Advanced Prostate Cancer
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Bone fracture when on ADT

Hi and a very Happy New Year to all from Down Under!

Has anyone gone through the experience of a bone fracture when on ADT?

I've been on Lucrin ( Lupron in the USA ) on and off for just over 2 years. I've been a runner for nearly 30 years. Xmas eve while running,I rolled my ankle and later after an xray found out I had fractured my 5th metatarsal bone. So cast and cructures for 6 weeks. I.ve had several ankle sprains over the years, but this is my first ever broken bone. I'm shattered ( excuse the pun!) because running has helped me stay sane and hopefully been beneficial to me fighting Pca for over the last 11 years.

i'm wondering if healing will be complicated by the ADT. Besides Calcium and Vitamin D3, I wonder if there is anything else i can take or do to for bone protection?.

Btw a Choline C 11 PSMA scan recently only showed Pelvic Node mets, all bones were clear. ( and that is another story on it's own after 2 false negative bone scans in 2014).

Cheers

Mark

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Can not offer any advice but I can relate. Been on Lupron for a year and a half with Zytiga added to the mix last summer. So far my bone density is no longer dense. Been on calcium citrate (body absorbs better) and D3 for about a year. Bone density still going down. Bigger problem is muscle loss. Walking is now hard and going upstairs really, really hurts, but still walking at least six miles.

But on the good side, still here.

Please focus on what you can still do. Hopefully someone else can give you medical advice. Lord knows my doctors can’t.

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Consider xgeva.. it strengths the bone and does have some anti tumor effect relative to the bones. Been on it so that hormonal treatment does not weaken the bones.

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Hi Mark, I've been on ADT since May 2017. Still playing tennis 3 times a week, and took a fall on the court in September while trying to run down a drop shot. Resulted in one cracked rib. Was off the court for 4 weeks but seems to have healed up OK now.

I had a bone scan a few weeks ago, and there were a few questions about this, because it showed up nice and clear on the scans!

But I can see that you have been on ADT longer than I have. I hope that the fact you have kept on running through ADT will have helped preserve bone density

On a similar same topic - I am seeing an exercise physiologist at Deakin Uni. Their Clinical Exercise school is engaged in other trials regarding exercise and prostate cancer so they are well versed in designing individual programs to preserve bone density and muscle mass. Its too early to tell if this is making a difference, but it feels god to me so far.

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I broke my ankle in 2014 four years into Lupron. The bone healed as good as could be expected the doc told me.

It was the muscle damage that took very long to heal. I do take vitamin d but never calcium.

Thomas

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Mark,

Throwing calcium at the problem is unlikely to help if bone density was good before ADT - & high calcium intake is associated with aggressive PCa.

No such problem with vitamin D3.

Many people know about calcium & D3 for bones, but not vitamin K - specifically K2. It is needed for calcium transport to bone.

But the big problem with ADT is that the body may not be making enough estradiol [E2] - it is aromatized from testosterone. Very likely, your E2 is <12 pg/mL. The solution is a very low dose E2 patch, such as the Vivelle Dot. The aim is to get E2 to ~20 pg/mL.

It's a more natural approach than bisphosphonates, of course.

-Patrick

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Patrick,

Is there a level at which E2 becomes dominant in your body and begins to interfere with ADT protocols? What dosage of estradiol keeps E2 at about 20pg/Ml? Thank you.

Bob

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Bob,

IMO, E2 becomes a problem when T is lowish - but not while on ADT.

Life Extension uses 20-30 pg/mL as the optimal range.

When not on ADT, E2>40 coupled with T<350 ng/dL, say, would be an example of estrogen dominance IMO.

With aging men, E2 often rises as T falls - which is why I think the E2:T ratio is useful.

With castrate T, the male body may not make enough E2. From what I can tell from studies, we run into bone problems when E2<12 pg/mL.

Dr Myers has mentioned using the Vivelle-Dot 0.025 mg estradiol patch twice weekly. Personally, I would test baseline E2 before deciding on the frequency, & would test again in a few months, adjusting the frequency if necessary.

Here's Myers:

askdrmyers.wordpress.com

Scroll to "Transdermal Estrogen + ADT" - May 27, 2016.

-Patrick

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I take vit K with nattokinase (in one supplement from Vitacost). I also like to think that the weight training I do (and have been doing for over 20 years) helps preserve my bone health. I've been off ADT for a while and my last T reading was a wimpy 238. I am 67. I wonder if I should ask for E2 testing in next lab work. Thanks for the excellent post, as always.

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Thank you for this information, very interesting.

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Hi Patrick and Others on this Thread,

One caution on Vivelle.dot estrogen patches. Dr. Myers had me on them to moderate side effects of triple hormonal blockade. Having cancer, taking estrogen, and long plane flights to and from South Africa equaled deep vein thrombosis and pulmonary emboli for me. Luckily they were picked up in routine prostate cancer scans, because there were no symptoms!

I was extremely fortunate not to die and spent 8 days in hospital.

Moral of story is be careful adding estrogen to your drug mix because it can cause blood clots.

Best wishes. Never Give In.

Mark, Atlanta

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Mark,

Having had a double DVT in my left leg & spending months in Coumadin hell, I sympathize.

However, I doubt that the E2 patch was a factor.

Before Lupron, DES (a synthetic estrogen) was used for ADT. Taken orally often in doses of 5mg or more, there were plenty of bad clotting events.

I know a number of men who are currently controlling their PCa with 1mg DES & it seems to be fairly safe at that level.

