Hello Health Unlocked gang! It's been quite a while since I've posted in the group and I wanted to give an update on my dad and see what your thoughts are on his latest test results.
So, my dad's last PSA test was done on December 19, 2019. It was at .26 at that time. He started Provenge in late January and was able to complete two rounds successfully before his oncologist terminated his treatment due to the virus! He has since had another Lupron shot and another PSA testing. His results came in today and he's at .33, a .07 increase in over 4 months.
I'm feeling pretty good about these results. Despite there being a seven hundredths of a point increase, I see that it's been spread out over 4+ months and that to me is a good thing!
We meet "virtually" with his oncologist on Wednesday. We've had two differing opinions on his PSA increases in the past. His local oncologist who treats 90% breast cancer patients has been eager to move from Lupron right along to Zytiga when his PSA has been very low and while was trending upwards, was not doubling. His urilogical oncologist at the Cleveland Clinic main campus has wanted my dad to take a more "wait and see" attitude and ride out his success with Lupron longer before jumping onto another medicine. We meet with the local oncologist on Wednesday and I'm thinking that I'm going to press for my dad to maintain the Lupron a bit longer before moving to Zytiga, so see if the Provenge will give him more time before switching. His last scans looked great with no evidence of metastasis on the scans.
What do you think? Is there harm in waiting to start another line of therapy or should he start immediately?
Thanks in advance!
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Lynsi13
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The way that his Cleveland Clinic oncologist described it was that each therapy only lasts for so long and that we should try to get as much length out of each therapy as we can without rushing headlong into the next available therapy because before long we'll be through with our options. She believes that we have to look at both the PSA and the scans to determine if he has really failed Lupron. She doesn't believe that the small increases that we're seeing is indicative of a total failure since his scans look good and that we can get more time out of Lupron. Our hope (and the oncologist's hope) was that we could gain some time from Provenge before starting another therapy!
Bad logic. Each therapy works better and longer if used earlier. It is using it later that "wastes" the therapy.
In the STAMPEDE trial, Zytiga given to newly diagnosed metastatic patients lasted a median of about 4 yearsbefore it failed. However, when Zytiga was given later (after castration resistance and after chemo,progression-free survival was reduced to 6 months. So, would you prefer that he get 4 years of benefit from Zytiga or only 6 months?
Before the STAMPEDE trial cited by Tall_Allen (see his excellent blog posts that he cited on this subject), many oncologists believed exactly what your Dad's oncologist said. Each therapy works for a fixed amount of time (different for each patient), so taking them sequentially extends life longer than taking them together and whenever one takes them, within some limits, they are equally effective. One of the world's leading experts on prostate cancer, Patrick Walsh, wrote in the first edition of his Guide to Surviving Prostate Cancer that men shouldn't even start Lupron until they have a high PSA and will soon have symptoms. It was only after results in other types of cancer showed that this wasn't true for those cancers that studies were done in prostate cancer and it was shown empirically that at least some combination therapies also work better in prostate cancer than do sequential therapies, and that therapies started earlier have a longer lasting effect than when started later.
One possible explanation for the latter behavior is that when the tumor cell population is very large (a single gram of tumor probably includes several hundred million cells) the chance that some of them are resistant to a particular therapy and maybe reproduce more rapidly is proportionally larger than when the population is small. Drug resistance can occur more quickly.
That doesn't necessarily mean that if you wait a bit longer the Zytiga will do a worse job, but I do think it's important that, when planning a "wait and see" approach, it's very important to know just what you're waiting for and just what you want to see before adding new therapies. Too many doctors don't give that information and don't think about it themselves. They're not sure what they'll do and will make a decision when the next test is done. There are multiple factors that they will (or should) look at, not just PSA values. Doubling time, patient age and condition, quality of life, past treatment history will all be considered.
One of them might decide to take action when PSA reaches 0.2 or doubling time is 6 months. Another might want 2.0 or 4 months. Still another might want 10 or 2 months. One may want to test PSA every month, another every three months, and another every six months.
One thing I have found with most all doctors is that they've got no shortage of patients and they don't think about any one patient until that person walks in the door and his test results are in the in-basket. That's what working life is like for a doctor. So an activist patient (or patient advocate such as yourself) may get a more activist treatment. The Cleveland Clinic has a very high reputation, but maybe pressing for an activist approach isn't out of line even with them.
