Rising PSA post RP and SRT, what mix of HT to use

VascodaGama said:

HT should be started after assuring recurrence
Traveler

Thanks for sharing your experience.
To radiate previous radiated areas is usually not recommended unless the isodosage applied in your first attempt was small, however, in the second attempt it is difficult to control and avoid areas that received the full dosage. SRT post SRT is complicated and it has not high enough successful rates to assure a good outcome. It is common to read that after SRT, pinpointed areas are radiated if cancer is confirmed to exist, such as at bone (spots) or far lymph nodes.

The image studies have revealed positive to deformations and lesions. The report does not confirm cancer because it requires a confirmation done with a biopsy of those findings. Many doctors make judgement on the findings based on their experiences, however, you could have a second opinion on those reports from a radiologist specialist on PCa.

Recurrence after a failed SRT is indicative of systemic case.
You do not describe about your PSA histology since your assumed nadir (0.03) but you may know that recurrence is considered on the third rise (test) from nadir, or it may be considered after observing a progressive rise in a period. This is a norm set by ASCO which serves as guidance to manage recurrence and treatment. Only one test is not enough for judgement.
The fact is that PSA curve fluctuates after radiation differently than after RP, and patients, with or without prostate, can experience bounce (ups and downs) in PSA, before reaching the real nadir. In some cases that is achieved two to three years after SRT and in some cases they can go up to values above 1.

I am not a doctor but I think that HT in your case should be started only after assuring that recurrence is present. I cannot understand your urologist approach regarding the treatment he is recommending you. Not just because he seems eager to start you on HT before confirmation of recurrence but also because he puts you on a low dose (25mg) of cyproterone acetate (Androcur), which is out of normal practice in recurrence cases similar to your diagnosis. As you comment, PSADT lower than 9 months is of high risk and deserves a more aggressive lookout. Get a second opinion from an oncologist.

Anti-androgens act directly on cancer cells closing their receptors to avoid “feeding” of testosterone. The usual recommendation is over 50mg, being 150/200mg recommended in aggressive cases. In my case (failed RP&RT, negative MRI&Bonescan) I took cyproterone 2x50 daily for the first month followed by Eligard 6-month depot (LHRH agonist). After SRT, I had a nadir of 0.05, confirmed recurrence on the 29th month (PSADT=9.7 months) and started HT on PSA=1.0.

Hope this helps in your quest.
Welcome to the board.
VGama

VascodaGama said:

I would choose Dr. Myers’ protocol of ADT3
Traveler

I agree with you. Your PSA histology indicates recurrence.
In my case recurrence was confirmed when the PSA reached 0.26 on the 29th month post RT. My doctor threshold mark for starting hormonal treatment in my case was PSA=1.0, which happen in November 2010 (4 years after SRT).

I was diagnosed with PCa in 2000 with a high PSA of 22.4. I had a voluminous cancer (6 cores positive) but low Gleason score of 5 (2+3), DRE negative. After RP I soon recurred and was diagnosed with Micrometastasis (the ones invisible to tests). WW during 6 years with no symptoms and negative image studies. When PSA reached 3.6 (non detectable metastasis) I was recommended for SRT.

My present uro-oncologist is a specialist in prostate cancer. His protocol is similar to Dr. Myers’ except that he doesn’t agree in Myers’ “remission” level of PSA<0.01 for cases similar to mine with a classified pre Gleason score of 2+3 (the newer, since 2005, classification of Gleason would be 3+3). I am now on mono blockade (ADT) with Eligard 6-month depot and that took me down to PSA=0.05. My doctor will add an antiagonist (50mg daily) if any variation occurs in the PSA within the 18 month initial cycle. Then I will start an intermittent modality.

In your case with probable detectable metastases, I would choose Dr. Myers’ protocol of ADT3 to pin-down the PSA to remission. In fact I have followed his practices since 2000 and believe in his approaches in the management of prostate cancer. I would recommend you to get a copy of his book “Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers that also have references to SRT. You can order used or new copies from the Amazon site.

When on WW, I was assigned to a project in the Philippines and my follow-up doctor was Dr. Alex Chang, oncologist, at Singapore Johns Hopkins (http://www.imc.jhmi.edu/). You could try a consultation with him. He is a member of the team of Dr. Patrick Walsh, famous JH urologist, and he is partner of Dr. Mario Eisenberg (who looked after my case) in JH Baltimore.

There is a famous oncologist specialist in prostate cancer now practicing in Singapore. His name is Dr. Stephen Tucker. I have read many of his published papers on the topic of prostate cancer. He was a partner of the famous oncologist Dr. “Bob” Leibowitz. These doctors have long years of experience in treating high risk and advanced PCa patients with a variety of drugs “cocktails”. Their protocols are unique for that they do not have a “remission” limit and it tends to manage the progress of the cancer at medium low PSA levels.
You can read about Dr. Tucker in this site;
http://www.pacificcancercentre.com/about/stucker.html

About Dr. Leibowitz here;
http://compassionateoncology.org/publications.html

I hope this post is of help to you.
Wishing you find a definite care program.

VGama</p>

VascodaGama said:

TravelerI am glad to know
Traveler

I am glad to know you got a satisfying answer to your inquire and that you are now more relaxed.
The protocol suggested seems right. His opinion to “…come off and watch to see if it reoccurred” is in fact one of the main benefits in interrupting (intermittent modality) the hormonal treatment. Apart of giving a relief from the side effects, it will give you a chance of verifying if cancerous cells died or become dormant.

Have you asked about items for follow-up and added prevention?
You will follow a regimen of periodical tests and you need to consider regimens for handling the side effects. Bisphosphonates are very important. Balanced Diet and Physical fitness are a must.
I would recall you to get a copy of Dr. Myers Book.

Wishing you the best.
VGama