Told to discontinue Casodex (Bicalutamide)

[Cheerr]

My dad was put on Casodex for 3 months immediately post-chemo. So he was on Lupride + Casodex.

Today we got his 3-monthly blood work reviewed, the MO has instructed to stop Casodex and continue with only Lupride and get back again after 3 months with blood reports.

Jan (after chemo): PSA: 0.04, ALP: 81

In Feb: PSA: 0.024, ALP: 124

Today's report: PSA: 0.015, ALP: 118

Due to Covid, we couldn't have a discussion about why these changes. I was under the impression that he will always be on Casodex until he needs to switch to Zytiga etc.

Is there a reason why the MO would want to discontinue Casodex and put him on just Lupride?

[Magnus1964]

I can't think of any reason. I would get on the phone and asked why I am stopping a drug that is working well. If he can't or won't give an answer, keep taking the casodex and find a new doctor.

[Cheerr in reply to Magnus1964]

Thank you, we will try to get in touch with the doc.

[LearnAll]

I value the advice of Magnus because he is living with Adv PCa for last 27 years.

Out of those, he was on Casodex for 5 1/2 years.

[noahware]

I believe, at least in the US, that the current standard of care has evolved away from using Casodex except for a few weeks/months in conjunction with beginning Lupron (or similar meds), which is the workhorse of ADT. This is to address "flare" issues. Sometimes Casodex is omitted from the ADT plan altogether.

I imagine this is, at least in part, because Casodex can in some cases eventually lose effectiveness at blocking AR activity, and even turn from AR antagonist to AR agonist (helping feed the cancer). Not a worry when used for the first time.

But for some MOs, a combined androgen blockade of two or even three agents that includes Casodex, used continuously for a year or two or more, is preferred. And for VERY few (especially in the US), an antiandrogen monotherapy of ONLY Casodex is prescribed. It is cheap, easy and effective.

[mklc in reply to noahware]

Hi Noah,

Is there any evidence of what you stated i.e.

Casodex can in some cases eventually lose effectiveness at blocking AR activity,

Many thanks. Mike

[noahware in reply to mklc]

ncbi.nlm.nih.gov/pubmed/110...

And this one, which suggests...

"it should be emphasized that bicalutamide resistance in androgen-independent prostate cancer may not be due to agonist activity but may instead reflect decreased bicalutamide binding to AR and hypersensitivity to low levels of endogenous agonist ligands"

cancerres.aacrjournals.org/...

[also... see MateoBeach comment below]

[mklc in reply to noahware]

Thank you so much Noah.

Now if ONLY I could understand what is being said.

Sincere thanks and good health to you.

[noahware in reply to mklc]

Ha ha, yeah, those article get a little technical for me, too! But bottom line is (and I was told this at my first meeting with an MO), most hormonal medicines eventually fail for most men, as the cancer become resistant to any particular one.

So far as I know, Casodex is the only one that not only prompts resistance in some men, but is suspected of actually FEEDING the cancer as the cancer evolves. That is not a reason to avoid Casodex for an initial course of extended treatment, perhaps even of many years if results are good, but it is a possible reason to avoid returning to Casodex a second time (after such resistance develops).

Best to you, as well, thanks.

[mklc in reply to noahware]

thank you so much for the explanation.

It makes sense to me now.

Best health to you.

[LearnAll]

To me it seems the whole "becomes agonist" is propaganda to defame Casodex and to sell other similar, newer Lutamides ( Enzalutamide, Apalutamide, Darolutamide) . Mainly because the older Lutamide , Bicalutamide (casodex) costs only 12 dollars a month.

If casodex loses effect ,then why we have so many people who were fine taking it for 5,7 or even 10 years ?

In many European countries..even now.casodex is still used as monotherapy in less aggressive cases. It has least side effects out of all lutamides.

[noahware in reply to LearnAll]

I agree (almost) completely. It seems to be a VERY good and effective drug. But Casodex monotherapy (@150 dose) was never approved in the USA by the FDA, in spite of its demonstrated efficacy, and safety, and decent side effect profile. I am having trouble finding an MO who is willing to give this treatment, although off-label monotherapy is a cheap and viable option.

But there is little doubt that Casodex in SOME cases can eventually fail, or worse. Dr. Bob Liebowitz included it as part of his primary "Triple AB" protocol, but insisted that after an initial course (whether six months or six years) that a return to that drug was, in general, contraindicated due to the risk of the PC having evolved a work around.

That doesn't mean it ALWAYS fails and turns "traitor," but just that it CAN fail. I suspect many MOs do not even know this, They disdain its use probably just because it's an "old" drug, and they think that newer must be better. Maybe not.

