Combination or Monotherapy

George7

Hi everyone. I am very happy I found this great forum! My father (76 yrs) was diagnosed with prostate cancer stage 4 with metastasis to a distant lymp node. The only treatment he can get is hormone therapy. We saw two very good doctors and they had different opinions on the type of ht to use.

1. The first doctor suggested Lupron injections every six months and casodex (50 mg) once daily. He also suggested having 4 sessions of breast radiotion to avoid their enlargement.

2. The second one said that the combination does not have an advantage and that only lupron would be fine until the psa starts rising again. Then he would use casodex. He also insisted that the radiation for the breasts is not needed for now and can be done only if a problem arises.

Which of the two do you think is better? I would greatly appreciate your feedback as we have to decide asap.

VascodaGama

If the case is Oligometastatic, think in adding focal radiation
George

Welcome to the board.
Firstly let me inform you that comments in this forum are from layman with no medical enrolment. Our suggestions are based on own experiences and researches done along the years as survivors of PCa. You will always need to get consultations with proper doctors and decide by yourself in which to trust. Your education on the matter is important and I would recommend you to read books for PCa advanced cases.

Regarding your question, I believe that both protocols 1 and 2 exist and are valid depending on the status of the patient. However, the suggestion of doctor 1 seems to be more balanced (probably he is an oncologist). Breast radiation to avoid breast enlargement (caused by HT) must be done before starting the treatment otherwise it will have no effect. However, protocols with one blockade (yours number 2) with an agonist do not usually cause noticeable breast enlargement (the doctor 2 seems to be an urologist).

In your post you mentioned that your father is a stage IV patient but this stage groups several status that range from far metastasis to just a nearby lymph node (close to the prostate) to metastasis in bone at the iliac or still far at organs (liver, lungs, etc.) or bone in the thorax or brain. A single lymph node positive to cancer should not be the reason for rejecting treatments other than hormonal.
In fact, if cancer is diagnosed as oligometastatic (few spots of spread at the iliac lymph nodes and bone) focal radiation in combination with hormonal give better results and possibility at cure.
See this;
http://jjco.oxfordjournals.org/content/early/2010/01/04/jjco.hyp167.full

The severity of his status will rule in the better protocol to his case, even if hormonal got preferences.
You need to share more info on his diagnosis, such as the results of PSA, Gleason score, type and results of image studies, actual health conditions (any other illness; ex; heart and liver related), tests on lipids, testosterone levels and bone health (osteoporosis). I wonder why his doctors recommended Ht and not radicals (surgery or RT) as prime modalities. Do you know what the reason is?

Do not rush to a decision without knowing the facts, risks and side effects entailed. Hormonal treatment can be started at any time.
The modality incurs hormonal manipulations aimed at “starving” the cancer from testosterone (cancer feeds on T). To achieve starvation, the drugs will involve a series of blockades starting at the testis.
Agonists like Lupron will cause the testes to stop production of T (chemical castration). The antiandrogens like Casodex will bind to cancer cells androgen receptors (mouth of cells) therefore prohibit it from receiving T. Still another drug used by oncologists, 5-alfa reductase inhibitor, will avoid the formation of dihydrotestosterone which is a ten folds powerful type of T. The three blockades are known as ADT3 or total androgen deprivation therapy.

Gonadotropin-releasing hormone (GnRH) drugs are the typical agonists like Lupron or antagonists like Firmagon. If patients have metastases at the spine (bone) doctors usually recommend Firmagon because it does not cause “flare” (a sudden increase of testosterone). In such cases, Lupron injections would be done after two weeks of taking antiandrogens (like Casodex) to avoid the “flare”.
Both drugs got similar side effects butsome guys report lesser side effects with one than the other. In any case one can change drugs any time along his journey.
http://www.webmd.com/infertility-and-reproduction/gonadotropin-releasing-hormone-gnrh-for-infertility

In your father’s suggested protocols, starting with a 3-month Lupron may be a better choice to verify if his cancer is hormonal dependent. He can then move up to a six-month injection at his second shot.

I recommend you to get second opinions on the suggestions and prepare a list of questions to the doctors to help you when going around. You can get some ideas to your list from these links;

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor
http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-talking-with-doctor
http://csn.cancer.org/node/224280

A good book explaining in detail the hormonal treatment is;
“Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers. This oncologist is also treating patients with oligometastatic cancer.

At the end of the line if undecided yet, your father can get any of the two protocols now and decide changing it after being more informed in three month time. Nothing to lose by doing so. From your post, Doctor 1 seems to be better informed.

Wishing you both peace of mind.

VGama

George7

VascodaGama said:

If the case is Oligometastatic, think in adding focal radiation
George

Welcome to the board.
Firstly let me inform you that comments in this forum are from layman with no medical enrolment. Our suggestions are based on own experiences and researches done along the years as survivors of PCa. You will always need to get consultations with proper doctors and decide by yourself in which to trust. Your education on the matter is important and I would recommend you to read books for PCa advanced cases.

