After Radical Prostatectomy PSA and R... - Advanced Prostate...

Advanced Prostate Cancer
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After Radical Prostatectomy PSA and Radition with/without Hormone Therapy

Bmhk
Bmhk

Hi Guys,

My Father (age 62) was diagnosed PC with a 14 PSA Score. 2 Months ago he had a robotic radical prostatectomy surgery. Patalogy report specified; pT3aN1M0, Gleaseon 7 (4+3), Pattern 4 rate %60, Grade Group 3 and unfortunattelly surgical margin is positive. (Carcinoma metastasis in 2 of 10 removed lymph nodes). After 30 days of surgery PSA was 0,24 and now after 70 days of surgery PSA is 0.59. I know he need some more treatment. Some RO says IMRT is enough and some others says that IMRT + Hormone Therapy is much better for him. Hormone Therapy may effect cardiovascular system in later time and he is just 62 now, I think he should begin hormone therapy if PSA will rise again after IMRT but I am really so confused :(

I would be glad if I could get your feedback.

(By the way he takes curcumin tablets, eats 3 brazil nuts and drinks pomegranate juice daily)

17 Replies
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He needs to begin ADT immediately, and will have to stay on it for 2-3 years after he has whole pelvic salvage radiation. This was suggested by the Touijer study discussed in the link below.

prostatecancer.news/2017/12...

I suggest you send the link to the study to his RO.

ADT has two effects:

(1) it radiosensitizes the cancer. This has to start about 2 months before the radiation for the full radiosensitization.

(2) it directly kills hormone sensitive PC cells. To do this "clean up" completely seems to take a long time after it's metastasized to lymph nodes.

The cardiac effects are mainly in men who already have coronary disease. They are less with Firmagon than Lupron, however with Covid-19 he may be better off with the 6-month Lupron shots.

BTW, curcumin may be interfering with his PSA tests. The brazil nuts and pomegranate juice do no harm, but they don't do any good either.

prostatecancer.news/2019/04...

treedown
treedown in reply to Tall_Allen

Thanks, there goes another one. I was taking it sparingly at best but will cease at this point and stick to eating Tumeric in my food for the taste. Glad I stopped it all together prior to radiation and my undetectable test and only restarted it recently.

TA: I think I speak for everyone in expressing my gratitude to you for being here and helping us make good decisions re: PCa treatment.

If I may ask you a few questions about ADT:

1) Under what circumstances, if any, does the patient's history of SE tolerance factor into the decision of when to start and how long to continue ADT? I know there are guys who hardly notice SEs, though I was miserable to the point of suicidality. It blew my mind when my MO, knowing this about me, cavalierly told me that I'll be on ADT for the rest of my life if my PSADT goes under 10 mos. A couple of years ago he listened to me talk, through uncontrollable tears, about blowing my brains out, and now he casually mentions I'll be feeling that way until I die? I feel there must be something profoundly defective about this man. Am I missing something?

2) What can you tell me (us) about high-dose transdermal estradiol used to medically castrate the patient? I'm referring to: efficacy, risks, and the profile of SEs, especially as they affect QoL, i.e., libido, fatigue, hot flashes, depression, aches, cognitive function, etc.

Thanks!

Thanks. I'm sorry that ADT affected you so profoundly.

1. There is a process called "shared decision making" that is supposed to occur when you and your doctor mutually decide on any treatment. Remember that your doctor is a fallible person, who sees a number of patients, and may forget your feelings, even when they were tearful (oncologists see tears at many visits). Remind him.

There is no one set way to do ADT. It can be as little as occasional Casodex pills, or as much as continuous Lupron combined with one of the "super" hormonal medicines.

There are also many ways of dealing with side effects. Adding Venlafaxine may help with hot flashes and also help with depression. Adding low-dose transdermal estrogen may help with hot flashes, bone mineral density, and lean body mass. It may also increase libido, but whether it will do that without any testosterone remains to be explored (it probably varies individually). Fatigue can be lessened with a heavy exercise regime, which may also benefit memory and mood.

2. Let me refer you to Richard Wassersug (PM him at "Wassersug") who knows a lot more about transdermal estrogen as a monotherapy than I do. There is a very large randomized clinical trial in the UK (PATCH/STAMPEDE) that will provide more info in a few years. He believes that the consequent gynecomastia will not bother many men. The other risk factor to be explored is the degree of blood clots (which is why oral estrogen is no longer used).

Thanks for this very informative response.

Yes, I'm aware that my doctors and I need to collaborate, and that I can refuse treatments that I feel will be intolerable.

I've spoken with Dr. Wassersug, and I'm onboard with tE2 as a montherapy, even if the American medical community isn't.