[jmurgia in reply to noahware]

I have been on Casodex (50mg) monotherapy for a year. So far, so good.

[GP24]

I think Cheerr means that his dad took Lupride plus Casodex after the Chemo. Because the PSA values are very low now the MO thinks Lupride will work just as well as Lupride plus Casodex. The benefit of Casodex in this combination is usually small and cannot be detected at a PSA value that low.

[Cheerr in reply to GP24]

Hi you’re absolutely right he has been on both casodex + Lupron post chemo. He is in Lupron since diagnosis (I think anyone with advanced pca would be).

So is it possible MO wants to save casodex for when it’s increasing again. So he would want to stop it for now.

[GP24 in reply to Cheerr]

At the end of the day you have to ask the MO why he recommended to drop Casodex. I believe he thinks your dad will be fine with Lupron monotherapy. Due to the very low PSA value I think he is right. You dad can add Casodex again whenever it seems beneficial. But as Allan mentioned below, he will probably get Zytiga at some time and not Casodex.

[Tall_Allen]

Great response to chemo! Casodex will eventually start feeding the cancer, and adds little to the Lupride therapy.

[Cheerr in reply to Tall_Allen]

Thank you. Is it okay for dad who has been diagnosed with advanced pca with bone mets to stay just on Lupron as of now?

(Asking this because I always assumed Lupron as not so effective as a monotherapy for patients with mets)

[Tall_Allen in reply to Cheerr]

Yes, but when PSA increases or new metastases appear, a more powerful hormone therapy will probably be added.

[immunity1]

What little evidence there is does support using bicalutamide as a combination with a GNRH agonist, if you don't mind possible additional side effects. Particularly as your PSA is decreasing. R

[Cheerr in reply to immunity1]

Fortunately dad never felt any additional side effects with addition of casodex. So we don’t mind. But if the doctor does want to stop it, we can’t help?

[Hidden]

That’s really good. MO looking for Casodex Withdrawal Syndrome after his chemo. Or, not really needed at this time. Keep on the Lupron and see what there is in three months. I have been undetectable since withdrawing from Casodex in 2005. Five years later I stopped Lupron and am still undetectable.

Gourd Dancer

[Cheerr in reply to Hidden]

Thank you. When did you stop casodex ? Was it right after chemo?

[Hidden in reply to Cheerr]

Ended chemotherapy /hormone therapy trial in January. Continued with hormone therapy (Lupron) and added Casodex. Stopped Casodex in September of same year. Continued with Lupron/Eligard.

GD

[2dee]

I'm an anecdotal steady of one. 2yrs ago 2018 when Dx stage4, PSA 1300+, I was started on bicalumide and on Lupron a couple weeks later I think. Dropped Bicalumide after a few months. Lupron only kept dropping PSA. Still on Lupron only and starting Xtandi soon as PSA has risen from 1.2 to 9.2.

2Dee

[Cheerr in reply to 2dee]

Hi, great results you’ve achieved with Lupron alone. I wish you goodluck with Xtandi.

[MateoBeach]

Conspiracy theories aside. I was on bicalutamide plus dutasteride without Lupron as I could not tolerate it. It kept my PSA at .02 for nearly 5 years. Then my PSA began to rise rapidly. When I then stopped the bicalutamide the PSA went down again while still not on Lupron or similar. It happens. So it can be very effective but must monitor PSA to identify if and when the reversal to cancer stimulation may occur.

[dougnola]

Hi there. Your Dad’s situation looks much like my own with me diagnosed in 12/16 at similar age. I too was taken off Casodex shortly after I was put on Eligard post chemo. Except with me, I was also put on Zytiga (with Eligard) at that early point - before waiting for my my psa to rise again and, thus, while I am still castrate sensitive. The result for me was my psa got even lower and has been N/D (<0.01) for three years now. I’ve seen different approaches in Zytiga timing here on the forum but that’s what I’ve done and it’s working pretty amazingly so far. Keep the faith! Doug in New Orleans. DougNOLA ✌️

[Cheerr in reply to dougnola]

Hi Dougnola,

Thanks for writing in, it helps since it’s a approx similar profile.

Yes I have read a lot of discussions on timing of Zytiga after Chemo. Some start immediately while others start only when PSA rises. Since you were put on it immediately, is that what your MO follows as SOC ? Did he talk about how it helps better if added early on?

Thank You

[dougnola in reply to Cheerr]

The STAMPEDE trial was just about to be published in 7/17 when I was coincidentally about to roll off chemo. My MO was one of the peer reviewers when it was being written up so he was keyed into it so I was one of the early folks I think to have my insurance cover zytiga that early on in my diagnosis. They sure did balk until my MO did a lot of conversation and showed them this article as soon as it came out. Good luck!

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