Looking for advice - advanced prostate cancer

VascodaGama said:

Pete, do not wait for confirmed spread
Pete

Your PSA chronology indicates recurrence and a very aggressive type of cancer. The Gleason score of 8 (probably 4+4) is of the type of cells with high probability for spread. Your case is risky but without any confirmation of distant metastases your case could be considered yet as localized.
The pathologist report from surgery in 2005 indicates negative margins but you do not comment on metastasis (positive/negative) to lymph nodes. Surgeons at the time of surgery usually dissect some close nodes to check for metastasis, particularly in guys with Gs above 7.

This would be an important piece of information because it is known that cancer spreads firstly to nearby lymph nodes and from there to bone and other organs. Your oncologist is exactly looking into the problem to identify where cancer is set. If considered Localized, RT with hormones is recommended and successful. The planning would include radiation of a larger areas predefined. However, if not localized, salvage radiotherapy may be useless (may be the case of Old-Timer, and one would end up with added side effects.

The negative bone scan and CT scan is not a surprise when PSA is lower than 10. Tumours smaller than 0.07 mm are hard to be caught on this type of scans. The test that have shown success in identifying metastasis at the lymph nodes (in the iliac area) is the USPIO (ultrasmall superparamagnetic iron oxide nanoparticles) MRI, which some guys reported to be available at Dattoli cancer centre. (http://csn.cancer.org/node/221178).
This is the substitute of the famous Combidex test developed in Holland that was successful in pin pointing PCa that had migrated to remote parts of the body. You can read details on both these tests by googling their names.

I cannot understand how Joel above got you a PSADT of 8.34 months. The doubling time is an exponential calculation and there are several sites on the net (MSKCC) where you can introduce your own PSA chronology and get the answer straight.
Your PSADT in the last three measurements indicate to be 2.4 months, and from your nadir at Jan 2009 it indicates to be 3.4.
Both PSADT are considered critical (less than 3). You can read about the meaning of this PSADT and its relationship to recurrence from a salvage treatment in this study with representative tables for survivals;
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667701/)

I do not agree with the threshold of PSA=10 to start hormonal treatment. You are in recurrence and your status is all indicative of uncontroled progress of cancer. In fact I am surprized that your oncologist have not recommended already for you to get a LHRH agonist (Lupron, Eligard or Firmagon) while waiting for a final decision on a salvage treatment or trials.

I do not know your age or any other evident aspect (medical problem or any permanent side effect from RT) which are required for in a proper diagnosis of you present status. Such could interfere with your possibility of entering into a Clinical Trial. If recommended by your doctor, you should be aware of its contents and know exactly if you do not become of the placebo group. You need to get a treatment to control the advance of the bandit.

I recommend you to investigate about salvage treatments, their side effects and diagnosis, etc. for recurrence cases. An excellent, easy to read and practical book for your case is the “Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers; which informs on diagnosis and treatments for recurrence systemic cases. This famous oncologist is himself a survivor of a challenging case on his 12 year of survival.
You can also listen to his videos on recurrence accessed at his net site, one being “PSA only Recurrence Disease”;
(http://askdrmyers.wordpress.com/?utm_content=amyson@comcast.net&utm_source=VerticalResponse&utm_medium=Email&utm_term=here&utm_campaign=Cancer Recurrence After Radical Prostatectomycontent)

Another thread in this forum addressing recurrence with links can be seen here;
(http://csn.cancer.org/node/222590)


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

VGama

PSA Doubling Time
Using the Sloane nonogram at http://nomograms.mskcc.org/Prostate/PsaDoublingTime.aspx, assuming that all PSA tests were performed on the 15th of the month as the specific dates were not supplied the nonogram calculated a doubling time of 8.34 months.
Joel

JoelT said:

PSA Doubling Time
Using the Sloane nonogram at http://nomograms.mskcc.org/Prostate/PsaDoublingTime.aspx, assuming that all PSA tests were performed on the 15th of the month as the specific dates were not supplied the nonogram calculated a doubling time of 8.34 months.
Joel

PSADT and MSKCC nomograms

Joel

You are right, MSKCC nomograms gives different results. For the last three tests the PSADT equals to 3.99 and for the total data is above 8. I have never realized and have been suggesting those nomograms but never made a comparison of the results between handmade exponential calculations and those at their site. Maybe the difference is in the “variables” (error probability) introduced in the mathematical formula by their researchers. (Am I correct?)

I read in the past and discussed with famous survivors in other forums about the controversy on the clinical use and the need of FDA’s approval of nomograms in the diagnosis of prostate cancer cases (ex: Kattan variables, Partin tables, Han tables, etc.). These are in fact tools to guide practice but some doctors actually do not recognize them.

Last year I read in the EAU Guidelines (European Association of Urology) about Ponholzer’s (Danube Hospital, Austria) nomograms which formula does not include variables. This nomogram is available freely in the net at this site;
http://adam.drahtwarenhandlung.at/webapp/mg2008/chapter_prostata4/example_psa
The variable portion can be imputed at random which allows doctors to account for any error in assays, day of drawing blood, laboratory reliability, etc.
I had a close look into both nomograms and would say that MSKCC may provide positive parameters in their results whether Ponholzer’s is based on each doctor’s own idea of variables for each particular case.

