Other drugs before Salvage Radiation

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compiler
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Date Joined Nov 2009
Total Posts : 7197
   Posted 3/15/2010 4:34 PM (GMT -6)   
I noticed some of you seem to be on Casodex and/or Lupron post surgery but before doing salvage radiation.
 
What is the protocol for that? Is it based on the pathology?
 
Mel

63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent!

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in late May.


John T
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Date Joined Nov 2008
Total Posts : 4188
   Posted 3/15/2010 4:54 PM (GMT -6)   
Most doctors just do Lupron without thinking it through because that's what they have always done. That's what my radiologist wanted to do. My onclogist said Casodex works just as well, if not better with 20% of the side affects.
If you are going to take any kind of HT at least get an opinion from an oncologist as surgeons and radiologists just don't have that skill set. The type and duration of HT will differ in what you are trying to accomplish so 1st find out what they want to use the HT for, then tailor the treatment to that end.
There are different reasons for using HT.
-to shrink the prostate and tumor before radiation or surgery.
-to slow the PC down while waiting for treatment
-to put advanced PC into remission
-To kill any stray cells that may have escaped.
-To make radiation more effective.
-As a treatment for localized PC
-To treat lymphnode PC

JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 3/15/2010 5:33 PM (GMT -6)   

John:

 

I thought HT is the therapy AFTER IMRT (Salvage) fails. But from reading assorted signatures, apparently not.

 

Mel


63 years old . PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (Free PSA 24%),  after 45 days on cipro! DREs have always been normal. PCA-3 was about 75 (way above the 35 threshold). That led to:

Biopsy on 11/30/09. 5 out of 12 cores positive. Gleason 4+3. 2 cores were 3+3 (one 5% and the other 30%) on one side. On  other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C.  

Surgery with Dr. Menon at Ford Hospital, 1/26/10. He says all looked good. Spared nerves. Unfortunately: Pathology Report: G 4+3 (65%-35%). Cancer in 15% of gland. Lymph Nodes: Clear.  Perineural Invasion: yes. Seminal Vessical Involvement: No.  Extraprostatic Extension: yes.  Positive Margin: Yes-- focal-- 1 spot .5mm. Final Weight is 52.7 gms.  (Second opinion from Jon Epstein at Hopkins confirmed these results)

 Incontinence: joined that club-- definite leaks—1 pad/day. Night is dry, was  using 1 pad at night for security, but pretty much dispensed with that most nights. Update: no pads at night. No pads while at home, but still very uncomfortable. Use 1 pad for out-of-house activities. Suddenly got MUCH better on 3/10/10, almost overnight. Still some urgency but no pads about 90% of the time.  As of 3/12/10--completely continent!

First post-op PSA on 3/10/10--DRUM ROLL: 0.01 Next PSA in late May.


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 3/15/2010 5:53 PM (GMT -6)   
Mel, even though I have never been on HT, I will pass the little bit I do know

They use HT pre-surgery sometimes, to slow down things for a variety of reasons.
They use HT pre-seeding, to reduce the size of the prostate
They use HT with salvage radiation at the same time
And of course, they use HT as a non-curative means if one's primary/secondary treatments fail.

For the record, after meeting with the 3 rad oncologists I consulted with, 2 of them wanted me to do SRT without HT, one wanted me to do it with HT. In the end, the one that wanted me to, admitted, that he couldn't prove that it would help me, and he couldn't prove that I needed it. So for me, I did the SRT without any HT.

david in sc
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, Caths #13 & #14 same time, 3/6 Cath #13 out - 4 days


Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 657
   Posted 3/15/2010 6:30 PM (GMT -6)   

Mel,

My younger brother had a positive margin. This question you ask is one of the items that he is gathering information on. (your post is timely) he has a scheduled appointment with a medical oncologist early next month and several of these questions are going to be targeted. Particularly the benefit of using HT/with radiation after prostate surgery for curative results.

Hero


Age 51, PSA 08/31/2009= 6.8, DRE Neg.
Biopsy 9/24/09 =10 of 12 positive. Gleason 6. involving up to 75%
da Vinci at Wash U, Barnes on 11/02/09
Modified Pathology, Gleason 4 + 3 = 7. Gleason 7 present throughout Prostate.  Negative surgical margins
4 of 4 periprostatic Lymph Nodes Negative, 10 of 10 pelvic Lymph Nodes Negative. Seminal Vesicles tumor free. No prostate extension
Post-op PSA 12/10/2009, Undetectable
12/12/2009, Pad Free and Started jogging.