I mention this because a low-dose E2 patch is (a) extremely low compared to 1mg DES, and (b) is absorbed very slowly, and (c) does not go to the liver in the "first pass" as do all oral meds. E2 patches at much higher doses are not associated with abnormal coagulation, the war oral estrogen is.

As you say, "having cancer ... and long plane flights" increase coagulation risks.

It irks me that cancer cases are not monitored for clots. My GP explained that away by saying that doctors lacked the tools to safely intervene at an early stage. Warfarin is too dangerous, & it usually takes a trip to the ER before one receives treatment - assuming one does not die en route.

As I have mentioned in a coagulation thread, D-dimer can be used to rule out a clot (ERs will do a D-dimer test if someone turns up with chest pains.)

If D-dimer is abnormal (or even normal-high) one can use nattokinase to speed up the breakdown of any clot.

Best, -Patrick

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Patrick,

Thank you for the information. I will certainly ask my MO about the patches. He did once suggest them as helping with my hot flushes which I continue to struggle with the 30 plus a day. His theory is that low E2 causes the hot flushes with ADT.

Cheers,

Mark

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Hi Mark,

Re: hot flushes - Dr. Myers says as much in the vlog link I posted.

There is absolutely no downside to making sure that your E2 is above 12 pg/mL. I think that 20 pg/mL is a good target.

No man on ADT should suffer from bone issues related to low E2. Seems to be a blind spot for many doctors.

-Patrick

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Patrick,

I've heard of a higher risk of developing man boobs as a SE of Estrogen patches. What are your thoughts on this?

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Mark,

It's an odd thing that males have nipples, & that enough estradiol [E2], in the absence of testosterone [T] will cause male breasts to develop. T opposes the pro-growth influence of E2, but the ratio matters.

"... an increase in the ratio of estrogens/androgens are thought to be responsible for the development of gynecomastia. This may occur even if the levels of estrogens and androgens are both appropriate but the ratio is altered." [1]

The point of low-dose E2 patches as described before, is to get E2 to a minimal range where bone density can be maintained. I define this as 12-20 pg/mL, although I don't have a specific paper to back that up.

With castrate T, will E2 of 12 pg/mL cause gynecomastia? It really isn't a lot of E2. Men in the group who have used E2 patches & monitored E2 should be able to answer that. Perhaps in a separate thread?

-Patrick

[1] en.wikipedia.org/wiki/Gynec...

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Hi

My bone density scan showed osteopenia after 18 months on HT. I can feel soreness in my bones but just keep trucking. Makes me respect the challenges the elderly feel every day.

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My husband has been on Lupron since February 2005. (continual, no vacations) (he's stage IV, Gleason 9 or 10, radical surgery, radiation) He was injured in a motorcycle accident in 2009. Shattered pelvis, every rib on his right side broken, his right hip and socket were also broken. He was in ICU for 5 days, surgery to repair the pelvis and hip. That was in May 2009 and by November 2009, he no longer needed a cane and doesn't have a limp or anything that would lead you to believe he had been so badly injured. I'd say he healed normally! His latest dexi scan showed normal bone density which shocked his urologist who assumed his bones would look like swiss cheese after being on Lupron so long. Nope. My husband is a picky eater and his diet stinks. It also doesn't help that I'm a bad cook. ;) He then broke his arm in a freak accident around the house and it healed in 6 weeks. More normal healing. I really believe it's an individual thing. Les continues to defy the odds and I hope he continues. Best of luck to you!

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Thank you bluepacifica. It's good to hear your husband's story. It gives me inspiration.

Wishing him the best.

Mark

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A fracture of the fifth metatarsal is called a Jone's fracture and is quite common. It often happens when you land a bit awkwardly on a curb, root, or rock. My guess is that it will heal fine as long as you follow your doctor's orders for non-weight bearing. Continue with your running once it heals. I used to run ultras after my prostate cancer diagnosis 12 years ago. I cycle now.

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My oncologist has me getting xgeva shots quarterly.

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You should have bone density scans while on ADT as well as periodic CBC (blood tests) . I was on prolia when I had RT to lymph nodes and after a met to femur I’m on xgeva.

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No broken bones so far (thank goodness) but I have water on the knee and beer in the joint.

Good Luck and Good Health.

j-o-h-n Tuesday 01/02/2018 12:32 PM EST

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I had a shoprt ADT vacation that failed, and was put on Trelstar. But before I got the first shot, I had to have a dexa bone density scan which showed osteopenia in a few places. The medical oncolologist told me I HAD to get Prolia shots to prevent bone fractures. I had a couple of falls (bad eyes) but no breaks. My last 2 scans showed no problems.

So I recommend getting a bone density scan like the ones I get, and taking a med like Prolia to protect your bones. And in the words of one of our esteemed members, but what do I know?

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Dr. Myers had me on Estradiol patches to help heal sclerotic areas on my bones where I once had active mets. They also help with hot flashes and SE's from HT. Estradiol is essential to bone repair. Dr. Sartor has me continuing to use these patches, I replace one every day keeping two on at all times.

Ed

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Mark:

My doc infuses Zometa every 3 months to fortify the bone. It's similar to drugs they give women with osteoporosis. Side effects are negligible. I've been on Lupron since 2014 without any mishaps. Doc says bones look good even post radiation. Plus weight baring exercises at the gym (of course you want to get your bone density up a bit first).

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Hi Deano58

I have been on leuprolide for more than 2 years for advanced pca with lymph node involvement. After 20 months it has become castration resistant. But luckily I didn't have any side effects like weak bones etc. Usually doctors advise patients to take calcium and vitamin D tablet to prevent bone weakening.

Goo luck to you.

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