Systemic treatment: Hi, Just had... - Advanced Prostate...

Advanced Prostate Cancer
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Systemic treatment

Fdccs
Fdccs

Hi,

Just had another chat with clinical nurse as I don't feel that the treatment is aggressive enough for my husband's PC (GS9, PSA 167 with spread to pelvic lymph nodes). Treatment plan is radiotherapy with HT.

She said that the only concern which no one can tell you even with localises low grade tumours is micro mets but they have to treat what they can see.

What I don't understand and forgot to ask is if there are micro mets why do you not add chemo as well? Presumably if they're that small that a scan can't pick it up chemo would kill those cells too

15 Replies
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While it is true that you have to treat what you cannot see, chemo is not the best way to do it - hormone therapy is. Chemo hasn't had very good results when combined with primary radiation.

pcnrv.blogspot.com/2016/08/...

Were you able to get an appointment with Peter Hoskin? If brachy boost therapy is unavailable to you, external beam with about 2 years of hormone therapy is about as good as you can do.

Fdccs
Fdccs
in reply to Tall_Allen

Thanks again! Sorry I have a lot going around my head and like to understand things.

I did email Peter Hoskin but havent had a response. The doctors in Bristol (UK) do have a good reputation so I was going to wait to meet oncologists to see what my thoughts are. As far as I can see they do have Brachytherapy

I just don't understand the thinking of waiting to see what turns up, why wouldn't chemo kill any microscopic cells?

Tall_Allen
Tall_Allen
in reply to Fdccs

You can't just imagine something in medicine is true (i.e., "why wouldn't it..."), it has to be shown to be true in real life. Evidently, docetaxel does NOT perform as you imagine. I can conjecture reasons for it (microtubule stabilization only kills cancer cells that have progressed to a certain point). It is also not particularly surprising, given that docetaxel only improved survival in men with multiple metastases, but not in men with few (CHAARTED).

The idea of brachy boost therapy + ADT is NOT "waiting to see what turns up," it is to cure the cancer by hitting it with heavy-duty radiation and long-term ADT. There is also probably an abscopal effect - the immune system is activated by the cancer antigens produced by the radiation.

Schwah
Schwah
in reply to Tall_Allen

Wouldn’t Zytega added to the ADT also be beneficial TA ? Or is it too early without any mets shown ?

Schwah

Tall_Allen
Tall_Allen
in reply to Schwah

Maybe. There's no data yet. I personally know 2 men who took Zytiga+Lupron adjuvant to radiation. I don't think most insurance would cover it.

Schwah
Schwah
in reply to Tall_Allen

So it’s only approved with proof of metastasis? Seems likely tho to help in his situation right? Since it was so life changing with early metastasis when combined with lupron ? With all you know, Would you add it for yourself you if you were talking in his shoes, assuming you could afford it?

Schwah

Tall_Allen
Tall_Allen
in reply to Schwah

Whether it adds life or only adds side effects is TBD. It is especially questionable with brachy boost or SBRT. My guess is it may or may not have a benefit depending on disease characteristics.

After surgery in Mar 14 (T2CNoMx), GS 8, Margins, ECE and Seminal Vesicles negative, 10% prostate involvement) and SRT (39 IMRT, 70.2Gya) in Mar 16 failed, my PSADT and PSAV were at <3 months I went to Mayo In Jan 17 and had the C11 Choline scan and met with Dr. Kwon. The scan showed four pelvic lymph nodes, PSA 3.8. Dr. Kwon and I talked about treatment options. While I didn't meet the criteria Tall Allen refers to in the CHAARTED study, with my clinical indicators, GS8, BCR after 18 months, PSADT and PSAV it wouldn't be long before I would...we agreed to start a regimen of 24 months of ADT (8 x 90 day shots), six cycles of taxotere and 25 radiation treatments (45Gya). I would do the treatments in Kansas City and return to Mayo for scans and consults in Mar and June 17 and Feb 18.

Prior to going to Mayo I met with my medical team here in Kansas City, when I brought up the idea of a combined regimen of ADT, radiation and chemotherapy only one was against it.

I returned from Mayo on 6 Jan and started treatment on 22 Jan (my PSA had climbed to 4.8...!). With the first Lupron shot and the first taxotere treatment my PSA dropped from 4.8 to .8, with the 2nd chemotherapy <.1 and stayed there. Subsequent scans at Mayo showed decreasing and finally no cancer. Throughout the treatment my testosterone stayed at <3, PSA <.1.

Dr. Kwon and I agreed to stop Lupron at 18 months based on my response, last Lupron shot was in May, August labs were PSA ,.1, T <3. October labs were PSA <.1, T 135. Next labs and consult are in February.

My radiologist was able to build a treatment plan which included boosts and wider margins around those four pelvic lymph nodes.

My rationale for doing this was I didn't want the standard of care, treatment that was linear and sequential with each destined to fail. It made sense to combine those treatments and bring them forward in a period where my PCa was vulnerable (ncbi.nlm.nih.gov/pmc/articl...). The outcome I was seeking was an elusive cure, if not a long progression free survival period and increased overall survival. Too early to tell obviously if I have accomplished those.

