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PSA rise with ADT

pnd
Posts: 7
Joined: Mar 2018

I was diagnosed for Prostate malignancy in 2013. I had radical prostactomy in 2014. Two years later I was started on ADT. This year, despite ADT every three months, the PSA shows a rising trend, reachig currently a level of 2.9. The current testosterone level is 29 ng/dl. The PSMA scan is unable to pick up any areas where the radiation beam can be targeted if that therapy is opted for besides ADT. I have no discernable symptoms of any kind of discomfort. There is a tendancy towards growth of belly fat. The doctor has advised me to continue with ADT. Is this PSA rise without any discernible discomfort and no detection of cancerous regions in PSMA and reasonably low testosterone level something alarming or an aberration. I am 79 years old. Kindly advise.

pnd

Clevelandguy
Posts: 455
Joined: Jun 2015

Hi PND,

Sorry for your continuation with Pca.   ADT will probably help but if your PSA is rising sounds like your cancer is still growing.  I would approach either your doctor or get a second opinion from another doctor or new tests to run to find the cancer so it can be treated.  Hopefully someone will chime in with the proper tests to run so you pinpoint the bandit.  Vasco, where are you?

 

Dave 3+4

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

I am here but why me, Dave?

PND, Welcome to the board. Please note that we are not doctors and what we suggest may not be the best option for you. As Dave comments above you may do extra tests trying to find what is the main cause influencing your present PSA. Surely I would recommend you to get a second opinion on the films/results of the PET exam, too. The present situation could mean refractory which should be subjected to an increase of the ADT protocol (3 blockades) but you need to get certain that something else is not behind the increase feeding the cancer.

You have indicated that you have grown a belly fat which usually is made of estrogens. These are also androgens that may feed the bandit when the real stuff (testosterone) is not available. Estrogens are products from testosterone (T), lowering its level in circulation. Such could have been risen by the body due to the demand from our systems for the lack of T. It usually stores in the belly. Therefore, you could start by testing your estrogens in circulation too.

I wonder about the protocol of ADT. Is it a single blockade done with a LHRH agonist (Lupron)? What is the PSA histology before diagnosis at surgery and after RP? 

T is now low but have you tested the level of Testosterone before starting ADT? What is the difference between the base line and the present level? Have you ever experienced hypogonadism before surgery?

Can you tell what your clinical stage was after RP. Did they find extracapsular extensions?

There are several isotopes in PSMA PET scans (68Ga, C11, F18-choline, etc), can you tell which one were used in your exam? I may help you more if you can paste here the contents in the report of the nuclear physician.

Best wishes,

VG

Clevelandguy
Posts: 455
Joined: Jun 2015

Good info.................

Old Salt
Posts: 720
Joined: Aug 2014

Sorry to see that your cancer appears to have developed resistance to the ADT agent that you are using. Which one is it? You should discuss with your oncologist whether another ADT agent would be useful. 

Information about the pathology of your prostate (the exam after the surgery) would be helpful as well. As Vasco already pointed out, it would be good to know, among others, how many cancerous loci there were, their Gleason score, and whether the cancer had invaded a nodule or nearby tissue.

pnd
Posts: 7
Joined: Mar 2018

Firstly, I am grateful to Dave, Vasco and Old Salt for taking pains to respond to my queries. I had PSA of around 16 when the whole thing started. In sonography, the weight of prostate was declared as 180. After RP the PSA had almost fallen to zero. Thereafter, there was neither any treatment nor any PSA tests. About 2 years after RP, in a test, PSA was found to be around 13. So, a PSMA scanning was done but it did not reveal any discernble problem area. at that stage, ADT was started Luprodex 11.2 mgm, a quarterly dose. The PSA first fell to around 8, then to around 4, then to1.28 and then to 0.429. At this stage one dose of ADT was skipped. Over next three months, it rose to 0.554.  Again the dose was skipped. After next three months, PSA rose to 4.05. So again ADT was resumed. Over next three months it fell to 0.916 but ADT was now persisted with. PSA values over nexttwo quarters were 0.837 and 1.428. At this stage another PSMA was done which again failed to find any problem area where radiation beam can be targeted. ADT was continued but the latest PSA value is 2.492.

