Ideas? Rising PSA post RP and SRT

Wavedancer

Hi all-

New to this board.

Hubby had RP in 2003, recurrence with one bone mets in Nov 2009 with PSA 3.69; began triple ADT Jan 2010 and then began SRT to pelvic bed and to mets in May 2010. By July mets was gone, pelvis and other scans were clean and CTC (circulating tumor count) was 0. Achieved PSA less than .01 in Dec. 2010. Came off hormones in Jan. PSA stayed below .01 until June when it has risen to .04 and then to .05 this month. His DHT was < 1.0 until May when it rose to 1.9 and in July is at 2.2.

Off to see oncologist next week and wonder what to expect. Very worried that cancer is back. Any thoughts, advice, ideas for questions we should ask?

Thank you for your thoughts, comments!

Patti

VascodaGama

Hubby has not yet got to the “logical” definite nadir PSA
Patti

It is too earlier to conclude that Hubby has a systemic case. His salvage treatment was a neoadjuvant hormone therapy (HT) started prior to radiotherapy (RT), and, as you posted, it ended with a successful result verified by the tests.
After RT (Jul 2010), the PSA started to go down to a nadir which may be reached at the 18 to 24 months. Hubby is at the 12-month mark which means that he has not yet got to the “logical” definite nadir.
This nadir PSA (the lowest level after RT) has been under the influence of HT, so that the “real” value can be obtained only at the end of drugs effectiveness period and half-life.

In his case the hormone portion in the treatment (ADT3) was finished at January (2011) and the drugs half-life and effectiveness have finished sometime in June 2011, which may be the cause of the apparent rise in DHT and PSA last values.

ADT aims at lowering the testosterone (T) level in our bodies. This is accomplished with the Agonists like Lupron, Eligard, etc., that interfere with the “manufacturing” of T at the testis. A testosterone test can certify if Hubby has already recovered from the drugs action. This would unravel the mystery behind the increase in the PSA.
However, as I comment above, his nadir PSA has not yet been reached so that you may expect to see now an increase followed by a decrease later.

The oncologist may wish to start/continue with ADT but you should inquire about a Testosterone test done now to verify the point I made above. I also would recommend Hubby to have a bone density scan to look for bone loss due to ADT.

Your questions could include the items I am signalling in this post in addition to;
1) What can we expect to occur if PSA doesn’t stop to increase?
2) Is there a next “step” treatment after HT+RT?
3) Would he recommend an increase of drugs potency to control a rise in PSA?
4) When or what is his Trigger PSA level to start an action (additional treatment or drug)?


I hope my insight is of help.
Wishing you both peace of mind.

VGama

Note;
What was Hubby’s ADT3 protocol of drugs?
Was the agonist a one, two, three or six-month shot?
Has he experienced any side effect?

Wavedancer

VascodaGama said:

Hubby has not yet got to the “logical” definite nadir PSA
Patti

It is too earlier to conclude that Hubby has a systemic case. His salvage treatment was a neoadjuvant hormone therapy (HT) started prior to radiotherapy (RT), and, as you posted, it ended with a successful result verified by the tests.
After RT (Jul 2010), the PSA started to go down to a nadir which may be reached at the 18 to 24 months. Hubby is at the 12-month mark which means that he has not yet got to the “logical” definite nadir.
This nadir PSA (the lowest level after RT) has been under the influence of HT, so that the “real” value can be obtained only at the end of drugs effectiveness period and half-life.

In his case the hormone portion in the treatment (ADT3) was finished at January (2011) and the drugs half-life and effectiveness have finished sometime in June 2011, which may be the cause of the apparent rise in DHT and PSA last values.

ADT aims at lowering the testosterone (T) level in our bodies. This is accomplished with the Agonists like Lupron, Eligard, etc., that interfere with the “manufacturing” of T at the testis. A testosterone test can certify if Hubby has already recovered from the drugs action. This would unravel the mystery behind the increase in the PSA.
However, as I comment above, his nadir PSA has not yet been reached so that you may expect to see now an increase followed by a decrease later.

The oncologist may wish to start/continue with ADT but you should inquire about a Testosterone test done now to verify the point I made above. I also would recommend Hubby to have a bone density scan to look for bone loss due to ADT.

Your questions could include the items I am signalling in this post in addition to;
1) What can we expect to occur if PSA doesn’t stop to increase?
2) Is there a next “step” treatment after HT+RT?
3) Would he recommend an increase of drugs potency to control a rise in PSA?
4) When or what is his Trigger PSA level to start an action (additional treatment or drug)?


I hope my insight is of help.
Wishing you both peace of mind.

VGama

Note;
What was Hubby’s ADT3 protocol of drugs?
Was the agonist a one, two, three or six-month shot?
Has he experienced any side effect?

VGama-
Thank you so much for
VGama-

Thank you so much for your time and the insightful response. This information is incredibly helpful. (If you can figure out how to bottle peace of mind, you'd win a Nobel prize!)

To answer your questions...
Hubby's ADT3 protocol: Casodex, 50 mg x 3/day; Ursodiol, 300 mg 2/day; Avodart, .05/day. After a week of that, he received his first Lupron shot.

The shot was a one-month for a couple of months and then went to a three-month. We had a scare at one point after the first three-month shot as the nurse had gotten mixed up and gave him the one month shot. His T flared up to 960.

