Advanced Prostate Cancer

Lupron plus Zytiga

Maybe it's "old news" with you all, but insurance companies are now paying for Zytiga for men that are hormone sensitive. I have Humana and have just started Firmagon/Lupron plus Zytiga. Human sent me a letter saying, "Ok, we'll pay for Zytiga for a year". Johnson and Johnson wants around $7000-9000 a month for this drug.

It's a direct result of the results of the trial (STAMPEDE?) published June 2017 stating that men lived something like 13 months longer on Lupron plus Zytiga.

The two doctors I was seeing had to send to the insurance company results of the trial, and both were approved.

Regards,

Craig

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Very important news about how to approach the Z cost issue. Thanks, Craig. I’m wondering whether to start with Nal’s ADT-5 (or, I guess, ADT-6 now that we know a couple of those fellows have long been on Metformin) and wait until that fails to start Zytiga. Another question is whether Zytiga + Lupron/Firmagon would be worth the expense if a patient had early chemohormonal therapy. Began taking Bioresponse DIM yesterday. Happiness is. Mrs. S

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Got my Humana approval letter yesterday. Co-pay is $980+. My surgical onc nurse is seeking a direct source with 0 co-pay.

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Good to have such an advocate! Someday this will be a level playing field.

Thank you.

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I had early chemo and ADT. I've now had 3 medical oncologists tell me not to do early Zytiga.

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Can’t tell you how much we appreciate this reply, gregg57! Three oncologists saying not to do early Zytiga is good enough for us. (I wonder why they concluded that.) Now if someone could confirm that Leswell should begin Casodex, Avodart, and Proscar. I’m thinking, yes. He’s on leuprolide at present plus a B12 injection. His PSA is down this second round from 169 to 96 with another blood draw next Tuesday. Lupron alone doesn’t seem aggressive enough, but I also don’t want him to become ill as he has never been.

P.S. Gregg 57 is interesting—the year we both graduated from high school. (Richey, MT, and Minnehaha Academy, Mpls. Did you hear about the explosion at the latter? Unbelievable. I was only there for my senior year, but three brothers attended, and long ago my dad taught math there while in seminary. Getting personal again. Sorry.)

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I think the main basis for not recommending early Zytiga after chemo is that it has not been studied. Early Zytiga and early Docetaxel separately but not together or sequentially. Also just had an interesting phone appointment with Kaiser's regional Oncology Prostate Cancer Specialist. She said that at an ASCO presentation this past June there was a specific question asked regarding doing early Zytiga after early chemo. The presenter said it is not recommended. To sum it up, they felt the risks of adding Zytiga after chemo could not be justified by the results. I've reached out to her to see if there is transcript of this Q & A session somewhere. I will post if I can get a source for that.

Actually, I was born in 57, graduated high school in 1975.

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To gregg57,

Yours is as clear an explication of our common issue as we could have imagined.

Our oncologist is intelligent and responsive. I will show him your post. Les and I have read this with full attention (as much as he is able while on ADT), and everything you reported will help many on this site, we’re sure. I wonder how many are in this particular ship adrift at our clinic or in our online community.

Especially since you are so many years our junior, we wish you were in another sailing vessel. (We’ve been escaping with a bit of the old “Winds of War” soap.)

With deepest appreciation to you and yours.

Leswell and spouse.

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Thanks. Please let us know what your oncologist says. I am still trying to get more information on this.

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Will do.

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My thought is to do Lupron and Zytiga, then chemo. The Lupron/Zytiga takes care of hormone sensitive cancer cells, the Docetaxel works on hormone independent cancer cells.

Does one "throw the sink at it" at the start, or dole out treatment, little by little. What about the idea of a durable remission? We may not have the drugs yet, but I wonder if Lupron/Zytiga/Avodart, then Docetaxel, then a vaccine might lead to long term remission in a significant percentage of men.

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Stampede is doing another arm where they are combining Zytiga and Xtandi early using that kind of "throw everything at it early approach." It seems to me that at some point throwing more things at it will eventually reach a maximum benefit. Maybe there's more to be had, but there must be a point of diminishing returns somewhere. Hopefully we'll be around to find out.

But I don't think we should assume that stacking up the treatments will necessarily stack up the benefits. I think that's a big part of all 3 doctor's opinions that I got. The studies showed us that there is an average 13 month overall survival benefit for early Zytiga and pretty much the same for Docetaxel. But no studies have shown that doing them both early together will add anything more.

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In the later Castrate Resistant, pre Chemo context, there are similar questions about possibly combining treatments, such as Xtandi and Zytiga. Here's a Clinical Trial that is comparing Xtandi alone with Xtandi plus Zytiga (& Prednisone).

clinicaltrials.gov/ct2/show...

