe as long-term treatment for financial reasons.
I know that chemotherapy isn't that horrible, but my father wants to postpone chemo, because he thinks he is quite old to undergo chemo and he is convinced that chemo can only help for a few months, considerably decreasing the quaility of life, and it's very difficult to perusade him.
if chemo is the only option, should he undergo treatment after PSA reaches a certian number like 10( or 20) or should he wait for symptoms to come?
I apologize for any mistakes as English is not my native language.
I would be grateful for any replies and sharing your experience.
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i just enrolled in this trial: NCT02090114. It uses testosterone, so unexpected. But ask around. It is being conducted at 17 locations in the US, so one may be near you, if you like the concept. Videos about it on YouTube. "Denmeade".
But also note that trials can be "free", with the exact details varying. Plus sometimes travel costs being a new class of additional expense. Not the $99,999/year though.
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Chemo gave 1 year bonus to patients with multiple mets at diagnosis according to the CHAARTED trial. I am 72, and chemo was not a big deal for me. The thinking now is that most treatments are better earlier than later. Of course there is a limit. Obviously not before you get cancer, for example.
I would not suggest waiting for symptoms - ie pain. Meanwhile try to avoid a heart attack or stroke. It sounds like you are doing that already.
Taking statins? Cholesterol is the "raw material" for testosterone.
Thank you for the advice, we live in Europe, and nobody has mentioned statins as a possilble way of treatment... I've read about them, I will persuade my father to raise this matter at his oncology apointment.
I believe casodex or generic bicalutamide blocks the adrenal androgens and Avodart generic dutasteride suppresses dihydrotestosterone and both of them together with Bilateral Orchiotomy would be equivalent to what we use to call adt3 or a complete blockade. Nilandron is the same class of drug as casodex /bicalutamide and sometimes works when casodex does not. Ketoconazole is next and it also blocks adrenal androgens. In my opinion these strategies could be used to possibly stabilize his disease. just a fellow patients advice.
Thank you for the answer. The question which we don't know is whether my father's PC is castrate - resistant. Probably we should try to add bicalutamide and see what it does to his PSA...
If your father has had an orchiectomy and his PSA is rising, unfortunately he is castrate resistant, no question about that. I agree with trying to add Bicalutamide. There are people that have used that as a mono therapy and gotten quite a bit of time from it. The best choices are Xtandi or Zytiga, but if those are not available, you have to go with what you can get. Chemo is also an option, I'm doing that now and it's quite tolerable for most. Good luck with treatment.
IMO adding Avodart , a basically benign drug used to lower DHT and shrink prostate would be good to add to Casodex/ Bicalutamide ,Its Generic is dutasteride. A recent paper out of New England Journal of medicine cites longer median time to progression when used with Ketoconazole esp significant if you go with keto at this time, but also good to do with casodex/bicalutamide in the opinion of many leading prostate specialist in this country, but not all. In this study the men were already castrate resistant. Here is the study one of the only ones done with adding dutasteride, also mentions that adding dutasteride to newer cpy34 inhibitors like zytiga should work well too. Here is the peer reviewed paper, I could not find the NEJM copy but this is peer reviewed from Harvard. clincancerres.aacrjournals....
You describe a tough call for your dad. Different chemo treatments have different downsides as well as potential benefits, so discussing these with your oncologist is important. It is also important that you or another third party join your dad in this discussion: any patient is likely to listen selectively to what your doctor is saying when it comes to scary sounding treatments. It might take more than one appointment for all of you to be clear about the options.
But once your dad is clear about the pros and cons of treatments, he has to make an informed quality of life decision. I'm about your father's age, and I'm OK about dying, but I'm also getting great satisfaction out of living. I've been through chemo, Provenge, radiation and Xofigo (Radium injections), plus Lupron, Casodex, Xtandi, and Zytiga. So far I've found that life is worth living, even with the side effects of all the treatments. BUT if and when I feel like the treatments rob me of my quality of life, I reserve the right to refuse treatment. That's not because I don't love the people around me, but because they can't make the quality of life decision for me. I have to decide for myself when enough is enough. If I were your dad, I'd start the chemo and see how it goes, but if it makes life awful, then I'd stop. If I were you, I'd want to keep my dad alive at all costs, but realistically, I'd know that I don't want him to suffer.
Thank you for the reply. Your approach to life is really admirable. I have never spoken with my dad about death, but I assume he is mostly afraid of suffering and being helpless, not death. So far my dad's quality of life has been quite normal. He'd had back pain before he learnt that he had PC. However, after initial treatment back pain went away, and he has been fine for 3 years. He still works, and I would say he lives his life as he used to in the past. For many people chemo is associated with suffering, I know it is a common misconception...I think we will try to lower PSA by adding bicalutamide. If it doesn't help, we might try statins, and then we'll do chemo..
I am not medically trained. But after accompanying my husband for all those years now and taking part in every single consultation with the doctor as well as having read a lot, I would think that if Xtandi and Aberaterone are not an option, then Chemo might be, but I would wait until the PSA has reached a level of let's say 30 or 40 and, most importantly, do a scan prior to starting treatments. I am saying this because, in our case, the oncologist sometimes has to be reminded that it is time to do a scan and not just give treatment.
So I would say see the oncologist and discuss it with him.
I would not say that at 70 your father is too old to receive chemo. If he is otherwise, apart from the cancer, in good health, and if his weight is okay, then it might be an option and he might get a good few years out of the treatment.