The chemotherapy was no walk in the park so one factor in the decision must be one's physical and medical condition. I was 61, in excellent physical shape and no health issues.

I told my medical team that I didn't want to talk about 15 year periods (when I was doing SRT and asked about combining it with six months of ADT I let my radiologist talk me out of it because there was no "long term data," epic mistake on my part and one I was determined never to repeat). So now we focus on the next five years knowing that as imaging and treatment continually evolves, new options will be available if or when my PCa returns.

I made the treatment decision that best fit my goals, I asked my medical team to support me decision and they did.

Peace

Kevin

Fdccs
Fdccs
in reply to Hawk56

Thanks Kevin

I'm waiting to hear back from nurses regarding any possible trials and I am going to mention some of the other treatments on offer. Really want to throw everything they have at this

Hawk56
Hawk56
in reply to Fdccs

May be worth the read...onlinelibrary.wiley.com/doi...

ehiker
ehiker
in reply to Hawk56

Hi Hawk, I am a bit unclear..you had original radiation to the prostate bed and the a couple years later radiation to the nodes...I am under false assumption you can only have one treatment plan to the prostate bed area? Thanks for clearing up. Great news for you. dan

Hawk56
Hawk56
in reply to ehiker

No, surgery in Mar 14, PSA was undetectable until Sep 16 when it was .2, then in Dec .3. We did SRT to the prostate bed only, the subsequent radiation after the Mayo visit was to the pelvic lymph nodes.

In contrast to approved Standard of Care protocols espoused by many, I underwent a six month chemotherapy - hormone trial in 2004. I have not looked back and enjoy the benefits of the trial which continues to result in undetectables and resolved metastases. The hypotheses of the trial began with:

"Chemotherapy is a setting of hormone refractory prostate cancer has shown palliative benefit especially with substantial PSA decline strongly suggesting that disease modifying potential exists. Recently, chemotherapy is beginning to show a survival advantage. The stage is set for chemotherapy given earlier in a disease course. As a working hypothesis, we suspect that the transformation from an androgen-dependent to an androgen-independent phenotype is mediated by the expansion of an androgen-independent clone already present at the time of androgen deprivation. If this model is correct, then it would be desirable to bring treatment to bear on the androgen-independent component when the corresponding tumor burden is minimal. Thus, we view the androgen-independent component as analogous to “microscopic residual” or “micro-metastatic” disease for which adjuvant chemotherapy has shown to be effective in other contexts."

A lack of understanding as to micro-metastases that people do not understand is that the unseen metastatic cells travel the natural byways and highways of the body - the vascular and lymphatic systems of the body. The only method known to cause Cellular Apoptosis of these type of cells, is through systemic treatment - chemotherapy. Oh yes, Cellular Apoptosis of seen cells happens through other treatment, but given a premise of micro-metastases, chemotherapy is the answer.

Unfortunately, there are many in a "do no harm" world who cannot accept that micro-metastases even exists. I offer that researchers in a setting of academia are best suited to understand.

Gourd Dancer

RICH22
RICH22
in reply to gourd_dancer

few questions, if you don't mind:

1) what were your Gleasons and PSA before you started anything?

2) are you still on the chemo/hormone tx?

3) what are they? how administered?

i ask because i'm ok with swallowing pills but RT and cutting are terrifying last resorts for me. don't like injections but that's as far as i want to go. i'm on casodex+flomax, gl 4+3, PSA dropped from 14.8 to <0.1

thanx for posting; fight on, brother.

Rich. My Cardiologist told me my PSA was 6.8 on December 8, 2002. On March 3, 2003 my Urologist confirmed Gleason 7(4+3) and PSA on 6.2. I had 117 Palladium Seeds on April 22 and started 25 sessions of IMRT on July 7, all part of my primary treatment. My PSA never really came down and on May 8, 2004 my PSA was 32.4, Scans skewed mets to L2 & T3. I started a two week regime of Casidex anfpd took my first 3 month of Lupron. On June 7, 2004, my PSA was 7.3 and I enrolled in a six month chemotherapy - hormone therapy trial. I ended the chemo portion on January 8, 2005. PSA was 0.5 and mets were resolved. I continued with the Lupron and started again with Casodex. On October 2, 2005, I stopped the Casodex.

Fast forward to February 11, 2010, at the urging of my Medical Oncologist, I had my last injection of Lupron. On January 11, 2012, I started wearing a 4 mg Androgen patch. At the time T was 31.4. My T since then has ranged from 383 to 733 depending when the blood draw took place and the use of Androgen. My PSA has remained <0.1.

Note: I had twenty-one nuclear bone and soft tissue CT scans since my journey started. Couple with eighty-five PSA tests along with T tests and another two pages of other tests results. Since April 1, 2006, my PSA has either been 0.0 or <0.1 every time.

Note: Chemotherapy was administered through a Port in my chest. Lupron /Eligard through injections every 3 months.

My friend, please get past the line in the sand on Radiation and/or Chemotherapy infusions. Di what is necessary to kill the bastard while your body is strong and the tumor burden small.

Gourd Dancer

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