In plain calculation of the PSADT of Pete’s case, using three results since nadir (0.2; 0.6; 3.0) and a variable of 10 percent, the result is: PSADT=3.4 months with a maximum error of 4.6 months. That may be the variable used at MSKCC nomogram. Nevertheless, a “beneficial” outlook for Pete with a risky case could lead to a precarious status. He is the only one to decide on which result to take.

There is a publication on the above matter at PubMed which site I used many times on my researches and that I take as reliable.
http://www.ncbi.nlm.nih.gov/pubmed/20592353

Thanks for drawing my attention.

VGama

peteclick said:

Thank you JoelT and VascodaGama
Vasco,

Thank you for all of the information that you have provided. It has given me a lot of home work. Last night I watched several of Dr Myer's videos, and I have ordered his book. After I have read the book, I am sure I will have more questions, especially when it comes to treatment options. I see already that Dr Myers recommends intermittent hormone therapy, and I surely like the sound of that.

I left a few thing out of my original post. I am 71. My gleason score post surgery was 8 (3+5). Is that better than 4+4?

The tumor had escaped the capsule, but the margins were negative. I can see no evidence that the pathologist tested tissue from the lymph nodes.

The oncologist informed me about a clinical trial for which I am eligible that compares the effects of an investigational agent (MK-2206) and Bicalutamide versus Bicalutamide alone. I am hesitant to join such a trial because of the possibility of being in the group getting the placebo. Do you have any thoughts on this?

I also want to thank you and Joel for your efforts and informative discussion regarding the doubling time. I know how crucial that is, and that is one reason I wanted to wait for one more PSA test before deciding on a treatment.

Thanks again, Pete

HT alone is also a viable option
Pete

I am not a doctor. My opinions are as that of a layman based on my own researches and knowledge gain since I became a permanent member of this boat in 2000. You should do your own researches and discuss with your family and doctors before making any decision on your case.

Gleason score 8 in both grades (4+4) and (3+5) present high aggressive types of pattern 4 and 5. However, in the combi (3+5) if the involvement of grade 5 is small relatively to the total (ig; 3=75%; 5=25%), it could be taken as better than the other combi with only aggressive ones (grade 4).
I would say that your Gleason indicates that lots of cancerous cells are of the intermediate risk for aggressivity.

The lack of info in the pathologist report on analyses of lymph nodes means that they have not been dissected at surgery. In 2005 (the initiation period of Davinci) the procedure would not include dissection of lymph nodes. Only few doctors actually would stop the robot and use their own hands to reach and cut the nodes out.
The principle of Davinci is to have the lesser incision possible (enough for the robot-arm) with a quick surgery to lead to a faster healing. Judgement on dissection of the nodes is done in advance with basis on the data from diagnosis.
What is striking in the report is the positive extra-capsular extension (tumor had escaped the capsule). This could very well mean that cancer is at close lymph nodes or relates to localized micro-metastasis.
The typical protocol for treating these cases is IMRT plus HT. I would suggest you read about this modality and that you get a second opinion from another oncologist. (Myer’s book addresses this too)

Hormonal treatment (HT) alone is also a viable option. It does not cure but gives very long periods of control on cancer progress by “starvation”. It aims in blocking the testosterone that feeds cancer and promotes its survival.
There are reported cases of guys on HT as their prime therapy in over 15 years of success. It can be administered intermittently (on/off periods on the drugs) with a relief from drugs side effects; and its protocols are for single blockade (ADT1) with a LHRH agonist; double blockade (ADT2) with an added anti-agonist like Casodex; and ADT3, triple blockade with added 5-ARI drug that stops the manufacturing of a more powerful type of testosterone named dihydrotestosterone (DHT).

What is been proposed to you in the trial is the use of an anti-androgen bicalutamide (Casodex) which is a hormonal treatment drug taken alone (placebo) or in combination with the Akt inhibitor MK-2206.
Bicalutamide acts on the cancer cell by attaching itself to cell’s receptors inhibiting the cell from feeding on testosterone, while the Akt inhibitor will attempt to stop cell proliferation (duplication).
The trial in my opinion can be beneficial to your case if they place you on the group taking the combo. I say this because in the hormonal context of treatment, Casodex is seen as the “mild” drug. LHRH agonist is the “heavy duty” drug that blows the cancer, by “closing down” the “factory” producing 95% of testosterone (chemical castration at the testis).
I do not know the length of the period of the trial, but you will not be allowed to take any other drug while on trial, and bicalutamide may not be enough in your risky case.

MK-2206 “drug” is on ASCO’s list of presented Trials since 2009. Merck Pharmaceuticals is the “owner” and the drug is part of the newer type of medicines “manufactured” with targeted intent to directly affect cancerous cells.
Some of these new generation “targeted type drugs” recently approved and already successfully treating PCa cases, is Xgeva (denosumab) that acts at cancer in bone and Zytiga (abiraterone acetate) that acts in intratumoral treatment. These drugs are specific to cancer cells, minimizing their effect on healthy cells

For details on the trial see this link;
http://www.clinicaltrials.gov/ct2/show/NCT01251861?term=MK-2206&rank=27

You can read publications on the drug in this site;
http://www.merck.com/licensing/our-partnership/astrazeneca-partnership.html

Here are press news about Merck’s Trials Network where MK-2206 is to be investigated, your doctor is connected with one of this centres authorized for the trial;
http://www.news-medical.net/news/20100604/Merck-launches-Oncology-Collaborative-Trials-Network.aspx

Hope this post answer your quest.

Take care.
VGama