Geebra
Regular Member


Date Joined May 2009
Total Posts : 476
   Posted 3/15/2010 6:48 PM (GMT -6)   
Aparently, the use of HT prior, during and after SRT (sometes for years after) improves overall suvival stats by a large measure, especially in high risk cases.

In my case, the high pre-op PSA, T3a, biopsy Gleason 8 (downgraded to 7) all led my radiation doc and my onc to suggest HT regiment. They want me on HT for 3 years post SRT. I am about six months into it and not yet sure I will do the entire three years. We agreed to take three months at a time.
Father died from poorly differentiated PCa @ 78 - normal PSA and DRE
5 biopsies over 4 years negative while PSA going from 3.8 to 28
Dx Nov 2007, age 46, PSA 29, Gleason 4+4=8
Decided to participate in clinical trial at Duke - 6 rounds of chemo (Taxotere + Avastin)
PSA prior to treatment 1/8/2008 is 33.90, bounced on 1/31/2008 to 38.20, and down at the end of the treatment (4/24/2008) to 20.60
RRP at Duke (Dr. Moul) on 6/16/2008, Gleason downgraded 4+3=7, T3a N0MX, focal extraprostatic extension, two small positive margins
PSA undetectable for 8 months, then 2/6/2009 0.10, 4/26/2009 0.17, 5/22/2009 0.20, 6/11/2009 0.27
ADT (ongoing, duration TBD): Lupron started 6/22/2009
Salvage IMRT to prostate bed and pelvis - 72gy over 40 treatments finished 10/21/2009
PSA 6/25/2009 0.1, T=516, 7/23/2009 <0.05, T<10, 10/21/2009 <0.05, T<10


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/15/2010 7:01 PM (GMT -6)   
You can use hormone therapy anytime in PCa, some use it as Leibowitz protocol as primary treatment ADT3 13 months, quit and proscar or avodart for maintenance thereafter. You could use a larger base of drugs on PCa, but uro-docs do love the profit margin on Lupron and LHRH at around $1000 profit per 3 mo. shot ($4000+ a yr. just on that....my uro-doc had us lined up and cranking them out), they would love to see you for life. Well Mel I know you don't want to hear from me, but you did. Best to you in whatever direction you go, now do you see why I posted the things I did in the past, is this a jungle or what???
Youth is wasted on the Young-(W.C. Fields)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 3/15/2010 7:29 PM (GMT -6)   
My medical oncologist makes only clinical application fees when prescribing Lupron. My three month shots were 3k but were reduced quite a bit when the insurance kicked in. Our center made about 300.00 per shot application for the cost of giving me the shot. They had no contract with them and would prescribe any of the LHRH or GnRH agonists depending on if being in study or individual patient needs.

If you search sanofi-Aventis, the maker of Eligard and Taxotere, the primary US research physician is Nick Vogelzang with Jon Epstein. He is my oncologist. He prescribed Lupron for me when I was on HT because it was in my insurance formulary. It was not because of profitability. If I had chosen to be in a study, sanofi-Aventis did have one going on at the time to which I was qualified for. And if I had, sanofi-Aventis would have paid for the drug no matter where I was being treated at. I would have been responsible for the clinical costs which my insurance would have picked up (gladly since they didn't have to pay for the Lupron).

You had a bad doctor if that was his true motivation. But that is not a good reason to eliminate a well known treatment that has been proven to be effective against advanced prostate cancer.

Tony
Prostate Cancer Forum Co-Moderator


JB71
Regular Member


Date Joined Nov 2009
Total Posts : 206
   Posted 3/15/2010 8:53 PM (GMT -6)   
You seem to be focused on the costs of HT, including Lupron and or Casodex.

Luckely for me up in my cold country (where do you think all those wintry cold winds come from?) of Canada, I dont need to worry about costs, and if you were in the same ship, WHAT would you do for HT drugs. (if any, of course)
.
Age, only 71.
 
July 2009, PSA 9.1, free ratio 0.16
September GLEASON 4+4=8, T2A
Prostate 44cc.
 