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That's an interesting one. Can't have had chemo though.

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But is there any studies that show that taking Zytga and Xtandi doesn't extend survival?

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I am on the thinking that I need to "throw the sink at it " early. Hope I continue to to be undetectable for a very looooong time.

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If I remember right, late (hormone refractory) Zytiga gave you 4 months longer.

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Yep, about 4 months longer Survival. And it also made a big difference in whether or not the Clinical Trial participants were "sicker" and had already had chemo, or whether they were still chemo-naïve. In Study 1 with men who were "sicker" and had already had chemo, the median Survival was 15.8 months for Zytiga compared to 11.2 months for Placebo. In Study 2 with men who were chemo naïve and less sick, the median Survival was 34.7 months for Zytiga compared to 30.3 months for Placebo.

Reference:

zytiga.com/shared/product/z...

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what is hormone refractory? does that mean that you use the zytiga after Lupron fails? Ive been trying to figure out if using Lupron and zytiga together last longer than using them sequentially?

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I started chemo when diagnosed, then started Zytiga and Xtandi a few moths afterwards. That was in 2011 and still on them. So far no problems but everyone's body is different. Has been undetectable since. My doctors always say I'm lucky, which makes me a little scared like it shouldn't be this way.

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I did early chemo and then Zytiga and Xtandi immediately after that. I'm interested to know what risk is the oncologist talking about. This was in 201 and so far, knock on wood, I'm still feeling fine and "undetectable ". Thank you Jesus.

If your doctor is affiliated with a hospital, they couldn't give medications early like I did because of hospital PROTOCAL. My doctor has his own clinic and is independent from a hospital and their PROTOCALS. In other words, their hands are tied up in what and when they can prescribe for you. That is my understanding.

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I think to a certain degree you are right, but my doctor did say that if I really wanted it, I could have it. I didn't push it, but I suppose they could still say no. My doctor said she was at the ASCO conference this year and they specifically said early Zytiga was not recommended after early chemo mainly because of additional toxicity, and also because it wasn't tested in the trial. Her reasons did seem a little weak to me, but it's hard to go against 3 separate doctor's opinions. I am asking her for something written to support that and she said she would try to find something. We need to have some guidelines published regarding this issue.

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How did you get insurance to approve Zytiga and Xtandi at the same time? Do you know where I can find a clinic that might be more likely to approve them? How does the zytiga affect you? Weight loss, cramps, high blood pressure etc? Does using Lupron and zytiga sequentially have shorter effectiveness than simultaneously? thanks,

George

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My doctors, Dr. Scholz and Dr. Meyers both have their own clinics. Call Dr. Scholz's office and visit or talk to the Dr. Dr. Meyers is retired. My insurance company is the sister insurance company to Blue Cross / Blue Shield on the mainland. Maybe it is how Dr. Scholz or Dr. Meyers orders the Zytiga and Xtandi. I forgot what they call it when they order it for a different disease and not prostate cancer. No weight loss, in fact I am trying to lose weight. I used to have leg cramps but not anymore. I think you got to drink more water for that. About 6 months ago, I used to have blood pressure of 110/70 or thereabouts. All of a sudden it jumped to 145/95 in the last 6 months. ????? I am trying to figure out why. It might be a couple of things: a real estate project that I am doing right now, but I've been doing it for a long time now. It might be that my in-laws are living with us for 6 months but are going home tomorrow. I'll see if my pressure goes down in a month or two after they leave to go home to China. Or it could be a side effect of the medications that I am taking - but I've been taking them for quite some time now. But that could be a reason too - that I've been taking them for a long time. I really can't figure it out. Ask me again about my blood pressure in a couple months . Good luck. Sorry that I don't know the answer to your last question.

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WHY?

Rich

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Why??

I started Zytiga early.

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Gregg57 I have been told the same thing, don't start using Zytiga until it's absolutely necessary being that I had early chemo and ADT, (Lupron, Casodex). It appears that some patients are being urged to use all their ammo at once.

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I'm still trying to find some published guidelines on this. I think it's time for that to happen. Or they need to do a study. I can see the logic people might use: If Chemo plus ADT gives you 13 months and Zytiga plus ADT gives you 13 months, it's possible that ADT plus chemo plus Zytiga gives you 26 months or maybe something more that exceeds doing it later. But at this point, it's a big assumption that adding the third treatment up front gives you anything.