After I completed 6 rounds of Taxotere chemo when my PSA was still less than 1, I asked 3 different doctors about going on Zytiga before castrate resistance. They all said no. Since then, a fourth doctor has also said he won't do it.
It's been proven that early chemotherapy or early Zytiga gives a survival advantage, but not both. That's the current state of proven treatments.
I ended up waiting until castrate resistance before starting Zytiga. So far, I've been on it almost 2 years so I've gotten a good response.
Once his PSA starts doubling above 2, then they will consider him to be castrate resistant and then he is technically approved for Zytiga or Xtandi. There have been doctors who've gone right to Zytiga after chemotherapy so I'm not saying they are wrong. I just want to pass on that I had 4 doctors who wouldn't do it for me.
That's good to know! My dad completed 6 rounds of chemo in June 2015. He had a wonderful response to chemo + Lupron since it's been nearly 5 years! I just see how slooowwwwly my dad's PSA is moving and the recent scans that looked so good makes me hope that he can go for a good while before starting another therapy! I was really hoping that the Provenge would give him at least a year. It was very disappointing that he wasn't able to complete the 3 rounds, but I'm hopeful that the 2 will still be effective!
It's wonderful you're continuing to be an advocate for your Dad. My 2cents-- I wouldn't start Zytiga if Lupron is doing the job. If PSA DT is more than 12-15 months, it would generally mean he is still hormone sensitive to Lupron. Zytiga is a different animal with its own SE's, save it for later when Lupron fails IMO.
That's good to know. His PSA in October was .23 and then .26 in December and now .33 four months later. It's moved a tenth of a point in over 6 months. Doesn't seem to be moving very rapidly to me!
It is good it not rapidly rising. All in all he’s doing pretty well.. Very good to hear from you again . Thank ou are on top of this as much as anyone could be . Great job loving dad . What a blessing you are .🙏❤️
The rise in your dad's PSA since December is very minute. I would tend to agree with the Cleveland oncologist and ride the Luperon train a little longer. Hope that helps!
I say add the zytega now. Clinical studies have proven that sequential use of lupron and zytega is far inferior to early use of both. 40% reduced deaths in the zytega/lupron arm vs lupron alone. Tall Allen is right ? Why not add zytega now.
Thanks Schwah! Is that study still appropriate since my dad had chemo early on? I know many of the studies that I've read compare early Zytiga+Lupron to early Chemo+Lupron and Lupron alone.. but not necessarily Chemo and Zytiga. I'd be interested to see the study! And the main reason for not adding Zytiga now would be to hopefully get more time out of Lupron if it's still working and hold off on Zytiga since it, too, will eventually loose it's efficacy. Does that make sense?
I think his age should be taken into consideration when choosing how aggressive a treatment plan to adopt. And as you also pointed out, he has a very slow progression.
To me, those factors would suggest a more minimalist approach. Just what ever you need to manage the disease and don't add more than that. That would be my approach.
No study yet on Lupton chemo and zytega together. But we do know that the combination of lupron early with zytega and lupron early with chemo decreases mortality by 40%. And numerous other PC drugs have been shown to be more effective given earlier in the disease progression. I do all three with success because I assume if A + B is better than B alone and B + C is better than B alone, that A+ B + C would be the best. You and your dad will need to decide what’s best for him tho. No guaranteed answer at this time either way. Studies are ongoing tho I’m told.
When I was diagnosed in May2019, I was offered lupron plus Doce chemo...Lupron plus Zytiga..Lupron plus Enza and so on. After studying PCa deeply and trying to know my unique parameters..I refused consent for all these combinations..and stayed on lupron for few months along with an intensive anti inflammatory herbs and spices ...4 mile a day walk
and my PSA dropped from 830 to 0.2. (without any surgery, chemo or radiation)
Now I am in OFF period of Intermittent therapy (means no lupron etc) for last 3 months.
My belief is that start one treatment at a time and watch biomarkers carefully...continue
as long as it is working...then..once it fails clearly..go take next medication train.
If a rifle is killing the bird...why use a cannon or machine gun ?
I've been on Zytiga since I was first diagnosed 27 months ago. My PSA has been 0.1 since first month treatment I have also had Provenge infusions which by the way don't do anything for the PSA and will stay in your body forever. I encourage you to have him start Zytiga. You can control this beast with standard of care medicine. Leo
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update on state 4 met
Zytiga failed now xtandi. PSA rise after only a few short months from 1.5 to 0.08 now 0.4. Moving on up 
Update on My Dad-Numbers Rising, Bone Marrow
