Lupron + estradiol patch

[leswell]

Just now applied first .1 patch. How often do you check the estrogen level? Do you keep it below 20 or between 20 and 30 as LEF recommends? Our oncologist doesn’t check the T level. Is that important?

[Dan59]

If you are just using the patch to combat hot flashes while on Lupron, I think it is 1 (.1mg) patch per week, I always used 90% alchohol to prep the area and increase absorption. it is different if you are using it to for primary adt , dose is different, but since you mentioned Lupron, I assume you are on Lupron as well. " A Doctor placing a Patient on hormone reducing Pharmacueticals and not checking Testosterone is akin to a regular Doctor putting a patient with diabetes on insulin and not checking glucose levels" Dr Stephen Strum. Just ask him if he could please check your T level, he should say ok, if not, it is time to move onto a Dr. who will listen to you and your request before you get too far into this.

[leswell]

Thank you, Dan59. We will request the test. Someone else asked for a more complete profile. Here it is.

Leswell has endured six cycles of chemotherapy concurrent with ADT and continued on Lupron for eleven months. His Stage Four diagnosis was made April 15, 2016, on the basis of a PSA of 1500, and a Gleason score of 7 + 9. The PSA reached an apparent nadir of 2.82. It ticked up to 2.85 and then to 3.01 after which he went on a three month intermittent vacation. In four weeks the PSA doubled to 6.7, in four more septupled to 49, and after twenty more days reached 90. He has begun a second round of Lupron and applied his first .1 estradiol patch today. We hope to keep his serum estradiol level at LEF’s recommended range of between 21.80 and 30.11 pg/mL. To date, he has not had genetic profiling. His NLR is 1.66. We’re considering requesting abiraterone plus prednisone to increase the months to mCRPC provided he isn’t CR already!

In addition to the PC, either the TRUS or Taxotere likely caused bilateral lymphedema, another incurable condition but one he is presently maintaining at level 1.

The bone scans reveal fewer mets after chemotherapy, but neither Firmagon nor IMRT sound wise due to the danger of infection at the injection site of the former or the possibility of advancement to a higher stage of lymphedema from non-Proton radiation.

In spite of the dire diagnoses, Leswell feels well except for back pain, eats well, and works hard in a 4400 sq ft organic garden.

All suggestions are welcome!

[Dan59 in reply to leswell]

Leswell , I am wondering who had the idea to go intermittent before reaching undetectable, before that time I would say you were having a fantastic response. I do not know the estradiol numbers needed to prevent hot flashes , most men just do the single patch and let it go at that. I myself presented as a Gleason 10 , BPSA 148 , stage 4 over 11 years ago, I have been on continual therapy since, and had a psa nadir of 3. Lets hope the Lupron brings that psa back down . Genetic profiling is good if they will do it , but I think only a 30% chance they will find something that makes a difference. I wish you both the best , Dan

[leswell in reply to Dan59]

Dear Mentor(s), We were delighted, Dan, to find your reply now that our email lives have become more orderly with Outlook. (Surprises abound.) Les’s response to ADT was, indeed, dramatic and positive. Now he’s back on it and having a few hot flashes once again. Let’s hope that means the drug is working! We’ll post when there is something definitive. I could tell my husband was moved by your response. Jan

[leswell in reply to Dan59]

Dan59,

How was the fishing?

I’m still thinking about your reply. Neither my husband nor I understand the choice of intermittent ADT. It was the oncologist’s decision for which we were unprepared. Although we had three months of life more as we had known it, we question whether the “vacation” was worth ending up at a 169+ PSA when we had been down to 2-3. We are relieved that it is coming down now that he’s back on the increasingly painful monthly Lupron injections.

Don’t worry about all of us. Take care of yourself and sleep well.

Leswell and spouse

[Dan59 in reply to leswell]

Leswell, I am pulling for you to get that psa back down, I am not leaving for Alaska until Sept 9, I feel much better these days, and we had a wonderful day with Family at the Pool today, Yesterday I was on a Lake up in the Adirondacks. I Have never been off therapy in all 11 plus years, Pretty sure after a while it will become the new normal and be more tolerable, Though I think the 1 month shot may be more effective the 3 month , 4 month and 6 months shots are available, with the longer shots one may want to check testosterone levels toward the end of the cycle.

