Failing Lupron? What's next?

[Lynsi13]

After more than four years on hormone therapy and 6 rounds of chemo, my dad's PSA is beginning to slowly rise. It has moved from .07 size months ago to .13 three months ago to .23 today.

He has been on Lupron and casodex for the past four plus years. Can anyone give me any insight into what we should expect? Will his oncologist suggest that he drops the casodex for its antagonistic behaviors? Will we continue to monitor the PSA since the rise is not doubling? Should we expect another scan? Which drug is it will be on the horizon next? Zytiga? Erleada? Provenge? Any insight you may have is greatly appreciated!

Also, when my dad was diagnosed his PSA was 257 with only a single lymph node outside the prostate impacted. Since he is considered oligo metastatic, would targeted radiation be a viable treatment option?

[LearnAll]

I will watch the behavior of PSA more before making conclusion that Lupron has failed.

I would like to check PSA every two weeks and chart the pattern. If it clearly shows a steady upward trend for 2 -3 months, I will assume that Lupron has failed. Just my opinion.

[Tall_Allen]

It really makes no difference to his Lupron therapy if it is no longer keeping his PSA in check - he keeps taking it. There is really no point in treating one pelvic LN. Where there's one, there's a LOT more you can't see. Now radiation to the ENTIRE pelvic lymph node may help. Possibly with Provenge at the same time. When his PSA is over 2 and a PET scan confirms progression he may qualify for Zytiga or Xtandi.

[DarkEnergy in reply to Tall_Allen]

TA,

But Zytiga and Xtandi were already approved for mHSPC, are you saying the approval was not retroactive with patients already taking ADT?

[Tall_Allen in reply to DarkEnergy]

Zytiga and Erleada have been FDA-approved for mHSPC. Xtandi probably will be shortly. I don't understand your question.

[DarkEnergy in reply to Tall_Allen]

Ok, this patient has been on ADT for 4 years, when Zytiga was approved for mHSPC, why wasn't it administered?

Meaning he was already "approved" for Zytiga, a while ago...

[Tall_Allen in reply to DarkEnergy]

Because he got early chemo instead, which was very successful. If he becomes castration-resistant, he will also be able to get Zytiga, Xtandi and Provenge. But since he did so well on Taxotere, Jevtana may be a preferred next step.

[tango65]

I am in a similar situation. My PSA is increasing slowly despite of ADT and intermittent Casodex since I do not tolerate it very well.

ADT will continue. I will have Ga68 PSMA PET/CT scans done. Provenge may be done when waiting for the scans. If the scans show few metastases they will be irradiated with SBRT. If there are many metastases or few which can not be irradiated I will try to get Lu 177 PSMA treatment abroad. Lu 177 PSMA may be more effective if used early.

jnm.snmjournals.org/content...

This plan is not the standard of care. The idea is to delay as much as possible the use of the new anti androgens and chemo. These treatments may have significant side effects for many patients. They may work well (less than for hormone sensitive cancer) for a while and then the cancer will be impossible to control.

I consulted at the MSKCC (Dr. Morris) and he agreed with the plan.

[GP24 in reply to tango65]

Here is a video with Dr. Morris where he presents the treatment of oligometastases:

urotoday.com/video-lectures...

[Lynsi13 in reply to GP24]

Thank you!! I'll check it out!

[Hidden]

Because you have a little time to experiment, you would seem to be a prime candidate to (a) Go onto a raw food and smoothie diet to maximise whatever remains of your immune system (b) use a low dose Xtandi in combination with Sodium Ascorbate to kill some of the cancer and buy you even more time. Both of these are gentle options with zero side affects that can be used for years and years - and they have the potential to outperform all the other things that you are contemplating. But you will not know if you do not give them a try. You will have your answer in 4 weeks. Zero harm done if they did not work for you - an important consideration when otherwise experimenting with sledgehammers.

[Lynsi13 in reply to Hidden]

Thanks David! I would have to say that he is pretty well near a raw food diet.. my mom is a health food nut.. salads, smoothies, micro-greens and wheat grass are a regular in his diet. Mom grows it all and they go after organic every chance it's available. His doctor is talking about starting him on Xtandi, too. I think one of the reasons he responded so well to his earlier treatment was the fact that he kept his diet clean, exercised and kept weight off. He's in his late 70s but you wouldn't know it by the way he works and feels!

[Hidden in reply to Lynsi13]

Remember I take Xtandi to boost the kill of the weekly Vit C - so there are gaps in the Xtandi that allow some recovery from the side effects. Keep going the way you are - it is working. You can add Sodium Ascorbate and that will work for a while, but the initial kill of around 30% will soon drop back towards 5%. But that can possibly buy you many months of low PSA problem-free living, and time to encapsulate or destroy most of the cancer. Some people actually get to a "remission" this way. If not, you would start the next phases with less cancer than you otherwise would have (it takes TIME with low PSA for the body to do its work). Medications reduce the body's defenses (e.g. full dose Xtandi by about 30%) so the less poison the better. For most of us with destroyed immune systems, the poisons are now keeping us alive, so avoid them as long as possible.

[JimVanHorn]

I had 42 radiations in 2007 when I was diagnosed, then in 2011 my PSA went up a little and they found bone metastases. So I was put on Lupron and had 30 more radiations. I stayed on Lupron for 6 1/2 years and now I no longer have any cancer. Each of us have different cancers in different parts of the prostate, so there are no guarantees. For example I could get cancer gain. I just want you to listen to your doctors and ask as many questions as you need to understand what is happening with his therapy. Look at his lab tests and start a notebook with the lab tests sheets. Then you can compare the results. For example my Vitamin D3 was low so now I have been given large quantities to make up for the loss.

[Lynsi13 in reply to JimVanHorn]

Thanks for sharing your story, Jim. How did you handle that much radiation? My dad watched his mother die of cancer in the 80s and he has a very STRONG dislike of radiation.. even mentioning it makes him shutter. I have tried explaining that the radiation of today is NOTHING like the radiation his mother experienced, but it's still a bitter pill for him. Since he's in his late 70s, I would imagine that he can still garner a full life from more system therapies such as second line hormone therapies and the like while hopefully not having to face his radiation fears. Still, I tell him on occasion that radiation might be a part of his journey, especially if he develops any bone mets. At this point it's only in his soft tissue.. the single lymph node.

[JimVanHorn]

Well he's the boss! I am 74 so not such a young chicken either. If he is worried I understand, but also remember I do not have cancer now and I had radiation. Does he know that they put three gold flecks into your prostate area in three dimensions and if your body moves during the radiation it immediately shuts off? They didn't do this 20 years ago. They explained to me that it is so accurate that they can kill a group of cells and not kill the ones next to it! In my case they put a very small tattoo on my chest that shows the center line of my body and aligned my body to this each time I was radiated. I really had very few side effects of radiation. He should talk to a radiologist about all of these problems, and then make a decision. Whatever his decision he has his own opinion.

[badmamazoo11]

This feed is old but many oncologists will stop the bicaludimide (Casodex) before going to other drugs to supplement the Lupron. The drop in PSA from eliminating Casodex, which happens fairly often, can buy a little time, perhaps up to a year before PSA begins climbing again.