Dad’s blood reports. PSA and testosterone down but ALP up

[Tinkudi]

Did some blood tests for day today

The last blood tests were done on 2nd May - PSA 18 Alk Phos 180 which led to the prostate cancer diagnosis. Was diagnosed with bone mets to a few bones.

Initially the plan was to do lupron and he was started on bicalutamide which he took for 3 weeks uptil 7th June.

But then we decided to go with relugolix and not lupron. He has been taking Relugolix from 8th June - 18 days And is supposed to start enzalutamide from this week

He had upper pain in one leg where there are mets in ischeum and femur. The pain has gone after a few days of taking the bicalutamide and now he walks almost an hour every day and does some stationary cycling .

Did some blood tests today and these are the results.

PSA 1.124 (18 on 2nd May )

Testosterone 39 (460 on 7th June - a day before starting Relugolix )

Alkaline Phos - 325 ( 180 on 2nd May)

Fasting Blood sugar - 135 ( 115 on 2nd may )

I guess this means the Relugolix is being effective ? What may be the reason for the increase in ALP ? All the other liver numbers are absolutely fine.

( Consulted MO yesterday and he was not concerned about ALP Said it could be due to bone healing)

[dave2]

ALP has multiple components (the medical/biochemistry jargon for this is "isoenzymes"). It's certainly possible that increased bone metastatic activity is causing serum ALP to rise. But there are other possible explanations. I suggest asking for at least for a bone-specific ALP test as one next step; his doctors may want other tests as well to help identify the cause of his high total ALP.

[Tinkudi in reply to dave2]

Thanks

[TomsD1]

This does look good! Please take steps around making sure you support his liver as that is what controls elimination of free testosterone.

[Tinkudi in reply to TomsD1]

Thanks

[dhccpa]

My alkaline phosphatase rose after starting Lupron in November 2018. Sometimes in 2019 it began a long decline, by 2021 it was below normal. I've been told those were both good reactions, rising initially then dropping steeply. It has remained below normal through today.

[Tinkudi in reply to dhccpa]

Did your MO tell you why it happens.

Are you only on lupron and nothing else. ( read your bio)

[dhccpa in reply to Tinkudi]

Yes Lupron and nothing else except denosumab for bones. I'm not sure that my oncologist even uses denosumab correctly.

He monitors alkaline phosphatase but says little about it. I read about it on this very forum.

[Tinkudi in reply to dhccpa]

To what level had your alk phos gone to. Do you remember ?

Why no xtandi or zytiga since you have bone mets too ?

My MO said to give dad 60 mg xgeva every six months. Another MO I met said 120 every month. Do you have osteoporosis. ?

[dhccpa in reply to Tinkudi]

I was not giving Zytiga or Xtandi a long with Lupron back in 2018. As I began getting second opinions a year or two later, those opinions varied about whether to add before Lupron "failed." Apparently the trials were done on newly diagnosed patients, not on patients who had been on Lupron for 10 months or more. Even Mayo and Moffitt split on the issue. Very confusing.

My MO arguably should have added it at the beginning, but he seems to think first of side effects. I gather most of his patients have bad co-morbidities that yield bad SEs on PCa treatment. Plus new developments reach this area 2-3 years later, if then.

The exception is PSMA scan and Pluvicto treatment. Apparently their reps are really beating the bushes for business.

My alkaline phosphatase jumped noticeably higher but my best recollection was high double digits; I have those results and can find if you need it. Say below 100 but getting close. Last reading June 6 was 29, I believe.

[Tinkudi in reply to dhccpa]

My lab range for alk phos is 50-129. I am In India. I don’t know what range usa labs use.

What did you mean by new developments reach this area 2-3 years later

[dhccpa in reply to Tinkudi]

I mean we're very slow here. Doctors here are very slow to adopt new protocols. Maybe their Medicare/insurance contracts that patients don't see influence what they do and don't do.

[Justfor_ in reply to Tinkudi]

Using 3 different labs on a rotation basis, each one quotes different normal ranges for ALP: (25-129), (40-130), (40-150). To be able to compare, I calculate the percentage of each measured ALP to the max applicable normal value. FYI, my average for the latest 5 years has been 42% with extremes up to 57% and down to 34%.

