ADT w/ Heart History

[Hope49823]

Hello, recently diagnosed with prostate cancer (no symptoms) and navigating care.

69 years old with current PSA of 7.692 (about 5-6 weeks after biopsy), Sept 23 (6.5), June 23 (5.5), March 23 (4.9), March 22 (3.8), March 21 (2.6), 2019 (3.4), 2018 (2.7), 2017 (2.9), 2016 (3.5).

Prostate MRI showed 2 PIRADS-4 legions within right peripheral zone 1 x 0.9cm and 1 x .07cm. “There may be subtle increased enhancement extending along the region of the right neurovascular bundle.”

MRI guided biopsied with 5+4, 4+4 on legions and one random sample of 6+6. Gleason 9. No PNI.

PSMA Pet Scan - malignant lesion laterally in prostate on the right. No metastatic disease identified.

Have heart disease. Bypass surgery 2001. Stroke 2020 (only deficit is balance). Heart Attack and Stent 2020. Recent diabetes controlled with diet (A1C 6.7).

Radiation Oncologist suggests 30 days of casodex, followed by Lupron injection, then 25 EBRT sessions, followed by 1.5-3 years of ADT, per NCCN guidelines. But referred to Medical Oncologist. Today MO scared about Lupron given heart disease. Referring to another cardiologist for consult. Also having radiologist relook at MRI for possible spread.

Thoughts on ADT with heart disease? Or the course length to hopefully avoid MI or stroke. Or a different course of treatment?

Thank you.

[Hope49823]

I forgot to add that current testosterone levels is 179 (pre casodex start 2 days ago).

[JohnInTheMiddle]

Regarding ADT there are two types of ADT: one is the GnRH agonist (like Lupron/Eligard) and the other is the GnRH antagonist (like Degarelix/Firmagon).

There is some evidence, although this is disputed, that an ADT antagonist is less associated with CVD.

It is for this reason that I did not switch to the supposedly more convenient 90 day injection for Lupron and stayed on the less convenient 30-day injection for Firmagon.

From my reading the evidence is sufficiently good to support my decision; other people disagree. (There is also the newer GnRH antagonist which is oral only but which is not adopted everywhere due to its expense: Relugolix/Orgovyx. It apparently it has a comparatively good CVD profile.)

Because you have pre-existing heart or CVD conditions these questions are of course really important and your MO is good to highlight them. Also because of controlled diabetes.

ADT is standard of care for 50 years and possibly unavoidable. In such a situation it's important to underscore positive contribution that you can make via exercise. Exercise is underrated in terms of contributing to prostate cancer therapy success - and I suppose for people with heart situations too.

One last comment that I have been reading about is the whole question of orchiectomy or orchidectomy. This used to be a common procedure even though personally and culturally it's kind of shocking. But it is not common now. Don't forget that ADT is otherwise known as "chemical castration"!

But from my reading actual castration might be an interesting option because then you don't have to do ADT! (I know that at this point a lot of people like to think about intimate relations and seem willing to sacrifice longer life for their sex life. Intimate relations can be much more than that.)

Even bringing up the question of surgical castration as an alternative to ADT is not common now. Mostly it's all ADT, all the time, plus the more advanced and sophisticated therapies. Might be an interesting conversation with your MO.

(If my suggestions for consideration are unwelcome, possibly in ways in ways I don't understand, or are medically incorrect, I apologize and stand to be corrected.)

[JohnInTheMiddle in reply to JohnInTheMiddle]

BTW following up from my suggestion above concerning orchiectomy or orchidectomy, it crosses my mind that because you are not metastatic that this possibility is more interesting for you than for me. Because I am metastatic, the cat is already out of the bag. I'll be very interested for any comments on this question from yourself or any other Forum participants.

[Hope49823 in reply to JohnInTheMiddle]

Thank you for taking the time to reply to this, especially about about the ADT drug choices. I have reading to do. As far as surgery, there are reasons RALP was not recommended and this may apply to a castration surgery as well. It hasn't been discussed at this point. More to learn. Appreciate the reply!

[Benkaymel in reply to JohnInTheMiddle]

Since the OP is non-metastatic and only requires limited duration ADT, I would think that surgical castration (obviously permanent) would not be very attractive.