Calcium: 2.46  (range: 2.20 - 2.65 mmol/L)
25 Hydroxy Vitamin D: 102 (range: sufficiency:
76 - 250 nmol/L)
 
Bone Scan: Negative
CT Scan scheduled for Dec. 1st. Negative.
 
Started Casodex 50mg. on Nov. 6, first pill of 30.
Got Lupron 22.5mg ( 90 day ) on  November 19.
 
No real side effects as of Dec. 15 except dry skin and hair but getting quite 'porky' in the belt area even though now I go to the gym, three times a week. Also I dont have a need to shave anymore so now I can save my 'shaving' allowance and direct it to my stash of Depends !
 
Christmas Day got my first hot flashes. Thanks Santa!
 
Open surgery scheduled for Jan. 22 by Dr. J. Chen
 
Open surgery done on Jan. 20th. by Dr. J. Chin at London's University Hospital.
 
Cath removel scheduled for Feb. 8th. Yes, I know,
that will be 19 days. Dr. is out of country until then.
====================================
Pathology Report:
 
Gleason Score: cannot be determined due to hormone therapy effects. ???????
 
Extraprostatic Extension:
present, left radial, multifocal
present, left basal, multifocal
 
Resection Margins:
Apical: involved by invasive carcinoma, multifocal
Bladder Neck: involved by invasive carcinoma, unifocal on left side.Other: non-tumoural prostatic present at resection margin.
 
Perineural Invasion: present.
Seminal Vesicle Invasion: absent
Lymphovascular Invasion: absent
Lymph Node Status: no malignancy in regional lymph nodes
 
Additional path. findings:
high grade prostatic intraepithelial neoplasia
 
Pathology Stage: yp T3a NO MX
==================================
Radialogist appointment was on Friday Feb. 26 with Dr. Glenn Bauman in London.
 
Got another Lupron 90 day shot today and he wants to start IMRT soon. CT Scan plus measure scheduled in about 3 weeks. ( march 20)
 
First PSA test since surgery on March 25th.
 
Next appointment with the surgery Doc is April 13.
 
.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 3/15/2010 9:39 PM (GMT -6)   
JB,
zufus' point is well taken, and while perhaps overstated, there are those that prescribe drugs based on their affiliations. In part this is a fault in the system. There are 4 very effect LHRH/GnRH agonists, and their manufacturers compete with each other. Some do offer perks for doctors to primarily use their products.

But it should be noted that ALL great prostate cancer oncologists us ALL of the tools available to them. Strum, Leibowitz, Scholz, Meyers, Vogelzang, for example, all will prescribe ADT, ADT3, DES, Leukine, HDK, statins, Taxotere, etc. At various points of a patients treatment, some are more effective than others, some quit working, some don't work at all. Sometimes it's the way you start switching things around that is what makes the best oncologists better than the rest. I know of many many cases in which each of the doctors mentioned above prescribed a LHRH/GnRH regimen. While DES has been very effective for zufus (it is inexpensive) I also now know a few guys that it did not work well at all for and they switched to other options.

Back to compilers question. There is a well known protocol (RTOG-9413) that shows that ADT is very effective when used prior to radiation. It used to be 1 year, but now most radiologists agree that 6 months is effective. The agents used in most recent studies are the LHRH/GnRH option combined with an anti-androgen. Perhaps zufus knows of studies that focused on the cheapest way to achieve these results in these studies?

Tony
Prostate Cancer Forum Co-Moderator


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/16/2010 5:01 AM (GMT -6)   
I never said don't use LHRH or any drug, I do say question everything and at anytime, patients are being taken advantage of in some scenarios and not told the complete story of their possible options, side effects and if or when they can switch to alternatives of THEIR possible choices. Just because Tony gets a price break for his protocol is meaningless compared to the majority of especially insured patients....whom are nicely priced and billed out. I don't care so much about what something costs, do care about gettting ripped off blantanly, and lied to and not told the whole picture, and less than full disclosures within our medical systems. The neo-adj. useage of ADT prior to radiations, see Bolla Study and the results, good information and shows more effectiveness.

Do you think our medical systems are going to help us find those cheapest ways to achieve results, since you asked me specifically? Is that how our medical system works in this country???
Youth is wasted on the Young-(W.C. Fields)


dkob131
Regular Member


Date Joined Apr 2008
Total Posts : 364
   Posted 3/16/2010 8:16 AM (GMT -6)   

Dr. Strum and Dr. Meyer's are considered by most individuals to be two of the leading experts on PCa and both seem to believe strongly in HT treatment.  Dr. Meyers in particular wrote a book about it and how it weakens and actaully kills cancer cells.  Both of their philosiphies seem to be "why would you not attack with everything you have at the beginning when the cancer is at its weakest".  Thus HT with SRT or even before surgery.