[Tinkudi in reply to Justfor_]

Thanks What do you think of the testosterone and psa readings. These were 18 days after starting relugolix. Earlier he was on bicalutamide for 3’weeks as I mentioned in the post.

The plan is to start him on xtandi from next week - Worried about that

[Justfor_ in reply to Tinkudi]

If memory serves, I had already given you my best estimate when you asked regarding when to test after switching from Bicalutamide to Orgovyx. It was 90% or more decline after 10 days. Your dad scored a 94% decline after 18 days. No need to further comment on this.

I would NOT started anything more at the moment and particularly under such high ALP. It is common knowledge that for bone metastases ALP is a better metric to PSA. You have been advised to ask for bone specific ALP. This would have been my next step.

[Tinkudi in reply to Justfor_]

This article is the explanation given by my MO - that it can be a sign of bone healing -“An ALP flare can just be a sign that treatment is working when there is bone metastasis”

karger.com/cro/article/14/1...

[Tinkudi in reply to Justfor_]

Bone specific ALP would help distinguish it being from bone vs liver ?

[Justfor_ in reply to Tinkudi]

Yes, it does. Also, it is very plausible that the bone ALP is a debris from killed bone metastases. But, no paper will confirm that. You have to wait and see whether there is a declining trend formed. What's the hurry? Any train leaving the station?

You reminded me the Americans that dropped the Nagasaki atomic bomb 3 days after that of Hiroshima. They just couldn't wait for the Japs to surrender, so they claimed. In fact they just wanted to test the second type of atomic bomb they had made. And what was the after math of such a hastiness? Double the amount of the Strontium/Cesium/Iodine radioactive particles that soon covered the earth like a blanket, the US included. In Greek we have this proverbial phrase: "If you pee in the sea you will find it in the salt".

[Tinkudi in reply to Justfor_]

No hurry. Just that MO said to start with xtandi from Monday and said not to worry about the ALP but I am worried to start it

[God_Loves_Me]

Rising ALP and declining PSA - Liver stressed

[Tinkudi]

showed the reports to my MO. He said very good response to the Relugolix and was not concerned about the Alkaline phosphotase. Just said to not bother about it.

Dad will start xtandi from next week

[NemoHic]

An ALP flare can just be a sign that treatment is working when there is bone metastasis:

karger.com/cro/article/14/1...

The increase is caused by the repair of osteoblastic lesions according to that paper. Anecdotally, mine went up to 1800 shortly after ADT began and then dropped to normal over the next few months. The leg pain went away in that time and my PSA has been < 0.1 for over six months now (triplet therapy with lupron, darolutamide, and docetaxel).

[Tinkudi in reply to NemoHic]

thank you ! 😊

[Tinkudi in reply to NemoHic]

Did it rise successively for some months before it began decline ?

[NemoHic]

It was at 210 four months before diagnosis, which was the first high reading I had. It wasn't measured again until after I started ADT when it had spiked to the extreme level. It was back to normal two and half months after the spike.

[Tinkudi in reply to NemoHic]

Thank you. Just got dad’s test reports. ALP at diagonsis was 180, went to 325 on starting ADT and today back to 57. Phew 🙏🏻😊

[Justfor_ in reply to Tinkudi]

Have I recommended to you milk thistle for liver detox?

[Tinkudi in reply to Justfor_]

No. Is it good to give

[Justfor_ in reply to Tinkudi]

I take it and my numbers are all time low.

[Tinkudi in reply to Justfor_]

What dose do you take. Do you mean ALP numbers

[Justfor_ in reply to Tinkudi]

For ALP, things are not clear as in the long past labs had different testing methods and not compatible normal ranges. So, I am comparing the percentage of each test to the each time quoted max normal value. It isn't a bullet proof method but gives me some rough idea. My average since 1988 is 42.1%, max 74.5% and latest test 40%. For SGOT, SGPT and γ-GT measurements have been more consistent. My current numbers are comparable to 1989 as earlier labs had different normal ranges.