We are all pulling for both of you.

Dan

[leswell in reply to Dan59]

To Dan59

P.S. Thanks again. It’s good to know that the one month shots are likely more effective. Les says he’ll stay with them. The oncologist made a note to himself about our request for a T and DHT reading. (We’ve never had one.) I doubt our clinic will do them regularly.

You know about Nalakrat’s recommendation for the 15 mo. Vantas, i.e. “Steady Eddie”. Don’t think Les’s oncologist is too interested in that as he wants to “keep an eye on him” monthly. He wants him to exercise an hour a day and remain positive.

P.S.s cont.: I’ve spent the past hour trying to force the Health Unlocked app to switch to landscape mode so I can see what I’m typing. Believe me, I’ve tried EVERYTHING. (I’m in iOS 11 which is still in Beta, so maybe there is hope by fall. It may be in the hands of Health Unlocked though. No big deal. Just forgive all typos.) Off to help reposition hoops in the garden. Mrs. S

etc. We had the best wild Alaskan salmon for our anniversary! And there are leftovers. He’s just brought the most gorgeous Savoy cabbage to the door. How can we not be positive.

[leswell in reply to Dan59]

To Dan59,

Since you have just been to the Appalachian Mts., I’m sending another P.S. My brother’s granddaughter (andyandasha.com)

is getting married in Tinmouth, VT, in the Taconic Mts. The wedding will take place here:

Several of the family from Northfield, Mpls., and St. Paul will be heading for the Appalachians in October. Here is the happy

couple:

Both are singers. She’s a graduate of Cornell and The New England Conservatory of Music and auditioned twice here in the

the Twin Cities for the Met but didn’t make it. So now she’s started a cake company!

We won’t be attending, alas. Fatigue and all that, you know. In addition to the wedding on the property, they’re apple picking,

beer tasting, and picnic hiking. Sounds fun.

Go better.

Mrs. S

P.S. Oops. Your were in the Adirondacks. New York anyway.

Can’t insert the photos. One was of their house in 1840 in Tinmouth.

[Dan59 in reply to leswell]

Mrs. S , I have been to the Appalachian Mts, It should be beautiful there in October! It sounds like a great time.

[leswell in reply to Dan59]

The big news today is ADT + Metformin and the Madison, WI study. Just wait until I see our oncologist. It’s even affordable. Hope springs.

Thank you.

[Sisira]

Hello Ieswell,

Though with an initial adverse pathology of Stage IV PCa, your diagnosis was only in April 2016 and the journey has just begun. Thank you for having given your detailed profile. Dan59 is an excellent mentor with more than 10 years successful battle experience with many types of treatment strategies used for his Stage IV, GS10 PCa. I am only telling you, that his further opinions can be very useful in managing your case should you have anything more to clarify.

Thank you Dan for helping us so generously.

Sisira

[pjoshea13]

The LEF estradiol [E2] range of 20-30 pg/mL is a rough guide. In terms of bone health, E2 should not go below 12. In the context of Lupron, I would aim for ~20 pg/mL.

Here is Dr. Myers:

askdrmyers.wordpress.com

Scroll to "Transdermal Estrogen + ADT" (May 27. 2016)

The patch he uses is the Vivelle-Dot 0.025 mg estradiol patch twice weekly.

His discussion of blood clot risk is a bit irrelevant, given the dose & intended target.

Once you have evidence that your dose is getting E2 into the right ballpark, I wouldn't obsess about E2 testing.

Men do better on ADT if low levels of T can be attained. Recent papers suggest that <20 ng/dL is better than <50 ng/dL. (i.e. <0.7 nmol/L versus <1.7 nmol/L.) It's worth testing T, I feel.

ncbi.nlm.nih.gov/pmc/articl...

Dr. Myers has said that the aim of ADT is to get DHT (dihydrotestosterone) down to therapeutic levels, & that some men with castrate T do not have castrate DHT. He always tests DHT & uses Avodart, if necessary.

-Patrick

[leswell in reply to pjoshea13]

Thanks for the articles and excellent advice, Patrick. We will aim for ~20 pg/mL with the estradiol and <20 ng/dL rather than 50 for the T. And we will discuss DHT testing and possible Avodart as soon as we know if Lupron is bringing the PSA back down at all.

Les–and Jan