The side effects included some fatigue, loss of muscle mass, loss of speed and endurance (he has been a competitive runner and triathlete for years) and a bit of an increase in emotional reaction. He continued to work out and believes that helped greatly physically, mentally and emotionally.

I am convinced that everyone who battles cancer are warriors and heroes.

Thank you, again, for your help, VGama.

I hope that you are doing well in this vicious battle.

Patti

tarhoosier

Ideas?
Welcome to this board. Sorry for the reason. Your husband is invited to represent himself. With due respect to Vasco, I read your initial post and conclude that your husband has systemic disease, as the identified bone metastasis reveals. This is not to say that in some individuals a limited metastasis my be successfully treated. I find it interesting that a circulating tumor cell (CTC) was conducted. This is uncommon. The zero reported is expected at this time in his treatment. Also the 150 mg or triple Casodex is quite unusual, at least in the United States. In addition, your oncologist is enlightened enough to follow DHT. A targeted radiation for a man in such circumstances means the oncologist and your team are at the top of their game. Oh, that more had such skill. Well done and I salute him/her. You appear to be in good hands.
Your report about psa is incomplete without a testosterone test. Surely this has been done. At this time psa is your friend. We are lucky in the convoluted way of this disease to be able to assess our progress with such a sensitive and specific marker (in post treatment milieu). I am reluctant to suggest questions because the path of his treatment so far seems to have been as aggressive as possible and addressing all potential avenues.

Wavedancer

tarhoosier said:

Ideas?
Welcome to this board. Sorry for the reason. Your husband is invited to represent himself. With due respect to Vasco, I read your initial post and conclude that your husband has systemic disease, as the identified bone metastasis reveals. This is not to say that in some individuals a limited metastasis my be successfully treated. I find it interesting that a circulating tumor cell (CTC) was conducted. This is uncommon. The zero reported is expected at this time in his treatment. Also the 150 mg or triple Casodex is quite unusual, at least in the United States. In addition, your oncologist is enlightened enough to follow DHT. A targeted radiation for a man in such circumstances means the oncologist and your team are at the top of their game. Oh, that more had such skill. Well done and I salute him/her. You appear to be in good hands.
Your report about psa is incomplete without a testosterone test. Surely this has been done. At this time psa is your friend. We are lucky in the convoluted way of this disease to be able to assess our progress with such a sensitive and specific marker (in post treatment milieu). I am reluctant to suggest questions because the path of his treatment so far seems to have been as aggressive as possible and addressing all potential avenues.

Thanks, Tarhoosier
Thanks for your comments, Tarhoosier.

In response to your question about Testosterone. While on ADT3, it was less than 0 and then began its rise to 407 in May; 454 in June and 362 this month.

As far as whether or not the cancer is systemic now based on a mets, that is the million dollar question.

There is lots of research out there on ogliometastatic disease that says targeted radiation on the mets (if five or less) as well as the pelvic bed can lead to long term success. Here is an informative video on the subject by Dr. Charles "Snuffy" Myers, one of the leading doctors dealing with advanced prostate cancer: http://askdrmyers.wordpress.com/category/ogliometastatic-disease/

Thanks, again.

Patti

mrspjd

.
.

Wavedancer

Just to follow-up on
Just to follow-up on original post...

Hubby's oncologist thinks the increase is due to post-radiation flare. He has seen that happen in a number of his patients who have also had RP at the 12 and 18-month range.

If it is not flare, he wants to wait until the psa goes to 2.0 and send him for a scan at Sand Lake imaging. They have a technique that will show where the cancer has returned. Possible site radiation at Dattoli afterward. This is the first time he has told my hubby that he was not going to die from prostate cancer.

VascodaGama

Wavedancer said:

Just to follow-up on
Just to follow-up on original post...

Hubby's oncologist thinks the increase is due to post-radiation flare. He has seen that happen in a number of his patients who have also had RP at the 12 and 18-month range.

If it is not flare, he wants to wait until the psa goes to 2.0 and send him for a scan at Sand Lake imaging. They have a technique that will show where the cancer has returned. Possible site radiation at Dattoli afterward. This is the first time he has told my hubby that he was not going to die from prostate cancer.

A check-up of other health concerns done now is a must
Patti

Thanks for the follow up report. I am glad to know that Hubby’s doctor judges his case as treatable and survivable.
Dr. Myers commonly increases the daily intake of mg of anti-agonists and 5-ARI in cases similar to Hubby to pin down the PSA. He also likes to see T level lower than 20ng/ml (castrate level).
Your doctor’s threshold mark of PSA 2.0 sounds logical because it has been “masked” by the hormonal drugs.

A sign of aggressiveness of the cancer can also be evaluated later on a PSADT (doubling time) lower than 9-month, which should be calculated from the third consecutive rise until it reaches your doctors threshold. These tests to qualify should be taken on periods longer than 6-weeks apart.
(In my case of SRT I usually had the PSA tested every three month)

I would recommend hubby to have a detailed check-up of other health concerns such as heart, liver, dental and lipids done now to serve as base-line data if he needs to be subjected to added drugs. Treatment medications tend to interact with some medicines taken for other purposes.

I read that Dattoli Centre performs USPIO-MRI (Ultra-small Super Paramagnetic Iron Oxide particles) tests to verify metastases. You can inquire about this new modality in your next visit with your doctor. You can also read about newer drugs like Abiraterone acetate used as second line ADT, and Denosumab.
Knowledge has given me confidence and trust when confronted with depression from this “bandit”.

The best to you both.

VGama