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Rising PSA post RP and SRT, what mix of HT to use

traveler
Posts: 21
Joined: Jun 2011

Hi ,
I was diagnosed with PC in 12/07 biopsy glesson 3+4=7 pre RP PSA 8.9.
post op pathology Glesson 4+3=7, negative margins, nodes and seminal vessals clear with small extraa capsular extension. PSA fell to 0.04 after 6 months but then began to rise and was 0.16 by 12/08, and SRT was recomended. Started SRT in 01/09 PSA fell progressivly to <0.03 in 03/10 and then started to rise with PSADT initially at 3 months now down to 2 months with PSA 06/11 at 0.86. My latest CT and bone scan has identified I have small tissue modularity in the prostate bed as seen on the CT scan and MDP avid focus in the left Ischium on the bone scan, though both reports state that it is not clear these represent metastasis. My urolologist has started my on mono line therpy of 25mg Androcur (an anti androgen) to watch and see what happens over the next few months. I have another opinion that says I should have a second bout of SRT and HT. I am seeing my radiation oncolgist tomorrow to seek his opinion (he had previously stated that I could not have further radiation). My question to the discussion board is, has anyone heard of treating only with mono line therepy and just anti androgens?
i would have expected with a fast PSADT that it should be hit hard with LHRH or even CAB for 9 mths and then see what happens. If anybody has found themseleves in similar circumstances I would be greatful for your experiances.

VascodaGama's picture
VascodaGama
Posts: 1511
Joined: Nov 2010

Traveler

Thanks for sharing your experience.
To radiate previous radiated areas is usually not recommended unless the isodosage applied in your first attempt was small, however, in the second attempt it is difficult to control and avoid areas that received the full dosage. SRT post SRT is complicated and it has not high enough successful rates to assure a good outcome. It is common to read that after SRT, pinpointed areas are radiated if cancer is confirmed to exist, such as at bone (spots) or far lymph nodes.

The image studies have revealed positive to deformations and lesions. The report does not confirm cancer because it requires a confirmation done with a biopsy of those findings. Many doctors make judgement on the findings based on their experiences, however, you could have a second opinion on those reports from a radiologist specialist on PCa.

Recurrence after a failed SRT is indicative of systemic case.
You do not describe about your PSA histology since your assumed nadir (0.03) but you may know that recurrence is considered on the third rise (test) from nadir, or it may be considered after observing a progressive rise in a period. This is a norm set by ASCO which serves as guidance to manage recurrence and treatment. Only one test is not enough for judgement.
The fact is that PSA curve fluctuates after radiation differently than after RP, and patients, with or without prostate, can experience bounce (ups and downs) in PSA, before reaching the real nadir. In some cases that is achieved two to three years after SRT and in some cases they can go up to values above 1.

I am not a doctor but I think that HT in your case should be started only after assuring that recurrence is present. I cannot understand your urologist approach regarding the treatment he is recommending you. Not just because he seems eager to start you on HT before confirmation of recurrence but also because he puts you on a low dose (25mg) of cyproterone acetate (Androcur), which is out of normal practice in recurrence cases similar to your diagnosis. As you comment, PSADT lower than 9 months is of high risk and deserves a more aggressive lookout. Get a second opinion from an oncologist.

Anti-androgens act directly on cancer cells closing their receptors to avoid “feeding” of testosterone. The usual recommendation is over 50mg, being 150/200mg recommended in aggressive cases. In my case (failed RP&RT, negative MRI&Bonescan) I took cyproterone 2x50 daily for the first month followed by Eligard 6-month depot (LHRH agonist). After SRT, I had a nadir of 0.05, confirmed recurrence on the 29th month (PSADT=9.7 months) and started HT on PSA=1.0.

Hope this helps in your quest.
Welcome to the board.
VGama

traveler
Posts: 21
Joined: Jun 2011

Hi VGama,
Thank you for sharing you insites it was helpful. My history of PSA is as follows
Post RP
05/08 0.02
08/08 0.085
11/08 0.16
01/09 0.2
Post SRT
04/09 0.1
05/09 0.04
11/09 0.04
03/10 <0.03(The cut oof at the path lab was 0.03)
08/09 0.07
11/10 0.13
02/11 0.27
04/11 0.42
06/11 0.86
So as you can see there is positive evidence of reoccurance.
I live in Singapore but recieve my primary care in Australia and had my second opinion in Apirl in the US(Which recomended the second round of SRT together with neo adjuctive HT).
My real concern is that todate those advising me have been acting in their sphere of speciality (Urologist on RP,Radiation Oncolgist on SRT) So I think I need a specialist medical oncolgist to advise on HT.
I am seeing my Radiation oncolgist tomorrow to discuss the idea of SRT mark 2 and a medical oncolgist to discuss the HT options so it will be interesting to hear their views V what my urologist has currently prescribed.
I have read a lot of Snuffy Myers papers and books and feel I need to consult with someone with his level of specialisation. I am detemined to get a durable managed remission program in place ASAP.
Thank you for sharing you PC progess, did you ever have detectable metastasis or did you progress to HT based solely on PSA readings.
I wish you continued succes in the battle!
Thx
Traveler

VascodaGama's picture
VascodaGama
Posts: 1511
Joined: Nov 2010

Traveler

I agree with you. Your PSA histology indicates recurrence.
In my case recurrence was confirmed when the PSA reached 0.26 on the 29th month post RT. My doctor threshold mark for starting hormonal treatment in my case was PSA=1.0, which happen in November 2010 (4 years after SRT).