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Gregg57

I found this, for what it's worth

Next Steps

“We had been treating metastatic prostate cancer the same way for 70 years until docetaxel chemotherapy was shown to improve survival in 2015, and now in 2017 we show abiraterone is also helping patients live longer,” said Dr. Fizazi. “The next step is to see if adding abiraterone on top of docetaxel offers further benefit,” a study which is currently ongoing in Europe."

asco.org/about-asco/press-c...

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Is that part of STAMPEDE?

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gregg57

It's part of the LATITUDE study.

janssen.com/emea/sites/www_...

Personally I'm not buying the 13 + 13 theory. What if the first 13 which is a median score turns into 36 and counting which it has for me, followed by another 36 with Zytiga? I think the best source of information regarding survival rates is this link. It was co written by an oncologist that I used to see before she moved.

ascopubs.org/doi/full/10.12...

She told me that I fit all the criteria for the 75 month median. She (Maha Hussain ) was also the first oncologist who told me that keeping me comfortable wasn't a priority, that keeping me alive was the main goal. Of course My intelligence rivals that of a south American tree toad, therefore I depend on people who have dedicated their lives to keeping me above ground for guidance and where to aim the next bullet.

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Based on these statistics, I would also fall into the 75 month median. PSA nadir and also time to nadir are two of the best predictors for overall survival.

I like the fact that they consider a PSA of .2 to be undetectable. That's where I'm at right now.

Interestingly, PSA at diagnosis is NOT a useful predictor.

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I have Blue Cross. They are paying all but $22 a month for my Zytiga that I am taking with Lupron.

Please do not think that your insurance company will not pay for it. Even if they refused a month ago they may now pay for it now.

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DR_WHO

What type Blue Cross plan.

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I live in Michigan. Through work I have retirement medical from Blue Cross on New Jersey. Please note the following. New Jersey has passed the Oral Cancer Fairness Act which forces insurance companies to cover oral drugs. Michigan does not. If my insurance was based in Michigan they may not cover it. Please check to see is your state has passed this act.

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Hello, Dr Who! Do you know where I may be able to find out if it passed in California? I've found some threads, but nothing too clear. : (

My father (76) was diagnosed the day after Christmas 2017 with Advanced PC- bone mets. Started Lupron Jan 29th. Follow up with Oncologist today (blood drawn at 5 weeks from Lupron) PSA was 334, today we were told it's down to 14. Like woah! We'll take it!

She suggested putting him on Zytiga along with prednisone and taking him off Casodex but continuing with Lupron. And then she tells us medicare may not cover it and we are looking at $8-10K a month for Zytiga?!

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My insurance pays for my Xtandi and Zytiga and I pay $7 for Prednisone. My insurance co. is connected to Blue Cross Blue Shield.

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Thanks, I will have to do some research to see if NC has passed this.

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Of course one of the big issues regarding this whole discussion of early chemo vs. early Zytiga is cost. Chemo has a fairly significant cost benefit over Zytiga.

I would imagine that doctors could be under pressure to recommend the cheaper of the two options since both have the same benefit if done early. I wonder how much that is playing into the recommendations that doctors are giving?

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Another consideration is how each approach works. Lupron plus Zytiga is a testosterone reducer. Stop the fuel, stop the cells. Chemo is like a shot gun blast, nailing rapidly dividing cells. That includes both the hormone dependent cells and the independent cells. As our cancers progress there seems to be more independent cells (neuroendrocrine like). But, they are with us even while we are hormone sensitive. So do we nail the 500,000 at the start and have only 25,000 survive, or do we wait and nail the 5,000,000 with 100,000 surviving? Logically, it seems that early "nailing" would be best because with few surviving independent cells it will take longer for them to get to a volume that will "nail" us. I wish logic worked in medicine. There are so many other factors and "unknowns".

Hence, studies.

Craig

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Don't know if this a good analogy, but I wonder if it's kind of like using those wasp traps. They work pretty well early in the season because each year, wasp hives start with one wasp and build up from there. The more you reduce the population early on, the longer it takes them to build up. Once the hive populations build up to tens of thousands or more, they don't work worth a shit. The more of them you kill early, the fewer there are to breed and multiply for later.

Seems like the trials are proving this to be the case with PCa.

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Exactly my strategy. Hit them hard with everything you got when the cancer's army is small. Then your meds and immunity system might better keep them under control or even kill the left over cancer cells. Just my strategy. Hopes it keeps on going for me !!! :-)

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I agree. I know for sure that my body was fighting off the cancer before I was diagnosed. I'm kind of hoping that it is still killing the cancer, especially now that we've brought in some air support.

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How are things going efsculpt? Hope you're doing well ☺

Jackie

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