Thank you very much for your reply. My father is in good health, his blood pressure is perfect, he is quite skinny, but I doubt that it can a be a problem. After trying Bicalutamide, our next option we' ll be chemo, I hope I will persuade him.
I am sorry to learn the unfavourable pathology of your father's PCa at diagnosis. At the same time I should thank you for describing the case briefly but very clearly. I would like to add my points as follows :
- Your father has undergone bilateral ochiectomy which is a permanent surgical castration and not reversible, suppressing the production of testosterone by the testicles as opposed to chemical castration which can give the same result by injections such as Lupron, Zoladex etc. But the advantage here is the suppression is temporary and the testosterone production will restart when the hormone therapy is stopped. In both cases androgen production from other sources, mainly from Adrenal gland will continue.
- Out of the drugs you have mentioned, Zytiga is the most effective second line hormone therapy which can go even to the extent of suppressing the androgen production by the Adrenal gland as well and by all sources.
- Bicalutamide type of drugs are called Anti-androgen and their action is to block the androgen receptors of the cancer cells preventing the entry of testosterone ( food ) into the cancer cells. When this action fails Xtandi which is the strongest blocker is used in advanced treatment.
- You have stated clearly you will not be able to use Zytiga and Xtandi because of the enormous cost. Not only you but because of the cruel pharmaceutical companies, many PCa patients are unable to bear the cost of these drugs. Even the permanent surgical castration is imposed upon people for the same reason because the chemical castration is much more expensive. However further down I will try to help you with some other workable options.
- Avodart ( Dutasteride ) is not a costly drug. It is called a 5Alpha Reductase Enzyme Inhibitor. Its action is to suppress the production of DHT ( dyhidrotestosterone ) which is much more potent than testosterone in fueling the growth of PCa cells. So if you use Lupron + Bicalutamide + Avodart, it becomes a stronger Triple Blockade.
- The treatment regimen your father has so far followed under your circumstances appear to be good enough. Other precautions taken such as avoiding red meat, dairy products, sugar are also good. But what about taking supportive supplements such as green tea, brocoli, lycopane, pomagranate, Vitamin D3 ( check the level and supplement - very important ) . Learn more about the good supplements and give him. I am also 70. Regular exercising is a must to overcome fatigue.
Now let me give you some affordable treatment options which do not involve the expensive types such as Zytiga, Xtandi, Radium 223, Provenge etc.
- Under the circumstances I agree with you Onco's advice to use chemo as early as possible. If you are willing to take this treatment it is unwise to wait further. What do you mean symptoms are there, when you say he has bone mets! Besides the cancer is GS 9 and you have to act fast. Initial PSA and the current increasing trend warrants immediate action. Please read the posting done today by our brother gourd-dancer titled "Stage 4 Treatment Success ( Metastatic Prostate Cancer). A properly administered Chemotherapy treatment has almost cured his Stage iv PCa and this is his 13th year since diagnosis.
- Beyond chemotherapy let me quote some treatment strategies used by the world famous Onco specializing in treating PCa. He is still living and also a PCa survivor for the last 12 years- Dr.Charles Myers! From his book Beating Prostate Cancer : Hormone Therapy & Diet
"Ketoconozole effectively suppresses adrenal androgen production, but also directly kills hormone refractory prostate cancer.In patients who have failed initial hormone therapy, a standard approach is to initiate ketokonozole."
"I have repeatedly used ketoconozole and transdermal estradiol together and found them very effective in treating hormone resistant prostate cancer, even after chemotherapy has failed."
- I should say Estrogen is the cheapest drug which can be used in treating PCa. But you should learn more about it.
- You should also remember the fact PCa cells in very advanced stages will become chemical factories and begin to produce their own testosterone from the cholesterol in the blood and also develop various devices to use different growth factors for their survival and progress unless we catch them early enough and kill them or put all possible road blocks to suppress their growth and progress.
- I don't want to discuss about the ATAMPEDE and CHAARTED Trials because they involve very expensive drugs but you may learn about them from the internet if you have time.
Feel free to ask anything on what I have written above should you need any further clarification.
Hope my points too will add to the useful replies given by other friends in our united group.
I appreciate your deep attachment to your father and wish you the best.
My dad walks his dog 3 times a day around 20 minutes each time, he used to walk much longer, but he is afraid that his back pain might come back if he walks too much.
I will look into all the supplements you mention, thank you so much.
I will make my dad raise all these options at his oncology appointment, even though, he is quite reluctant to ask a lot of questions. He thinks his oncologist (or any oncologist) is a professional and knows what to do.
I've read gourd-dancer's post and unfortunately my dad is one of the people who thinks that side effects might be worse than illness itself, and it takes a lot of time and nerves on both sides to talk him into taking an action.
It seems quite logical to me to try all hormone theapy options and then move on to chemo , but who knows...
once again thank you so much and I wish you the best!
I am 74 and will be starting on my second round of chemotherapy in 2 weeks. My first chemotherapy treatment was 5 years ago. I tolerated that with few side effects and nothing really bad. I think chemo is the strongest cancer killer you can use. Don't be afraid of it. It will extend your dad's life.
Thanks a lot for your reply, I will translate your message to my dad.
Thank you
I hope your father's understandable fear of chemo doesn't prevent him from considering this very effective treatment option. Perhaps you can show him the favorable discussions of chemo on this discussion board --- maybe use 'Google translate' to allow him to read these. BTW, at age 67, I don't consider 70 to be that old.
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