Advanced Prostate Cancer
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Need to decide path forward... which way to go?

March 6th PSA 467, Vitamin D 16. January 22nd -2nd PSA 393 (taken at lab after DRE) January 16th -Initial PSA 384.1 Age: 53, Stage 4, cT2c, N1, Gleason 4+4=8, Volume: 51.0 grams, Bxs: 5L + 5R

New diagnosis of stage IV Gleason 8 prostate adenocarcinoma to lymph nodes (N1); metastatic pelvic lymphadenopathy. High risk.

Started with a double loading sho of firmagon March 6th.

Discussed the additional recommendation of adding Zytiga/prednisone (STAMPEDE) or docetaxel (also STAMPEDE) to hormonal therapy in node positive disease setting; overall survival benefit is noted. Would want to start either therapy within a 3-month period; docetaxel would be for 18 weeks, Zytiga for two years

Discussed the need for prostate/pelvic EBRT down the road after systemic therapy, would initiate after his Taxotere chemo or after at least 3-6 mos Zytiga. RT would be for definitive intent. His pelvic LNs would be able to fit in a radiation field.

Plan to return April 3rd to begin Lupron shots.

My question: If you had to choose between these 2 plans, which would you go with and why?

Also, is it normal for the PSA's to increase so much in such a short amount of time?

What else can be learned from the info above?

He has now had CT, bone scan and 3T MRI

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Aubern Angel, My first thought is vit D is way low,Could be a reason for getting PC in the first place. He should be supplementing to get it to at least 50. I think you are talking about psa going from 384 to 393, could be the noise in the test or ,maybe even the DRE that did that.He should get a good response now that he did Firmagon. Either way you go the results have been shown to be good, others will post the data from the trials. I wish you both the best, keep us posted.

Dan

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The most recent PSA was even higher. March 6th PSA 467

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Much argument to the subject---but many of us---maybe not the majority---would want to debulk the core of the cancer, by RP. And then follow one of the stampede protocols.

Nalakrats

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Here's a discussion of those options, as well as some others:

pcnrv.blogspot.com/2017/06/...

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Swing for the bleachers. His first shot at this has to be his best one to gain a durable remission or possible cure. IMO getting a prostatectomy by a skilled surgeon after getting PSA down to a low point (.50 is ideal) will give your husband the best chance. The weaker the cancer is will generally yield a better outcome. This is where you need a specialist in Oncology to make this happen before surgery or radiation. Another pro to surgery is an accurate pathology report that will show exactly what's going on in there.

If your current doctor doesn't want to go this route it seems the major research hospitals will. If going the surgery route you are going to want a surgeon that has a lot of experience and willing to tackle those nodes too. If interested I can give you information on an exceptional one. Just message me.

I would also recommend early chemo consisting of docetaxel. If there are any cells circulating in bloodstream or lymphatic avenues this will give best chance at getting to them. In my case it cleaned up a lot of cancer before the surgery.

Your husband is young and given the aggressiveness of his disease he may need the radiation therapy later. God willing and surgery works out he may never need it. This is only my opinion and given his age an extra card to play may be worth keeping. There are no guarantees with anything but don't rule anything out either.

Your husbands case is similar to mine. February 2016 at 46 years old I started with a PSA of 286, Gleason 9 (5+4) and a lot of disease in pelvic and abdominal nodes. Casodex and Lupron up front, 18 weeks of Docetaxel, December 2016 prostatectomy with extended lymphadenectomy with preoperative PSA .51 and postoperative <0.01 and remains there. When dealing with aggressive disease I recommend an aggressive approach.

Ron

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Surgery hasn't been recommended because it has spread extensively in the pelvic region but doesn't appear to have gone to the bone yet.

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When I was initially diagnosed I used my local cancer treatment center and surgery was not recommended either however radiation was. My local doctors all were on the same page and I was given the "it's outside of the prostate" speech. I even went to the closest big treatment center 4 hours away and to my disappointment was told the same thing. I almost listened but it was actually this site that made me try again. I watched an amazing video posted of Dr. Kwon at The Mayo give a presentation on treating oligometastatic disease. I called them (Urology Department) and after consulting with my local docs to get an insurance referral flew out for their opinion. It was decided I was a candidate for surgery.

Most hospitals will not offer surgery with Stage IV and it seems the biggest research centers are now doing it. I still work with my local doctors and go to The Mayo once a year for follow ups. My local docs were astounded by my results and have learned as much as I have from this. Your current doctor should have no problem if you want another opinion. They should support it. The Mayo is great at working with your local doctor too as I'm sure any major hospital would be.

It's a couple plane tickets on a credit card and an insurance referral. There are places to stay for Mayo Clinic patients that offer very affordable rates. The place I stayed was only 40 bucks a night. I am sure that's the case for any major facility offering cancer treatment. It seems overwhelming but it's not once you get started. Never give up and when he's feeling exhausted from it all keep him pushing forward. He will have you waiting over the next hill.

Ron

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Surprised that Mayo will do debunking surgery on a metastatic patient. Reducing the number of cancer cells in your body by surgery is intuitively logical to me, but it is not yet part of the “standard of care.” And that’s the problem. Luckily for all of us treatments are evolving rapidly in an area that my urologist described as the wild Wild West. The problem is finding and getting these newer treatments when the “standard of care” seems to be a barrier. I fear that doctors bound by the standard of care concept are using yesterday’s protocols. Seems to me that divergence between “cutting edge” and standard of care is too great.

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What are the benefits of adding surgery to the plan as Well?

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It's also seen in the lymphnodes.

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There is growing evidence when prostate cancer has a limited amount of tumor burden (oligometastatic) it can be beneficial to debulk the disease. Oligometastatic prostate cancer is different in that a combination of primary tumor treatment (surgery or radiation), metastasis-directed therapy, and systemic therapy (ADT and chemotherapy) can potentially delay disease progression or in some cases be curative.

By removing the prostate it is eliminating the primary tumor cells constantly being delivered into circulation starting the metastatic process. When those cells land it creates more metastatic disease and etc and etc. This is also why it is beneficial to remove any affected lymph nodes or radiate any spots that are found before the tumor burden is to high.

There are pros and cons to both surgery and radiation. In your husbands case he may very well be considered for both. By having surgery first the radiation can be used afterwards to possibly clean up any cancer that may be left. It's like a one two punch being thrown at the cancer. If having only radiation done and that does not get all the cancer it will be much harder to have salvage surgery. Radiation can only be done once and this will limit any further options. It is very difficult to perform a prostatectomy after radiation therapy because it leaves a lot of scarring in the prostate bed. Also surgery has the benefit of an accurate pathology report. If choosing surgery it is essential it is done by an experienced doctor to prevent serious side effects.

Hope this helps,

Ron

BTW: Don't let the fact he has disease in his lymph nodes deter you. My pelvic and abdominal nodes held a lot of disease. 42 were removed along with my prostate.

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Thanks for that. So far we've heard start with 240 mg firmagon shots for first month and then switch to Lupron. Within first 3 months begin either the Taxotere chemo for at least 16 weeks or the Zytiga and prednisone for 2 years. Then redo scans and do radiation to any remaining. I'm curious if other treatments like cryotherapy or the seeding would also work at this point. I really don't have a leaning at this point just trying to learn all that I can.

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That is the order in treatment I did with the difference being I went with a prostatectomy instead of radiation. I didn't choose that order it's just the way things fell. I was scheduled for radiation but opted out because I was worried it might fail. At 46 years old I didn't want to limit my options being that once radiation is done not much else can be used. In my case they couldn't radiate the abdominal nodes and I figured surgery would be my best bet.

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