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Bicalutamide and Finasteride

daytona19
Posts: 54
Joined: Sep 2014

I had a prostatectomy March 2005 after surgery my psa was .01Before the surgery my gleason was 6 and my psa was 2.70.

 By Sept. 17, 2009 it gone up to .69.

I started salvage external beam RT to prostate bed and seminal vesicle bed.

July 23, 2010 it was a .52 Oct. 27, the psa was .77.

by Sept. 15,2012 it was a psa of 1,84. I had scans done and it didn't show anything so I started on Bicalutamide and Finasteride. My psa went down to .10. It is now going up and as of July 14,2014 it was   .32.

My question is has anyone else have a history like this and what would be the next step? I hate the side effects of the pills( sore chest and my incontinence got worst I had it under control till the pills)

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Daytona

Welcome to the board. Thanks for sharing your story.

From your description it is clear that the ADT protocol (hormonal treatment) is not enough to hold down the cancer. You should increase the protocol probably by adding an LHRH agonist such as; Lupron, Eligard, Zoladex, etc. Any of these drugs will drive you down to castrate levels (testosterone less than 30 ng/ml), which is now feeding the cancer. Some doctors in similar situations just increase the dose of antiandrogens (bicalutamide) from a daily 50 mg pill to 150 mg. The Finasteride is a 5-ARI whose job is to avoid the purification of testosterone (T) into the more powerful (10 fold) androgen Dihydrotestosterone (DHT). Your testes are in “full strength” of operation producing T indiscriminately. T levels may be high in your system which may render the usefulness of Finasteride to zero.

Can you share details of your regular tests done to monitor your status?

Once HT drugs stop doing its job, patients are put on a second line HT drugs and from there to chemo therapies. I think that you may still get benefits from hormonal manipulations but you should discuss with your oncologist about that increasing in your ADT protocol.

Here is a cheap, old but still good book on drugs and protocols for hormonal therapies;
Beating Prostate Cancer: Hormonal Therapy & Diet by Dr. Charles “Snuffy” Myers

The side effects in hormonal treatments are best countered with a change in life style, diets and with physical fitness programs. I do not know your age or any other health problem you may have but you can find some ideas in the net adaptable to your conditions.
http://seniorhealth.about.com/od/stayingfit/a/best_fitness.htm

 

Best wishes.

VGama

daytona19
Posts: 54
Joined: Sep 2014

Thank you for your response VGama in is good to talk to some else about it,

I am 66 and go to Moffitt every 4 months to get my blood tested. On 7/30 my PSA was 0.32 and it had been 0.22 the last time which was 4/08. my testosterone was 147.0 pg/ml

I am in pretty good shape and I walk 3 miles every day( I just started that when i retired last month). I though my next step would be Lupron. I keep hearing about new meds but they are in testing and very expense.

 last scans showed nothing and in the next few months I will have new scans done.

I will get Dr. Myers book he talked about another drug Metformin that reduced hormone resistance?

I am going back to Moffitt next month and I will let you know how it goes.

daytona19 

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

 

You are welcome. Survivors in this forum try to help others with lay opinions based on own experience or in researches done along their journey.

The measuring units used at your laboratory (Moffitt) to represent the testosterone are not typical. If I am correct, Picogram per milliliter (pg/ml) equals to 1/10th in Nanogram per deciliter (ng/dl). This means that your circulating testosterone is very low at 14.7 ng/dL, therefore in castration levels.
I wonder if this is your natural level or if you are taking some sort of supplements, etc. Adding a LHRH agonist (Lupron) to the protocol would not signify much in the treatment because you have already low T levels.

I think it better you confirm the above results to rule out any positive judgment in a refractory situation. I say this because HT refractory is verified when a patient in low levels of testosterone (castration=< 20 ng/dL) has continuous increases of PSA. This could well be your case.

Your comment regarding Dr. Myers, tells me that you attended last week’s PCRI meeting at Los Angeles. Unfortunately I only followed the comments on the meeting, far from my corner in Albufeira, Portugal. Myers is my “hero” as a medical oncologist. I think you would get better advice for your case if you consult someone of his grade. He is a magician when using second-line drugs to lay down the bandit. Typically low testosterone PCa patients get some relief from estrogen patches that help to counter hypogonadism symptoms and combat the cancer. This and other tactics distinguish good oncologists when confronting the treatment of difficult cases.