[JohnInTheMiddle in reply to Benkaymel]

You're correct that the OP is non-metastatic. But don't forget: "Have heart disease. Bypass surgery 2001. Stroke 2020 (only deficit is balance). Heart Attack and Stent 2020. Recent diabetes controlled with diet (A1C 6.7)."

And the MO is very worried about heart and stroke risk associated with ADT!

So it's easy to say surgical castration "is not very attractive" and (obviously) "is permanent" -- and then an option that previously was very successful is off the table. It's almost always off the table now, to my understanding. But this is an ill-judged prejudice I think.

The prejudice is cultural and psychological certainly. But the prejudice is also likely distorted by financial incentives for other expensive therapies.

My sense is that in the right circumstances surgical castration might provide a significantly better outcome then a cascade of radiation, other surgeries and drugs.

[Benkaymel in reply to JohnInTheMiddle]

Would surgical castration remove the need for radiation, other surgeries and drugs?

[JohnInTheMiddle in reply to Benkaymel]

I'ma not the person to ask - maybe Tall_Allen could comment. At minimum though I believe it means that ADT may not be necessary.

Here are some references on the topic of surgical castration in circumstances of prostate cancer, especially in comparison to ADT therapy:

ncbi.nlm.nih.gov/pmc/articl...

tau.amegroups.org/article/v...

ncbi.nlm.nih.gov/pmc/articl...

ncbi.nlm.nih.gov/pmc/articl...

cuaj.ca/index.php/journal/a...

There's a lot of interesting material in these references. The decline in surgical castration as an option is highlighted. And also there is material discussing the question of cardiovascular, heart and stroke risk associated with ADT versus the absence of the same with surgery.

[Tall_Allen]

Orgovyx (relugolix) has less cardiac toxicity vs Lupron, especially for men who already have cardiac issues:

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

auajournals.org/doi/abs/10....

(email the links to your new cardiologist before your meeting)

It sounds like your radiation oncologist plans to duplicate the POP-RT trial with you, which had excellent results:

prostatecancer.news/2021/08...

There's also the possibility of a shorter duration of ADT, if combined with a more intensive hormone therapy, as in the AASUR trial:

prostatecancer.news/2021/06...

There is also a clinical trial that you qualify for that uses Decipher scores to determine duration and intensity of hormonal treatment:

clinicaltrials.gov/study/NC...

[Hope49823 in reply to Tall_Allen]

This is a wealth of information and still absorbing it. Thank you very much for this and your work. I may have more questions, but one that I have now is whether there is a data about length of course of ADT and when the increased heart issues happen....is it 3 months? 6 months? or father out? If a shorter course makes sense for me. Thank you.

[Tall_Allen in reply to Hope49823]

Shorter duration of ADT is exactly what the trials in last 2 links try for. In the end, you will have to use your judgment about the trade-offs.

[Shamrock46]

My husband has similar history. While getting tested for meniscus repair in 2010, found to have had a silent heart attack with 1/3 of heart dead....1 stent, 1 clogged artery had created its own stent and another was completely blocked. He'd had no symptoms and had a physically demanding job. Switched primary in 2014 and dx with prostate cancer, surgery with kidney failure due to Toradol. Released 11 days later with no instructions for vigilance though hospital records showed PNI and positive margins. Also had implantation of cardiac defibrillator. 2018 1st recurrence found in ER being treated for kidney stone, PSA 18+ and changed drs. to Loyola cancer center. Lupron started, then bicalutamide added...PSA went down...then up and advanced to bone mets...changed to MO who provided info on ADT choices. We chose Xtandi due to heart problems...added to Lupron @ 3-mo. intervals. PSA undetectable until 2022 with worsening SEs and rising PSA ...2nd recurrence. We were offered surgical castration, radiation, chemo or Abiraterone (which has even worse cardiac implications according to literature). He made decision to refuse all and stopped treatment in July this year....now receiving palliative care at home and actually feeling better off all the drugs and their side effects, including the memory problems/brain fog MO attributed to Lupron. He also had his defibrillator deactivated. MO had originally said that treatment works until it doesn't because the cancer eventually outsmarts it all...and he was tired of dealing with all the SEs and feels they contributed to his now having CHF and feeling awful. Hope you have better luck.

[Hope49823 in reply to Shamrock46]

I’m sorry about the rough road. Wishing you peace and the best days your husband can have.

[Shamrock46 in reply to Hope49823]

Thank you....I wish you the same!