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Advanced Prostate Cancer
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TIMING questions for a multimodal approach oligometastatic PCa with CVD

we are discussing our protocol now with oncologist, radiologist + cardiologist.

The idea is a multimodal aggressive approach for oligometastatic PCa (T3b N1 M1, Gleason 9, PSA 29 now) with:

1) radiation + radiation to pelvis lymph nodes and metastasis

2) ADT + Zytiga

but we need also to do

3)stents

Timing could be important because of side effects and best results.

Radiation could begin with ADT together, or, some argue to begin with ADT to get a very low PSA before radiation, but

In the meantime CVD risks could occur caused by ADT side effects, so maybe stents should be the first thing to do (they will require at least 6 months of dual antiplatelete therapy)

If stents first, there could be a problem with the stability of the "eluted drug" on the stent coating under radiation.

The stents wouldn't be that urgent (no symptoms under physical stress), but with ADT it could get worse, plaque could get instable...

So I really don't know the safest approach , a question of TIMING!

We will get a second opinion, but do you have one?

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ADT and radiation at same time ASAP would be my choice...I went a different route because that's how mine played out...you may wish to fast for a day before radiation--not proven, but puts some extra stress on the cancer cells in my opinion...I say waiting for ADT to kick in just allows more time for cancer to grow and hit it with a sledge hammer ASAP... it's the old hit it with the kitchen sink as soon as the bell rings.....Sounds like the stenting can wait...... watch --certain supplements have warnings regarding radiation... maybe jdm3 will chime in...our stories are similar... you can message him or TWTJr-a retired Radiologist... George71 is also looking at this issue closely....George71--you out there, brother??...there will be plenty of suggestions....Your plan, your choice.... Best of luck....

Fish

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Still worried about heart, since under stress (in my opinion more of a mental stress in hospital since sport was never an issue) he had a stress test showing 15% perfusion. And ADT could (not sure) precipitate things.

I also would prefer degarelix because of heart and they are proposing zoladex + zytiga.... double heart issues.

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If he has an 85% occlusion and it is of his LAD--left anterior descending--they call heart attacks on that vessel..."The Widowmaker".....high risk of going into cardiac arrhythmia and dying--in that case --fix that now... and get on ADT .... if the ADT gets his PSA to near or undetectable, then the disease is not progressing or real slowly...buys time for the radiation--that is likely the safest best option in my opinion....All the best...

Fish

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You know.... you're an Ace.... bless you for all your help here...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 03/08/2019 2:27 PM EST

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May God bless you, my Consiglieri de Umorismo... the laughter you bring is a blessing indeed...

All the best,

Don Pescado

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He has an 70% occlusion on LAD, but in the middle session. In addition, he has a right dominant coronary circulation. I don't know, but I have the impression that the risk doesn't diminish with stents since studies show that stents do not prevent heart attacks or prolong life.

(because the big majority of events are NOT where the stents are placed if I understand it correctly... so why taking this extra risk?) and the plaque rupture because of destabilisation can occur in different points anyway (specially with my unstable plaques + ADT).

Much more worried about ADT changing things to bad, so I am thinking of avoiding Zytiga, doing just degarelix and monitoring cholesterol, blood pressure and blood sugar.

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Actually, I reviewed some articles and it looks like the outcomes are no better than life style changes and medications for overall survival...get him walking, change the diet, lose weight... and the degarelix + radiation sounds safe....all the best...

Don Pescado

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He is already on a whole food plant based diet, almost no oil (alla Esselstyn), running, BMI 22, body fat 12%, hoping this will help! Thanks!

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Degarelix for ADT should cause a much lower cardiovascular risk than Lupron. Discuss this with your doctors.

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The timing is something that is case dependent, especially in your case. I had an RP 5 months into my ADT. He suggested to wait for the prostate to shrink.

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Are you taking a statin? It could very well help both your heart and fight the PCa at the same time. Good luck what ever path you choose.

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yes! first we were against statins (also his cholesterol is very very low till now), but after reading the PCa research he is on atorvastatin 20mg, in addition it could help stabilise the plaque. He is also on metformin for the same reason.

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