You have not shared details on the type of image studies (scans) you have done or are going to do but traditional CT and MRI (1.5T) do not detect cancer at low levels of PSA (less than 10). Newer machines with 3.0T capability and refined contrast agents, and techniques are better to locate cancer of 3 mm in size. Without the prostate gland and after localized radiation (SRT), this sort of exams should have the purposes in locating metastases at lymph nodes and bone. This is the only locations that could still give you a chance of cure, with focal RT. You can find details on my comment by researching the net typing “oligometastases, prostate cancer”.

I would recommend you to do other health exams typical of 66 years olds. DEXA scan and vitamin D are important in PCa treatments. DHT should also be tested (finasteride pills) and you should read about the controversies of this 5-ARI and its effects on PSA, and low grade Gleason cancer.

Best wishes in your continuing journey.

VGama

 

 

daytona19
Posts: 54
Joined: Sep 2014

Thank you for your response,

I did not attend Dr. Myers meeting in L.A. but I did see him at a meeting in Sarasota Fl. last year. I got the info about the Metformin from a friend who follows him

I do take 5000 units of vitamin D3 along with 2500 of vitamin B12. I also take Simvastatin 20 mg but would like to get off it and take vitamin B6 and Folic Acid. ( haven't yet)

I also take Losartan. Moffitt is a cancer center in Tampa Fl. and that is where I go for treatment.

The scans I had done were Pet bone scan whole body-sodium fluoride and MRI pelvis w/wo contrast. neither showed anything. I will see about the newer test next month.

That testosterone was the free the level is H 975.

I will find out about the finasteride if it is still helping ( not sure if it ever did)

I also try to play golf one a week but in Florida this time of the year is hard( hot)

My next appointment is Oct. 21th.

Thank you again for your response.

daytona19

 

 

My next appointment is Oct. 21th.

 

daytona19
Posts: 54
Joined: Sep 2014

Hi VGAMA,

Went to my Radiation Ocologist and had a blood test. My PSA went from .32 to .62 in 3 months and my testosterone level went from 975 to 1116. My free is still around 150.

She is scheduling 2 tests for Nov. a PET/CT tumor image skull  to thigh and a MRI pelvis w/wo contrast. After that I will see my Genitourinary oncologist for a change in meds.

I will keep taking the Bicalutamide and Finasteride till then. The new drugs might or might not be Niladron or Xlandi. Both expensive but not prohibitive because of Medicare.

I asked her if she has other men  with the same history and she said yes but not one that was this agressive that was a gleason 6.

Thank for your input. It just helps to communicate with someone that has  had the same bandit that I have.

I guess after the surgery and radiation I thought that would take care of it.

daytona19  

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Daytona

If you reread my above posts you will understand the value of the drugs in your treatment.

The last results of PSA=0.62 (ng/ml) and Testosterone (T)=1116 (ng /dL) makes it evident that you have to add an LHRH agonist (Lupron, Eligard or Zoladex, etc) to the present protocol for controlling the progressive status. You need to lower the level of testosterone circulating in your body.
I hope you read the soonest the book of Myers to understand the details of hormonal therapy and its effects, and how to counter the symptoms.

Nilandron (nilutamide) and Xtandi (enzalutamide) are antiandrogens that function similarly to bicalutamide. They address the androgen’s receptors of cells. They are good to control temporarily any progression of PCa. Xtandi is more refined that the traditional antiandrogens (the others listed) because it works at intratumoral levels (within cell’s function). However, mutations of these receptors occur so that the cancer manages to feed on the circulating testosterone. Agonists block the “production” of testosterone by the testes avoiding free feeding of cancer cells. Probably your oncologist is suggesting continuing on monotherapy with solo antiandrogens because she may believe that your cancer will “react” better to nilutamide. They use such strategies (increase doses or change drugs) before giving up with any protocol.

In my case, your PSA is still low and your doctor may have a higher threshold to trigger the new treatment. In my case,  I started HT when the PSA reached 1.00 (ng/ml). I took antiandrogens for one month followed by three shots of Eligard during 18 months of treatment. Then, I started a “vacation” period free of the drugs, which is still running at three years’ time. My present PSA is 1.24 (ng/ml).

I believe that the image studies recommended by your doctor will be negative. This is typical of Gleason 6 patients with low PSA values (less than 2.5). Exactly now I am waiting for an increase of the PSA, to reach the 2.0 level so that I will do a C11 PET/CT to try locating the bandit’s hidden place.

