With what I am sure is good advice from this support group, I quit Bicaluatamide150 mg, - which I had been taking in addition to a monthly Firmagon injection - when my testosterone dropped to 9 ng/dl = 0.3 nmol/l. I understood that B gives little in addition to F when T is so low.
When I tried to contact doc about this, he let his assistant write me that I had been prescribed Bicalutamide and should continue with this for (at least) the full six-month period, simply saying that it works in a different way than Firmagon, which we all know.
I feel I need more to stand up against doc.
Anyone with advice. or study to point to? I am hesitant to go against his urging, also because I have an aggressive PC. Dx September2020, Gs 4+5, low-PSA type 1.7 at Dx, intraductal cancer in two of the biopsy samples. I had EBRT + Brachyboost late last year.
Searching past posts, I understand Bicalutamide may start feeding the cancer and, not surprisingly, have side effects. On the other hand, I saw one post pointing to a study indicating better time-to-treatment failure (TTTF) & time-to-disease progression (TTP), although not necessarily overall survival, with the combination of B and LHRH for men with advanced prostate cancer. [1] pubmed.ncbi.nlm.nih.gov/171... I can´t judge how relevant this study is for a case like mine.
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The data provided above by you about your PCa ( low PSA type, Intraductal, GG 4+5 )indicates aggressive type. Lupron alone may not be enough in such a PCa type. Only in non aggressive type, Lupron alone can be enough.
This is a most interesting study that gave me other insights. However, I can´t find any evidence of the effects of combined androgen blockade compared to only LRHR (Lupron/Firmagon and the like). Maybe I have missed something....
They did not compare the combined ADT to ADT monotherapy. But they report: "The median time to CRPC development was 140.7 months." This is longer by far than you usually achieve with ADT monotherapy.
Can´t change since I am at the best clinic for prostate cancer in this part of the world. Only problem is that communication with the chief doctor is only 45 minutes every six months or so.
The most severe side effects (liver related) are extremely rare. Even if it may not make much of a difference if you take it or not, for a full six months, I suspect taking it is more likely to be beneficial than harmful.
But there is a less severe and very common SE that would be a good rationale for telling your doctor you will not continue with it: gynecomastia. Bicalutamide very often causes some degree of breast growth/pain.
The idea of adding 150 mg to ADT for a combined androgen blockade (CAB) is kind of an old-school approach at this point, but I would take that as a sign your doc really thinks it has potential benefit. But the higher dose of 150 mg (compared to 50 mg) is NOT the established standard of care in the US.
If you add Bicalutamide to Degarelix, you will not get much gynecomastia. This would be the case if you have a Bicalutamide monotherapy.
Gynecomastia is caused by the imbalance of testosterone and estrogen. Degarelix will reduce both so far that Bicalutamid does not have much effect regarding gynecomastia.
Advanced PCa is a killing monster. Myself, if I had it down....I wouldn’t quit and take my foot off it’s neck and let it get up and start killing me again. For me , bigger boobs - side effects are FAR preferable to the alternative of quicker death. That’s just my take. Always listen to your medical crew that is keeping you alive first and foremost. If you don’t like the doc , change the doc. If you are doubtful of his advice, get a 2nd opinion and .....of course..... get the sage advice of the very knowledgeable PC brains on this group. You are trusting your doctor with your life, stick with his counsel first.
This is just my perspective, many others may vary .. good luck brother warrior.
For a good customer that you are, you get free views of my Mammies.....and you can juggle them if you want....But no kissing them.. or any other linqual caressing/affection......
You: " Dx September2020, Gs 4+5, low-PSA type 1.7 at Dx, intraductal cancer in two of the biopsy samples."
Well, I've had a different Dx, PSA 1000+ with extensive pelvic area metastasis My pelvic scan looked horrible, tumors all over the place and one was extending from my prostate invading the bladder wall. My urine flow was blocked with shredding like pain.
Was given Bicalutamide and in just 12 hours all symptoms relieved. Then after two weeks, Bicalutamide was stopped and was given an Lupron injection followed by daily Abiraterone.
So, asked why stop Bicalutamide when it worked so well? The rationale was, Bicalutamide proved my PCa is hormone sensitive, consequently, Lupron with Abiraterone is an efficient treatment for overall survival.
Search the forum for a member that tapered off dosage. Started with 150mg, switched to 50mg per day, then 2 pills per week and lately 3 pills per week. Don't think that he had such aggressive disease as yours, though.
My understanding is that you are taking hormone therapy as an adjuvant therapy to your brachy boost therapy for high risk PC. But why only 6 months? There is strong (Level 1) evidence that 18 months of ADT gives superior results to 6 months:
Is ADT alone enough? In one of the STAMPEDE clinical trials, they looked at high risk patients treated with radiotherapy (not brachy boost) who were randomized to 2 years of ADT or 2 years of ADT+abiraterone. What they found was:
"Failure Free Survival (FFS) was improved in ADT + abiraterone in N0M0 patients compared to ADT alone (HR 0.14, 95%CI 0.07-0.30), with 3-year FFS of 80% for ADT alone vs 98% for ADT + abiraterone."
(1) You need at least 18 months of adjuvant ADT therapy
(2) Adding abiraterone may improve results (unclear whether still necessary with brachy boost).
(3) There is no known benefit to adding bicalutamide. Ask your RO what research he has seen that "combined androgen blockade" improves outcomes for high risk patients receiving it as an adjuvant therapy with brachy boost.
Thank you, TA. I realize I was unclear - I have N1M? with the question-mark meaning "50% risk" of mets to bone, to be clarified in a few weeks time. I understand I need long-range ADT therapy, perhaps 18 - 36 months of Firmagon, I would think this is even more important when metastatic...?.
Assuming I have mets to the bones N1M1 (four mets if so) which I think is likely, and reading Prostate Cancer News about best options for newly diagnosed metastatic men, I understand that adding abiraterone/zytiga is beneficial at this state for someone like me with GS-9, low PSA, intraductal. That Newsletter is from 2017 - do you know if there is something new to be said from the trials about the comparable benefits between adding zytiga, docetaxel or erleada to ADT/Firmagon? As I am writing this, I realize it´s a huge question and will rewrite it shortly as a main post. I would much appreciate your comments, here or in the main post.
Some randomized clinical trials (RCTs) are definitive, so updating is not needed. For Zytiga, two large, well done RCTs (STAMPEDE and LATITUDE) established it as a SOC. In research terms, it is level 1A evidence, meaning it has been confirmed.
For newly diagnosed metastatic patients, I keep this frequently updated:
As you see, there are now 4 approved medicines along with ADT for this situation (Zytiga, Xtandi, Erleada and Docetaxel), plus radiation to the prostate if oligometastatic, which you've already had.
However, you are not "newly diagnosed." They mean men who are first diagnosed with distant (M1) metastases and haven't had any treatment. I'm pretty sure all the same medicines would work for you, but optimum sequencing hasn't yet been established, and your insurance company may not agree.
Thank you again, Tall Allen, I had missed seeing "frequently updated" in the newsletter, this is impressive.
I understand there are probable strong benefits to adding one of those 4 medicines in a case like mine, if side effects can be handled, with a small plus for Zytiga which can be considered the front-runner, all other things equal.
I recall a post of yours saying Docetaxel is the most beneficial cost-wise, but with generics of Zytiga on the market this should not be a major issue.
Zytiga plus 5 mg prednisone for the castration-sensitive.
If side effects are severe, reduced dose of Zytiga in combination with food regimen may be an option.
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My Intermittent Bicalutamide mono therapy
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Options when Docetaxel stops working 