 

I can put all the RP records and PSMA records next time. AS far as I can recollect the Gleason score in the biopsy was 6+6. During RP lymphs were checked for metastasis but nothing was detected. Even before RP, in bone scanning no metastasis was detected. PSMA was Gamma PSMA. Testosterone test has been done first time. I will submit RP data as well as PSMA reports next time alongwith any further information that may be required.

pnd
Posts: 7
Joined: Mar 2018

I have been recommended Calutide 50 mg. tablets along with quarterly dose of ADT. I forgot to mention earlier, that I have had a CABG around 21 years back and apparently have had no serious problem since then, although now-a-days breathlessness does come if I have to climb stairs. I have to take blood thinners, beta blocker and a calcium blocker, Statins as well as proton inhibitor because of hyperacidity. I take B-complex, Coq-10, Calcium, Fish oil and multivitamin-minerals supplements.

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

PND,

Calutide and Luprodex are generics of Casodex and Lupron made and sold in India. I assume therefore that you have been treated in India. Surely Indian doctors are as good as in other countries but their treatment standards differ because of the different guidelines imposed by their institutions (Association of Surgeons of India in this case), in such regards, the use of drugs as well protocols follow different theories.

In Europe and the USA the guidelines for hormonal treatments' drugs are practically based on clinical trials done by pharmaceuticals. Lupron (same as Luprodex) in ADT for prostate cancer (PCa) is available in doses depending on the period established by the oncologist. These are administered monthly (7.5mg), every 3-month (22.5mg), every 4-month (30.0mg) or every 6-month (45.0mg). The Lupron 11.25 mg you have been taking is usually recommended in women affairs for the treatment of endometriosis and pain.

In regards to ADT protocols, oncologists tend to have patients under hormonal administration continuously during long periods. Intermittent protocols follow basic procedures dependent on each patient status but they all require at least one year in PSA remission levels of less than 0.05 ng/ml, before stopping drugs administration. Your descriptions above makes me think that your urologist either: has not enough experience in treating prostate cancer with hormonal manipulations, or follows a different standard probably based on his association's guidelines due to your past history with coronary artery bypass grafting. Or else.
In fact, they tell that patients on Lupron have ".... Increased risk of heart attack, sudden death, and stroke can occur in men using LUPRON DEPOT. Discuss this increased risk with your doctor before starting treatment and report any new symptoms during treatment".

Please read this;
http://www.lupron.com/
http://www.lupron.com/important-safety-information.aspx?ref=3

There is a series of missed interpretation in your descriptions above. You are not a doctor and this all may be difficult for you to understand. I also noticed that you are taking a series of precautionary medications regarding BP and that you are not young (79 yo) so that doctors tend to follow palliative approaches. The breathlessness situation may be due to fatigue that is common in ADT therapies. One must also think that as we age more and more health issues are expected and doctors do not disregard them when recommending something.

The term "Gamma PSMA" is new to me. Can you tell what kind of medical equipment was used in your image exam? Was it a PET machine?
Gamma radioisotopes are the typical tracers in present PSMA exams. But there are differences in detection capabilities depending on the type of cells being exam. Ga68, C11 and F18CH are the best for PCa. Get me a copy of the scan report.

I wonder if your doctor has been discussing with you any possibility in involving radiotherapy in your continuing sequential treatment. RT is typical used in failed RPs. He/she may be trying to resolve the recurrence issue with a palliative approach (low level of ADT) for your other health issues. Radiation is also kept to treat pain when the patient has advanced metastatic disease. I really would like to know what your pathological stage was after surgery to comment further.

Best of lucks.

VGama

 

pnd
Posts: 7
Joined: Mar 2018

Dear Mr.Vasco, I again cannot thank you enough for your detailed response. Some clarification. The PSMA was with Gallium68. I wrongly wrote Gamma. The radiation therapy was offered to me. Firstly, I was rather not prepared for the 35 seatings required and the cost involved. Later, since two PSMA did not bring out specificity for the beam direction, they decided to hold on.

I am from India. At my age, I am not looking for extension of life. I am a bit worried about the painful end. I am told I am more likely to die from other ailments before PrCa has had a say. Which will be fine. Is it safe for me to augment Luprodex 11.2 quarterly with Calutide?

