Orchiectomy rather than chemical castration?

[Muchacho]

I had salvage radiation early this year for biochemical recurrence with a PSA of .2. My urologist planned to give me 6 months of Lupron but stopped after 4 months due to an allergic reaction to the Lupron. With the Lupron, the PSA was undetectable. The urologist wants to wait 3 months from now for the testosterone to recover and take another PSA to see if these treatments were effective. If they were not, he recommends an orchiectomy rather than chemical castration due to concern about allergic reaction to a different medicine.

Do you fellows think this is a good approach or would a different path be better?

Thanks

[RalphieJr64]

You'll have to explain a little more. So you received a six month Lupron injection and you had an allergic reaction four months later? No question, Lupron is a nasty shot. I had my 6 month injection a few weeks ago and have the same extra fatigue and hots that I always get. I get the shot because I want to keep my balls for now. Still counting on going into a remission from this crap. Always hoping.

[Muchacho in reply to RalphieJr64]

No, the ADT was adjuvant to the salvage radiation. First a one month shot, which I had a milder allergic reaction to, but I did not recognize as an allergic reaction. The a 3 month Lupron, which caused a severe, debilitating rash on my face and neck

[GP24]

After orchiectomy you can not wait any more for testosterone to recover. If the reaction is really caused by low testosterone, orchiectomy is not a good idea. I would try Degarelix instead or Casodex.

[Tall_Allen]

Are you allergic to Firmagon as well? How about 150 mg of Casodex?

[Muchacho in reply to Tall_Allen]

I have not been tested for allergic reaction for Firmagon. I discussed the Casodex with the urologist who said it has never been proven to extend life. He had me see an immunologist who had never seen this kind of reaction to Lupron. She said no more Lupron and advised the uro administer a very small dose of another shot, which I cannot recall the name, to see if an allergic reaction occurred. Then she recommended close monitoring if the uro proceeded with a full dose. I believe the uro feels the safer route is the orchiectomy.

[Magnus1964 in reply to Muchacho]

I was on casodex for 5 years and my PSA was undetectable.

[Muchacho in reply to Tall_Allen]

Now I remember, it was Trelstar that the immunologist wanted to do a low dose injection to test for an allergic reaction.

[Tall_Allen in reply to Muchacho]

Casodex has been found to reduce progression when added to radiation:

nejm.org/doi/full/10.1056/N...

I suggest you get treated by a medical oncologist rather than a urologist.

[Muchacho in reply to Tall_Allen]

I am also going to be meeting with a genetic counselor at Christ Hospital in Cincinnati in a couple of weeks to see what we can learn about my situation. Not sure this will have any immediate value.

[Muchacho in reply to Tall_Allen]

Is there an objective way to find a medical oncologist that specializes in prostate cancer or how do you suggest one be identified? Thank you

[Tall_Allen in reply to Muchacho]

Here are some tips:

pcnrv.blogspot.com/2017/12/...

I would think that Indiana University is the major cancer center closest to you that has some top doctors. I recall that someone on this site was very pleased with Roberto Pili there.

[Muchacho in reply to Tall_Allen]

I had thought of the Cleveland clinic which is a 4 hour drive. Us news ranks it as best in USA for urology.

[Tall_Allen in reply to Muchacho]

It's a long drive. But Jorge Garcia at Cleveland Clinic might be a good choice.

[Muchacho in reply to Tall_Allen]

Thank you Allen. Going to a NCI designated cancer center is a great idea.

[GP24]

There are two studies which provided data for adding ADT to salvage radiation. One did six months with Lupron:

thelancet.com/journals/lano...

and this one did 24 months with Bicalutamide:

urotoday.com/recent-abstrac...

Both showed a benefit and therefore the guidelines recommend this now. If you follow the first study, you just need six months of Lupron and doing orchiectomy instead is a real bad recommendation. If you follow the second study, you can use Bicalutamide.

However, there is new data that adding ADT to salvage radiation is beneficial for high risk patients only. See this article which is based on a new evaluation of the Bicalutamide study I mentioned:

astro.org/News-and-Publicat...

There is an older study which also recommends to add no ADT for low risk patients:

clinical-genitourinary-canc...

Since your radiation is now more than six months ago, I would just ditch the plan to add ADT now.

[Muchacho in reply to GP24]

Yes, that is the plan. In the event the salvage/Lupron did not work, the question is how to proceed in that event. The urologist is recommending the orchiectomy. He was not sure if my allergic reaction was caused by the Lupron itself, the inert material mixed with the Lupron or the dosage. As the immunologist is not able to help, he feels safest path if treatment fails is the orchiectomy. This is a tough choice for me. My father died of this disease in 1988. He had an orchiectomy as part of his treatment.

[Muchacho in reply to Muchacho]

My treatment plan was based on the study you site with the 6 months of Lupron. It was derailed because of the allergic reaction. The doctors felt it is possible my next allergic reaction could be an inability to breath, thus, the Lupron is stopped.

[GP24 in reply to Muchacho]

Your plan was 6 months of Lupron. Orchiectomy is life-long hormone therapy. You will become resistant just as you will with a long Lupron therapy.

I suggest you just do nothing and observe the development. You will have to do hormone therapy at some point for life-long. Why not spend some time without these nasty side effects?

[Muchacho in reply to GP24]

That is the plan to observe. We are allowing 3 months for testosterone to recover, then do a psa to see if the salvage radiation and 4 months of Lupron have worked. The orchiectomy is "plan b" in the event they did not work and I need hormone suppression. Thank you GP24.

[GP24 in reply to Muchacho]

If it did not work, you do not need ADT yet. You shall not fight the PSA value but the cancer. This is what the guidelines say:

healthunlocked.com/advanced...

So: "an alternative is a close observation until progression of the cancer". You can follow the guidelines and start ADT when mets become visible on a CT/bone scan.

[GranPaSmurf]

I started on this journey planning to have an orchiectomy right away... learned that Testosterone can come from adrenals and even the tumor itself. FOR ME it didn't seem worthwhile. But, given the exfra-gonadal sources, wouldn't one still need to be on some sort of ADT anyway?

[Muchacho in reply to GranPaSmurf]

What you are saying makes sense. My uro did not address the extra gonadal testosterone production. That will be a question for him when I see him for the 3 month follow up.

[GP24 in reply to Muchacho]

Lupron does not suppress the testosterone made in the extra-gonadal sources also. So Lupron and orchiectomy have about the same effect, orchiectomy usually suppresses a bit more. If you want to suppress the testosterone made in the extra-gonadal sources you need to take Abiraterone.

By the way, the best you can do is find a different URO.

[Magnus1964]

If you are young i.e. 55 or less I would say get the orchiectomy. If older go for casodex. It is an ADT drug with fewer side effects.