I was diagnosed with PCa in 2000 with a high PSA of 22.4. I had a voluminous cancer (6 cores positive) but low Gleason score of 5 (2+3), DRE negative. After RP I soon recurred and was diagnosed with Micrometastasis (the ones invisible to tests). WW during 6 years with no symptoms and negative image studies. When PSA reached 3.6 (non detectable metastasis) I was recommended for SRT.

My present uro-oncologist is a specialist in prostate cancer. His protocol is similar to Dr. Myers’ except that he doesn’t agree in Myers’ “remission” level of PSA<0.01 for cases similar to mine with a classified pre Gleason score of 2+3 (the newer, since 2005, classification of Gleason would be 3+3). I am now on mono blockade (ADT) with Eligard 6-month depot and that took me down to PSA=0.05. My doctor will add an antiagonist (50mg daily) if any variation occurs in the PSA within the 18 month initial cycle. Then I will start an intermittent modality.

In your case with probable detectable metastases, I would choose Dr. Myers’ protocol of ADT3 to pin-down the PSA to remission. In fact I have followed his practices since 2000 and believe in his approaches in the management of prostate cancer. I would recommend you to get a copy of his book “Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers that also have references to SRT. You can order used or new copies from the Amazon site.

When on WW, I was assigned to a project in the Philippines and my follow-up doctor was Dr. Alex Chang, oncologist, at Singapore Johns Hopkins (http://www.imc.jhmi.edu/). You could try a consultation with him. He is a member of the team of Dr. Patrick Walsh, famous JH urologist, and he is partner of Dr. Mario Eisenberg (who looked after my case) in JH Baltimore.

There is a famous oncologist specialist in prostate cancer now practicing in Singapore. His name is Dr. Stephen Tucker. I have read many of his published papers on the topic of prostate cancer. He was a partner of the famous oncologist Dr. “Bob” Leibowitz. These doctors have long years of experience in treating high risk and advanced PCa patients with a variety of drugs “cocktails”. Their protocols are unique for that they do not have a “remission” limit and it tends to manage the progress of the cancer at medium low PSA levels.
You can read about Dr. Tucker in this site;
http://www.pacificcancercentre.com/about/stucker.html

About Dr. Leibowitz here;
http://compassionateoncology.org/publications.html

I hope this post is of help to you.
Wishing you find a definite care program.

VGama

traveler
Posts: 21
Joined: Jun 2011

VGama,
Once again many thanks for you comments. I met with my radiation oncolgist and a medical oncologist yesterday. The view was clear, the risk of furhter radiation far outweighed the potential benefit even if it could be determined if the spots found on the bone and CT scan, and from what I have read I tended to agree with this prognosis. The medical oncolgist was just a puzzled as I was with the use of an antidrogin and at such a low level.
He has recomended that I go onto an LHRH program he was relaxed as to which drug was used, he felt that this should be pursued for 18-24mths and depending on PSA,scans etc to then come off and watch to see if it reoccured. He also suggested that I up the Androcur to 100mg from now and stop it 2 weeks post my LHRH injection. He was not a fan of MAB to start with but would look at it if there were problems in the future.
I am heading back to Singapore and will chat with my GP and I think get a second opinion from Dr Tucker if i can get to see him quickly.

VascodaGama's picture
VascodaGama
Posts: 1511
Joined: Nov 2010

Traveler

I am glad to know you got a satisfying answer to your inquire and that you are now more relaxed.
The protocol suggested seems right. His opinion to “…come off and watch to see if it reoccurred” is in fact one of the main benefits in interrupting (intermittent modality) the hormonal treatment. Apart of giving a relief from the side effects, it will give you a chance of verifying if cancerous cells died or become dormant.

Have you asked about items for follow-up and added prevention?
You will follow a regimen of periodical tests and you need to consider regimens for handling the side effects. Bisphosphonates are very important. Balanced Diet and Physical fitness are a must.
I would recall you to get a copy of Dr. Myers Book.

Wishing you the best.
VGama

traveler
Posts: 21
Joined: Jun 2011

VGamma,
Thx again for you comments. I have now seen Dr Tucker in Singapore, and started ADT3 today with Zoledex, Casodex150mg and Proscar 5mg. We are going for a 12 month program and hope that all important markers fall to allow droping back to just Proscar for maintainance.
Thanks for pointing out that Dr Tucker was in Singapore, i found him to be very helpful and clearly knowledgable.
I had read Snuffy Myers book a while ago and adoted his diet 3 months ago (lost 6kg so far) and walk 2hrs per day 4-5 days a week and walk two rounds of golf on the weekends and try to carry my bag on at least one round (a little resistance excercise!).

I am hoping I can focus on the end game and not get distracted by any side effects the program may cause over the next 12 months.
Hope your readings remain low and thanks again for your help.
Best
Traveler

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