I am a bit unclear what I should say about my pathological condition after the RP, but in all the tests doctors have found no metastasis so far. The rectal examination has been acceptable so far. They are suggesting one more PSMA. But this is very costly here - yes, it is PET scanning - and I wonder at PSA of 2.9 will it succeed in revealing anything which it could not even at 14.0. I am at the moment leading a fairly comfortable life for my age.

I do not know how to attach the reports to notes here. I will figure it out and send you the attachments. Thanks a lot again.

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

PND,

You are welcome. We are both survivors in the same boat. I hope I can navigate you through these rough waters as Vasco-da-Game did when he reached your shores in the XV century. I do understand your worries and intent in advancing with radiation once proper targets are identified. Guessing is like playing Russian roulette. One can be lucky hitting the bull's eyes or just acquiring the side effects and risking something more adverse. In any case, radiation is advisable for situations as that of yours.  

My lay opinion from the info you have shared so far, is that I believe that you may well die from other ailments before PCa has had a say, too. Patients of systemic cases with extensive cancer metastases are the ones at high risk for painful deaths. This seem not be the case you are confronting at present. You are asymptomatic, your Gleason score 6 (3+3) is the lowest in risks for metastases, and such case has been commented by your doctor (... doctors have found no metastasis so far. The rectal examination has been acceptable ...) and all these have been confirmed with two  68Ga PSMA PET exams (at PSA=13.0 ng/ml and at PSA= 1.428 ng/ml). So far they used the proper tools to verify your PCa status. You are worried but things seem OK. I wonder how much you trust the physicians assisting you.

In your shoes I would get a second opinion on the PET exams (2016 and 2018). You need to get a copy in CD format and send it to a reliable nuclear clinic doing PET exams, probably at the USA. You can discuss this with your present doctor and ask for the film to be sent for a second opinion. If you decide to get an additional PET scan then you should not be under the influence of hormonal drugs. False negatives could render the benefit of such exam to nothing. In this regard I wonder about the last PET that has been done probably still under ADT influence.

If you decide to start ADT again then I would recommend you to increase the blockades (ADT2) with a daily Calutide 50mg plus the LHRH antagonist Firmagon which is friendlier for guys with coronary issues. Changing drugs in refractory cases is also practiced by famous oncologists and ADT would not interfere with a radiation approach if such route becomes your wish in the future.

Best,

VG

pnd
Posts: 7
Joined: Mar 2018

Thanks for a very comprehensive advice. I have the cds but I would not know where and to whom I can send without any contacts and of course equally importantly what it would cost. I will try to send you the reports for whatever they are worth. I will consult people here about ADT clouding findings in PSMA and carry on with ADT + calutide etc. Thanks again.

Regards.

PND

VascodaGama's picture
VascodaGama
Posts: 3008
Joined: Nov 2010

Please note that ADT stands for Androgen Deprivation Therapy. It includes all drugs (Calitude, Luprodex, Firmagon, Ketokanazole, Zytiga, etc) and manipulations done to interfere or prevent the cancer from feeding on androgens. Any of these actions is subject to failure, named refractory. When this is declared one must be careful and stop the therapy, in particular the Calitude (bicalutamide) as the cancer may have start feading on bicalutamide itself.

Please read this;

https://deepblue.lib.umich.edu/bitstream/handle/2027.42/58635/23473_ftp.pdf?sequence=1

VG

 

pnd
Posts: 7
Joined: Mar 2018

VG

Thanks for the caution raised with regards to Calutide. I have been advised a month's trial to be followed up with a PSA assessment. I was also suggested Orchidectomy. But during RP I had to be put on ventrilator due to my CABG history. SO another operation would be a last resort. I also have hypothyroidism for which I am on Thyronorm 50 mcg. I have an appoitment with an oncologist on Tuesday. I will report further after that.

Regards.

 

PND

 

pnd
Posts: 7
Joined: Mar 2018

 I met the hospital Oncologist with all the reports etc. According to him, I am, at the moment , doing fine and I should continue with Lupridex inj.+Calutide. I should have another PSA test after a month and see him with the report again thereafter. He said, there is no logical explanation for the rise in PSA despite the Lupridex inj. taken 3 months earlier.

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