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A VERY ODD TREATMENT PLAN?

SV
Posts: 56
Joined: Sep 2010

The following excerpt was posted on a website regarding a treatment plan involving Chemo I have not seen before. Is the Canadian healthcare system ahead or behind?

"The really bad news was that Grant was diagnosed with aggressive prostate cancer just before Christmas, after a sharp rise in PSA level and other indicators prompted a biopsy and other tests. Thus began several months of further testing, differing diagnoses and treatment recommendations, depending on which medical specialist we consulted with. Surgeons recommend surgery (cut it out!), radiologists recommend radiation (burn it out!), and chemical oncologists recommend chemotherapy (poison it!). Actually, because of the stage that Grant's cancer is at, the specialists all recommended 2 out of 3 - surgery and radiation OR radiation and hormones OR chemo and surgery! Look at where the prostate is located. It is in a very sensitive area, and all these treatments come with significant risks to QOL (Quality of Life) :-(

So, after a lot of anxious research and consultations, we were able to get him into a clinical trial in Vancouver. He was randomized into the group that gets 4 months of chemotherapy and hormone therapy followed by a prostatectomy. His surgery will be done by the best surgeon in Vancouver, one of the best in North America, so we're very encouraged, as the skill of the surgeon is key to reducing the risks to QOL...

He started the chemo in late March. Fatigue is the most significant side effect. He's on a 3-week cycle, and for 2 of every 3 weeks he has to stay away from other people because he's very susceptible to infection, and he's only able to work a few hours a day. Then the week before his next cycle he's got more energy and can work a normal day (that's a 7-8 hour day, not his usual 10-12 hours). He's had other side effects, including loss of beard and most of his hair, but he's tolerating them okay, and his PSA has dropped every cycle, so the poison is working! After a short time to recover from the chemo, he's scheduled for surgery at the end of August, and we're hoping he'll be recovered enough to travel to California in October."

VascodaGama's picture
VascodaGama
Posts: 1594
Joined: Nov 2010

SV

I do not think that treatment methods differ by country or that some are ahead than others. Medical practice guidelines are usually followed by the whole medical world but the care giver is free to choose the protocol he/she thinks most suitable to a certain patient status.
In Japan is common to start the treatment of prostate cancer with a neoadjuvant HT, but surgeons do not like the touch of the gland affected by the hormones. They say that it feels sticky and soft.

Chemo is in fact the only way to reach the cells all over and commit the kill. Radicals are good for localized treatments, dissecting or “burning” a targeted tissue.
Hormonal is a palliative mode for interceding with the feeding system of the cells. Like chemo it addresses any cell wherever they may exist.

Some doctors prefer to administer chemo first (particularly in young fellas) under the idea that a healthier body got more chances to recover from the therapy. In any case the effects are nasty and in many older patients the benefits are severely reduced. They move later to a radical.
In another forum I have been following a G9 survivors’ story (48 years old) that has chosen the “mother of all treatments” starting with surgery followed with RT, then chemo and now HT, all in one decided protocol. The whole process is taking two years but he reports on the success in remission.

Chemotherapy is now friendlier to take with the newer drugs of lesser side effects. The clinical study commented in your post may involve those newer drugs.

What about you, how is your case going?
Have you recover completely from surgery?

http://csn.cancer.org/node/202020
http://csn.cancer.org/node/220674

Nice to read another of your posts.
Good luck.
VGama

SV
Posts: 56
Joined: Sep 2010

Thanks and I will respond to your question in my original thread.

rajivsaha
Posts: 5
Joined: Jun 2012

My Father who is now 76yrs old , had his early prostate cancer detected in 2000 and subsequently the castration was done in 2001. He was all well till 2012 feb having no/little complaints of obstructed urine etc. Dr.had never asked us to check PSA in between. Only as last time we did PSA test in Dec 2009 - which was 0.43

Suddenly in 2011 June , he had started complaining for back pains.