Regarding your question, I believe that both protocols 1 and 2 exist and are valid depending on the status of the patient. However, the suggestion of doctor 1 seems to be more balanced (probably he is an oncologist). Breast radiation to avoid breast enlargement (caused by HT) must be done before starting the treatment otherwise it will have no effect. However, protocols with one blockade (yours number 2) with an agonist do not usually cause noticeable breast enlargement (the doctor 2 seems to be an urologist).

In your post you mentioned that your father is a stage IV patient but this stage groups several status that range from far metastasis to just a nearby lymph node (close to the prostate) to metastasis in bone at the iliac or still far at organs (liver, lungs, etc.) or bone in the thorax or brain. A single lymph node positive to cancer should not be the reason for rejecting treatments other than hormonal.
In fact, if cancer is diagnosed as oligometastatic (few spots of spread at the iliac lymph nodes and bone) focal radiation in combination with hormonal give better results and possibility at cure.
See this;
http://jjco.oxfordjournals.org/content/early/2010/01/04/jjco.hyp167.full

The severity of his status will rule in the better protocol to his case, even if hormonal got preferences.
You need to share more info on his diagnosis, such as the results of PSA, Gleason score, type and results of image studies, actual health conditions (any other illness; ex; heart and liver related), tests on lipids, testosterone levels and bone health (osteoporosis). I wonder why his doctors recommended Ht and not radicals (surgery or RT) as prime modalities. Do you know what the reason is?

Do not rush to a decision without knowing the facts, risks and side effects entailed. Hormonal treatment can be started at any time.
The modality incurs hormonal manipulations aimed at “starving” the cancer from testosterone (cancer feeds on T). To achieve starvation, the drugs will involve a series of blockades starting at the testis.
Agonists like Lupron will cause the testes to stop production of T (chemical castration). The antiandrogens like Casodex will bind to cancer cells androgen receptors (mouth of cells) therefore prohibit it from receiving T. Still another drug used by oncologists, 5-alfa reductase inhibitor, will avoid the formation of dihydrotestosterone which is a ten folds powerful type of T. The three blockades are known as ADT3 or total androgen deprivation therapy.

Gonadotropin-releasing hormone (GnRH) drugs are the typical agonists like Lupron or antagonists like Firmagon. If patients have metastases at the spine (bone) doctors usually recommend Firmagon because it does not cause “flare” (a sudden increase of testosterone). In such cases, Lupron injections would be done after two weeks of taking antiandrogens (like Casodex) to avoid the “flare”.
Both drugs got similar side effects butsome guys report lesser side effects with one than the other. In any case one can change drugs any time along his journey.
http://www.webmd.com/infertility-and-reproduction/gonadotropin-releasing-hormone-gnrh-for-infertility

In your father’s suggested protocols, starting with a 3-month Lupron may be a better choice to verify if his cancer is hormonal dependent. He can then move up to a six-month injection at his second shot.

I recommend you to get second opinions on the suggestions and prepare a list of questions to the doctors to help you when going around. You can get some ideas to your list from these links;

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor
http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-talking-with-doctor
http://csn.cancer.org/node/224280

A good book explaining in detail the hormonal treatment is;
“Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers. This oncologist is also treating patients with oligometastatic cancer.

At the end of the line if undecided yet, your father can get any of the two protocols now and decide changing it after being more informed in three month time. Nothing to lose by doing so. From your post, Doctor 1 seems to be better informed.

Wishing you both peace of mind.

VGama

Thank you so much for your
Thank you so much for your reply. He has a gleason score of 7 (4+3) and his psa before his biopsy in January was 8.29. He had a lupron injection in the beginning of March and from his yesterday's blood test, he has a psa of 4.86. He cannot take radiation again because he had surgery for colorectal cancer in 2003 and after that he got chemo and radiation as well.

VascodaGama

George7 said:

Thank you so much for your
Thank you so much for your reply. He has a gleason score of 7 (4+3) and his psa before his biopsy in January was 8.29. He had a lupron injection in the beginning of March and from his yesterday's blood test, he has a psa of 4.86. He cannot take radiation again because he had surgery for colorectal cancer in 2003 and after that he got chemo and radiation as well.

Check Testosterone levels too
The drop in PSA shows good response by the cancer to the treatment. 50% drop in four weeks is very good. You may see it decreasing further to a nadir where it flattens. I would recommend your father to get a testosterone test done together with the PSA. This is the only way that we can confirm the drugs’ effectiveness. HT also causes bone loss so that your father should get a DEXA scan to check for osteoporosis. Discuss the matter with his doctor. (it is typical of urologists in not getting testosterone tests)

I am also on HT and taking 6-months shots of leuprolide acetate (Eligard same as Lupron). It took 12 months to get to nadir and now after three continuous shots my cancer reached remission levels with a PSA of <0.02.

I hope your father manages to get a “grip” on the beast and enjoy life as usual. I have experienced numerous side effects but mild; however, many guys report nasty symptoms. Fatigue is the most annoying.
Changing diets and keeping fit physically is good to counter the effects from the drugs.

Hope for the best.
VGama