Another question if I may. Can you please comment on the considerable volume of medical literature suggesting that curcumin has a salubrious effect on PCA? scholar.google.com/scholar?...

Thanks.

Ten times zero is still zero. Quantity of worthless studies does not in any way compensate for lack of level 1 evidence, which is totally lacking for curcumin. Please read the detailed critiques in my article that I provided links to.

Here's the article:

prostatecancer.news/2019/04...

In particular:

nature.com/news/chemistry-c...

pubs.acs.org/doi/pdf/10.102...

In the latter, the authors directly address your question when they write:

"The authors of ‘Curcumin May Defy Medicinal Chemists’ state that ‘even if 1% of the papers published make sense, it would still be a sizable number to warrant against passing a negative verdict on the whole field.’ This seems to equate the number of manuscripts with scientific fact. If the fundamental foundation of curcumin bioactivity was based on 100 papers that did not take into account its Assay Interference Compound potentials (e.g., aggregation, fluorescence, and reactivity interference, etc.), or did not consider the difference between curcumin and Curcuma, the amount of confounding variables would make the following work inconclusive at best, regardless of the number of manuscripts.”

I think this says it best:

youtu.be/a6r2BsYEtIM

His PSA doubling time (PSA-DT) seems high, from 0.24 to 0.59 in 40 days. Hormone therapy seems inevitable. Hopefully radiation will cure him.

Antioxidants (curcumin) is a big no, no, at least during the treatment. You want to weaken the cancer cells, not strengthen them!

PSMA PET/CT before anything else. SRT has a 40-50 percent success ratio. It will be a total waste to learn after irradiation and a long term under ADT that the origination of the PSA was somewhere else.

If he could, he should discuss getting a PSMA PET/CT (Ga 68 or DCFPyl), may be at UCLA or at Stanford, to see if there are distant metastases and if there are no metastases it will help with the planning of the radiotherapy.

Related to the hormone therapy, there are recent data showing that hormone therapy is only beneficial for people with a PSA greater than 0.6.

pubmed.ncbi.nlm.nih.gov/322...

Good advice from all on this. TA's point regarding inaccurate PSA test results due to interference from Turmeric/Curcumin is definitely valid. I've experienced this two times before I learned of it. False low levels.

Thank you very much for all your comments and support. PSMA PET/CT GA68 test results was clear, there was no distant metastases before surgery (70 days ago). Do you suggest to renew the test? Is it possible to have distant metastases in 70 days? :/ By the way I stop him to take curcumin. When his PSA was 0,24 he was not using curcumin than he started to take curcumin and in 40 days psa was increased to 0,59. We will test PSA in 30 days to see if not taking curcumin will affect psa. Thank you very much indeed. Your comments are really so helpful for me.

Tall_Allen
Tall_Allen in reply to Bmhk

No reason to repeat it this soon. New detectable metastases are slow to grow at first, it can be years between the first detectable met and the next one (btw- this is one reason why uncontrolled studies on metastasis-directed therapy are useless). Like most biological systems the cancer growth follows an exponential growth curve - VERY slow at first, accelerating later. Given the limits of PSMA PET/CT detection, it is highly unlikely that something entirely new will show up in just 70 days.

Yes, repeat the PSMA PET/CT for three reasons:

a) Local region. The original scan had the prostate illuminated, so anything within range was masked. This time it will be plain light naked. A positive detection here enhances expectations for a successful sRT.

b) Distant regions. The original scan will be used as a baseline in a comparative study. It is by far easier to discern a difference between two images than to spot a pattern in any single one*. Negative detection has also its merits signifying that you are not dealing with a very aggressive case. A jump from 0.24 to 0.59 in 40 days is not a very promising omen in this regard.

c) You will be dealing with drs that can interpret the info contained in such an imaging. The majority of the: "No, you don't need that" use this as a their shield to the your obvious query: "Now, what does this test tells us ?"

(*) I had been a TV network engineer for almost 3 decades. When suspecting a TV camera as faulty we would always shoot at some standardized test pattern because we knew how the picture had to look at the monitor. Looking at it's on-air picture while switching cameras would raise suspicions, but the proof would always come from the lab.

1. I wouldn't repeat the PSMA PET, in my experience the repeatability is high and they are expensive. With this past 'clear' PSMA result you need to hammer it hard NOW, not later.

2. I would definitely do salvage radiation, after ADT - reasons as per TA.

3. Side effects manageable (at least for me).

BTW fill us in on his location? treatment center(s)? doctor's names? All info is voluntary but it helps us help him and helps us too. Thank you!!!

BTW what's with the 3 Brazilian nuts?

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 06/16/2020 6:33 PM DST

Thank you very much to everyone who shared your comments. We are in Turkey. Brazilian nuts are for selenium.

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