We did not know any such PSA monitoring and hence did not. In Feb 2012 , he again started complaining of back pains and this time we did PSA test which was reported at 64 and a stage IV metastasis.
Immediately Dr. Asked us to start Bicalutamide 50mg/day and monthly PSA check. After two month's PSA (was stable at ~60)had increased to 90. And then Dr. had increased the Bicalutamide dose to 150mg/day and asked us to monitor PSA within next 15-30days. Last three months' he is also under IV infusion of Zoledronic acid(Zometa)for bone metastasis.

In case of a further increase , Dr. would define a 2nd line hormone therapy with HONVAN etc.before administering Docetaxel /Ketoconazole at his age of 76yrs(keeping in view of chemotherapy effects at his age). We are now in 7th day of 150mg Bicalutamide dose and just waiting for the next step.

Does any one of you have any suggestion for further delaying the process of chemotherapy or increasing life expectancy without any further problems/criticality expected.

Will be obliged if anyone can guide.
thanks ! rajiv/india.

VascodaGama's picture
VascodaGama
Posts: 1594
Joined: Nov 2010

Rajiv

I wonder what made the doctors to diagnose your father as stage IV metastasis patient. Was there any image study or bone biopsy performed?

The description on the protocol administered seems to be correct in PCa patients with the symptoms of your father. Zometa helps in controlling cancer in bone and increasing drugs’ potency are in line in HT protocols. Surgical castration in 2000 may have been helpful in controlling the beast along the 12 years however only proper scheduled tests could confirm the success.
Moreover, some cancers produce lower levels of PSA so that a small difference is significant and could be related to increased activity of cancer indicating metastases. PSA of 64 could relate to big tumours.
Again, proper diagnoses through tests are important and you should insist in getting them. It is traditional reading posts from patients in India where doctors do diagnoses based solely on past experiences.

One important aspect in your father’s status is the condition of being hormone castration resistant. Surely a high PSA in a guy with surgical castration confirms the above, but the adrenal glands also produce androgens so that only through testosterone test together with a DHT (dihydrotestosterone) test one can confirm on the benefits from the Bicalutamide.

The increase of the dose of the antiandrogen may as well be the cause of the increase in PSA. Antiandrogens got the bio structure of testosterone which initially tricks the cancer cells in seeing it as the real thing but after a certain period (differ from patient to patient) prostate cancer androgen receptors (AR) are known to mutate and start feeding on the drug. This makes doctors to stop administering Bicalutamide. They name it Androgen Withdrawal Treatment (AWT).

http://jnci.oxfordjournals.org/content/91/21/1869.full
http://erc.endocrinology-journals.org/content/5/4/325.full.pdf

Here is an article on the AAWR (Anti-Androgen Withdrawal Response);
http://www.prostate-cancer.org/pcricms/node/202

Honvan is an estrogen and used in second line hormonal treatments. The principle is the same in trying to induce low levels of androgens in the body. Ketoconazole is an older drug in the same line and it seems better than estrogens, however, it must be administered with more attentive care.
Other drugs who have shown successful control in advanced cases is Zytiga (abiraterone acetate) and still a better drug just approved for administration is the newer antiandrogen Enzalutamide (named MDV 3100 when in trials) which seems to extend the time of response by the cancer before becoming refractory. These drugs address the problem from within the cells (intratumoral activity).

For metastases in bone you got Alpharadin and a newer drug in Phase III trial named Cabozantanib. Try to research about the drugs in the net typing their name. Here is the link for the trials which you could discuss with your father’s oncologist to find about possibilities of participating;
http://clinicaltrials.gov/ct2/show/NCT01605227

Can you describe the histology of your father case, with Gleason score, any biopsy and events?

Wishing that my post is of help.

VGama

rajivsaha
Posts: 5
Joined: Jun 2012

Dear Friend.
Indeed much of help was offered by your mail. Thanks.

We had biopsy done for my father's case in 2000 (but, could not keep a track of Gleason score) but certainly it was malignant with low potency. Hence Dr. here had removed the SOL at that time and asked us to go for .

In 2012 , Dr. had asked for a bone scan (on my father's repeated complaint of back pains) and hence it was confirmed for multiple bone mets. I can share the scan report of his bone scan on personal email ID , if you permit.

