Rising PSA, Casodex and MRK2206

jdwadenc

I am looking for any advice concerning Casodex and MK2206 trial.  I had RP in 2004 at Ford Hospital using the robotic DaVinci.  My PSA had went from 0.9 to 5.6 from March, 98 to June, 04.  In May, 03 it was 3.6 but I guess my Urologist was using the <4 rule so nothing was recommended.  After biopsy with Gleason of 7, I elected RP in Nov., 04.  Surgery went OK, but the doctor explained that he had to shave up the bladder neck margin? 

My PSA stayed <0.1 until Nov. 07, I was told 0.1.  Then 0.16( Feb. 08), 0.14(Jul. 08), 0.28(Feb. 09), 0.3(Aug. 09), 0.32(Oct. 09).

In Oct., 09, I elected (ON MY OWN) to go for radiation of the prostate area, total of 37 sessions.  

My PSA values afterwards were: <0.1 (Apr.10), <0.05 (Nov.10), 0.05 (May.11), 0.15 (Nov.11), 0.15 (Jan.12), 0.22 (Apr. 12), 0.28 (Jun. 12), 0.32 (Aug. 12), 0.42 (Dec. 12), 0.59 (Feb. 13), 0.71 (May. 13) and NOW, 1.12.  I am told that the PSAV is 5 months!

I would like some discussion as to what are my best options at this point.  I am 69 years old.

Should I go into a Casodex and MRK2206 phase II trial knowing that I might be placed in the Casodex only group?  Since the trial is 72 weeks, does anyone have experienced with Casodex only treatment?  Without drugs like Lupron?

Should I forgo the trial opportunity and go for intermittent hormone therapy?  If so, when should I start?  Now, I would think?

VascodaGama

Would the trial include a USPIO or PET/CT scan? Accept if YES

 

JDwadenc

I received your mail and will answer to your post here.

The info you provide does not include any past or present data on positive image studies or any other fact that could prove or negate the presence of metastases, other than an increasing PSA. By the numbers, the PSADT is lower than 9 months, which after a SRT is considered aggressive. Such a possibility could be due to the Gleason pattern 4 found in your RP’s pathologist report.
Guys with such aggressive type of cancer cells are very much in the “line of fire” for spread. Usually doctors recommend bone scans to look for existing metastatic cancer.

I do not know how you came into the matter of a trial but the phase II “Bicalutamide With or Without Akt Inhibitor MK2206” trial maybe risky if you are put into the placebo (no drugs at all) group for 72 months. That could leave your case untreated and prone to easy spread if not constantly checked with proper means rather than simple PSA tests.

The trial does not consider thresholds but times into the medication or placebo. Here is the link;
http://clinicaltrials.gov/ct2/show/NCT01251861?recr=Open&amp;cntry3=EU:IE&amp;locn=Cork&amp;lup_s=05/06/2013&amp;lup_d=30

In my lay opinion, (remember that I am not a doctor) in a case as yours, I would only engage in this trial if I would be assured of getting the Casodex WITH the Akt inhibitor, and that it should be stopped when a threshold PSA reaches the mark of 2.5 ng/ml (if ever).
I say this PSA level because it is considered by specialist oncologists at present times as the marker which may allow modern equipment/modalities of finding/detecting oligometastatic cancer. This “oligo cancer” status is considered as the progression stage before the cancer starts its way to become systemic and therefore untreatable.
I would not recommend a case of Gleason grade of 4 to allow progress in a PSA above 2.5, without starting a more aggressive treatment, such as ADT2 or ADT3. This level may be the limit when one may still have a chance in “claiming” a cure. A chance in radiating those oligometastases, avoiding spread.

 

I would recommend you to research on the newer ways of testing PCa such as the USPIO and the PET/MRI 3T scan done with the latest contrast agents (C11 and F18) to try to locate the cancer and try in getting rid of it.

The benefit of having Casodex alone is “short lived” in a progressive case as that of yours. Casodex with Ark may improve the action of the bicalutamide at the cells AR receptors but it is well known that the cancer can feed on its intratumoral low testosterone levels of a more potent less prevalent type named dihydrotestosterone. To handle this problem, there is now a newer drug with improved AR action named Xtandi enzalutamide (former MD3100) which received FDA approval. This expensive drug can be administered alone (solo) but doctors use it at refractory patients.
https://www.xtandihcp.com/

Cheaper ways are the traditional protocols that include castration. The heavy duty drug Lupron is just for that, and they “fit” to be taken with other drugs such as Casodex, etc.

A note on your question mark; “…had to shave up the bladder neck margin?” may have had the meaning at your RP that the surgeon was delicate when dissecting the prostate gland close to the bladder sphincter. That may have resulted in a successful control of incontinence. 

Please get the opinion about your progressive case from a medical oncologist specialized in prostate cancer treatments. The last decision is done by you at it should be decided now. 

 

Best wishes for a successful outcome.

VGama 

 

 

 

 

 

VGama