In your case with the backup of Medicare covering the exams costs you have nothing to lose in doing the tests recommended by your doctor, however, a single C11-PET/CT of the whole body could be more beneficial because it could detect cancer in tissue and bone.

Best wishes in your continuing journey.

VGama

daytona19
Posts: 54
Joined: Sep 2014

Hi VGAMA,

You should be a doctor as you have great suggestions and do great research. When I meet with Dr. Fishman on Nov. 26th which is after the tests I will bring up the subject of the Eligard. I agree I would like to lower my testosterone and I will ask about the C11PET/ct test next week before I take the other tests. Thank you for your advise it really helps.

daytona19 

daytona19
Posts: 54
Joined: Sep 2014

I  had two tests done 2 weeks ago. a MRI pelvis with contrast and a PET bone scan whole body-sodium fluoride. Both were negative. even through my PSA is up ( .32 to 62) he wants me to stay on my meds and see him again at the end of Jan. The Dr. was very positive I guess my next step is lupron which should put my PSA down to almost 0. My surgeon said maybe go to xtandi but it is so expense. 

daytona 19

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

Daytona

I am not surprised for the results of your latest image studies. In fact I think it was a waste of money and time. Well, it is nice to have the feel that one is doing something but your doctor surely knows about the limitation in those tests in detecting metastases, providing false negatives in patients of our status (Gleason 6 and low PSA).

Have you inquire about your doctor's threshold PSA that will trigger a change in the present protocol?

Xtandi is expensive and its effect may be short lived too. This is a drug used in the second-line HT protocols. These are also more effective when administered in combo therapies or combo blockades (ADT2). It does not address the problem well when the patient has much testosterone in circulation.

My lay suggestion is that you should be looking for a second opinion from a better medical team. You do not need to rush yet because your PSA (0.62 ng/ml) is very low but if the trend is continuing increases then you should have a purposes for your next step.

Hope for the best.

VG

daytona19
Posts: 54
Joined: Sep 2014

V Gama

As always thank you for your help. I am going back to see the Doctor on Jan. 27th and if the PSA is going up ( which considering the trend it probably will be) I will ask him about the  C11 PET/CT scan.I know those tests only show that the cancer has not gone far enough to be seen. I will ask him at what level my PSA needs to be to start the Lupron. It is nice they have all these new drugs but they are so expensive.

Enjoy your holidays and I will let you know what happens next.

Thank you.

daytona

daytona19
Posts: 54
Joined: Sep 2014

 

Hi V.G.,

Went to Dr. Dattoli's office today and they gave me a Firmagon shot and I will get one monthly. they put me on two finasterride a day, cabergoline three times a week, estradiol patch two a week and ordered Zytiga which will take two weeks to get here. I go to Sand Lake Imagining center in Orlando on Oct. 13 and 14. I will let you know how it goes.

daytona19

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3258
Joined: May 2012

Daytona,

I nursed a friend through Zytiga treatments several years ago, when the drug was relatively new.  It can be quite effective when taken exactly as ordered. Zytiga is taken with the steroid Prednisone. Prednisone can increase appetite, cause weight gain, and cause sleep difficulties in some users. Both Zytiga and Prednisone are given in pill form, so no IVs are required.

He later went on Taxotere (a conventional chemo), and then Jevtana (a post-Taxotere chemo for patients for whom Taxotere has lost effectiveness). You have much cause for hope in the Oncology arsenal.

http://chemocare.com/chemotherapy/drug-info/zytiga.aspx

You can follow the link to the other drugs I mentioned as well, or to any chemo agent and virtually all HT drugs also.

 

max

 

VascodaGama's picture
VascodaGama
Posts: 2969
Joined: Nov 2010

I think that the protocol you comment here is Dr. Myers prescription. This is the traditional ADT3 (three blockades) but more refined, composed of an agonist (Firmagon) plus an antiandrogen (Zytiga) and a 5α-reductase inhibitor (Finasteride). Cabergoline may be to turn AR more sensitive. The estradiol patches will aid with the side effects apart of lowering T. How about supplements, is there any?
Worderful.

Thanks for the info. Please read my post in your other thread in here;

https://csn.cancer.org/node/296402

Best wishes,

VG

 

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