Today also we had done one Liver function test (post administering 8 days of 150mg Bicalutamide) and Alkaline Phosphatase is still on higher side at 668 U/L. The medicine is told to be continued atleast till next 15days to see its effect on PSA control.

I need certain guidelines for his advanced treatment.

1. Incase bicalutamide 150mg does not control rising PSA levels , can we start Honvan ? or would Ketoconazole be a better choice theoritically ? (Dr. is trying to delay the process of chemotherapy with Docetaxel , keeping my father's 76 yrs age in concern).

2. As far as I know , Abiraterone Acetate is not yet available in India - can we get it imported (thru friends/family staying in the US) to our country with any help ?

3.As common men , do we have access to " Enzalutamide " ? is it approved only in US - then what would be the cost of this medicine?

4. Here Dr. is insisting on continuing Zometa , till next 10 months - can we stop Zometa and start "Alpharadin" ? Is it available all across ?

5. Do "Alpharadin" and Zometa work in similar way ?

6. Phase III trial drug "Cabozantanib" - is it approved for the patients ?

7. Do you have any idea on treatment of Prostate Ca with multiple Bone mets , with "Sodium Bi Carbonate" or "Oregano herb" ? - Some of our friends have suggested these alternate foods to carry out a preventive control for the disease.

If you can pl help me understand aforesaid ones - but thanks anyways for all those kind guidances.

We can interact at personal ID, if you permit.

rgs/rajiv

VascodaGama's picture
VascodaGama
Posts: 1594
Joined: Nov 2010

Rajiv

You should do your own investigations and get second opinions on the case of your father from specialized oncologists. That can be done at the offices of doctors you trust (in other countries included) sending all info, tests results and diagnosis by courier. Guys in this board, like me, are layman without any medical enrolment. Our opinions are based on own experiences and researches done along the years as survivors.

You can e-mail me to this CSN Email account if you prefer. Nevertheless, the forum is for sharing information so that many guys (members and visitors) can benefit from reading our posts.

The high Alkaline Phosphatase you commented is expected because of his bone metastases. When cancer spreads to the bones, the bony tissue breaks down and releases increased levels of alkaline phosphatase into the bloodstream.
This is in fact a test done at diagnosis (before confirmed metastases) to check for any possibility/suspicion that prostate cancer has spread to the bones, and it was the Test of Preference before the start of the PSA age.

Regarding the Bicalutamide, it should be taken every day and only stopped after confirmed hormone refractory. In any case, such may be already your father’s diagnosis because of the increased PSA in a castrated environment.
If the PSA continues to rise then the antiandrogen should be stopped (AAWR). (Refer to my above post)

Regarding the newer drugs that have been successful in dealing with advanced cases similar to your father, they are expensive and may not be available in India. You may try to obtain them through your family living in US or EU. However, they are not available “over the counter” so that you should arrange firstly to get a consultation with a proper oncologist.

I would recommend you to discuss the above with the doctor treating your father to access about any possibility of engaging into an overseas clinical trial. Some of these trials are started or funded in the USA or Europe but some hospitals in other countries, through conveniums, may submit requests for participation. Surely his doctor could also request the matter to another colleague in US or EU (through their oncologic association).

Your queries;

1) The cancer may respond to Honvan but in a castrated environment Ketoconazole may give better results. Your father may start now chemotherapy or do it after the second line HT.
Response to the drugs and the side effects are not dependent on the age of the patient. One can stop taking anything if it shows to be difficult or too nasty and deteriorate the quality of living.

4) Zometa is a bisphosphonate used in prostate cancer treatment to help/prevent deterioration of bone and bone loss, due to long periods of castration (low levels of testosterone) and due to bone metastases. Alpharadin does not help in bone reconstruction but it attacks directly cancerous bone. The drug is a radioactive substance (radium 223). Search the net about details.

7) I do not know about those substances. Nevertheless there are many that seem to improve symptoms. Cure is not the aim when taking supplements and one should consult their doctor on the matter. Drugs interact among them and cause damaging reactions.

Take care.
VGama

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