I do believe it is based on pathology also, the minute I was diagnosed as a Gleson 8 there was really no discussion, it was a given that if I had a reoccurence there would be HT added. 

I wonder sometimes why we use examples of Strum and Meyers protocols and opinions for some issues and ignore their suggestions for others.  

David

 

 

 


 54 y.o.
 Diagnosed 4/10/08
 DRE Normal
 PSA-5.5
 Biopsy- 12 cores, 4 positive highest 4+4=8
 Bone scan, CT scan and Chest X-ray clear 4/16/08
 Urologist suggested surgery 4/16/08
 MRI on 4/24/08 clear no suggestion of lymph node   involvement.
 4/24/08 -Started on Lupron and Casodex preparing for HDRT and IMRT in late July.  This treatment will not preclude me from surgery if I change my mind.
Decide to have DaVinci surgery after another consult with surgeon.
6/19/08- DaVinci surgery at University of Washington.
6/25/08- Path report, clear margins, no noted extension
9/12/08- PSA <0.02 
12/05/08-PSA <0.02 Six months after surgery 
3/02/09-PSA <0.02 Nine months after surgery
5/02/09-PSA .10
8/17/09-PSA .21 Begin HT and set up for SRT to begin in 2 months.
 


Doting Daughter
Veteran Member


Date Joined Aug 2007
Total Posts : 1064
   Posted 3/16/2010 8:59 AM (GMT -6)   
My father was prescribed HT by his doctor ( and it was recommended by all of the opinions he sought) prior to his adjuvent therapy in the hopes of shrinking any remaining PC prior to radiation. His protocol also included two years of HT following radiation. He started with Casodex to minimize the HT "flare" and then went on Lupron for two years.
Father's Age DX 62 (now 64)
Original Gleason 3+4=7, Post-Op Gleason- 4+3=7,
DaVinci Surgery Aug 31, 2007
Focally Positive Right Margin, One positive node. T3a N1 M0.
Bone Scan/CT Negative (Sept. 10, 2007)
Oct. 17 PSA 0.07
Nov. 13 PSA 0.05
Casodex adm. Nov 07, Lupron beg. Dec 03, 2007 2 yrs
Radiation March 03-April 22, 2008- 8 weeks 5x a week
July 2, 08 PSA <.02
Oct. 10, 08 PSA <.02
Oct. 9, 09 PSA <.01 Last Lupron Shot
Praying for a cured dad.

Co-Moderator Prostate Cancer Forum


Bootheel
Regular Member


Date Joined Oct 2007
Total Posts : 300
   Posted 3/16/2010 9:22 AM (GMT -6)   
I had the IMRT without HT. I was told that if the PSA went down after the treatments that I had a good chance of a favorable outcome. However, if I had HT along with the IMRT and the PSA started to rise after treatment, The PCa would probably be systemic. Not my words, just that of my Doc.
Age 65
Diagnosed 10/12/07
PSA 6.3
Biopsy 18 core samples, 2 positive <5%
Stage T1a Gleason 6 (3+3)
LRP  1/29/08
Post-op
Gleason 7 (3+4)
1 positive margin (.3cm)
T2C
4/16/08- Started Bi-mix injections 
5/15/08- 1st Post-Op PSA 0.07 Undetectable
8/11/08 -2nd Post-OP PSA 0.02 Undetectable
8/15/08- No more pads as of today  Whoopee!!!
11/13/08- 3rd post-op PSA 0.02 Undetectable
03/02/09- 1 yr. post-op PSA .09 Undetectable
05/13/09   PSA .18 (ouch)
Started IMRT June 13, 2009
Completed 37 treatments July 31, 2009 (66.6gy)
11/23/09 Post IMRT PSA .18
2/12/10   Post IMRT PSA 0.00


dkob131
Regular Member


Date Joined Apr 2008
Total Posts : 364
   Posted 3/16/2010 11:32 AM (GMT -6)   

Bootheel:  Whether the cancer is systemic or not, when HT is started the overwhelming number of patients have a  substantial drop in their PSA.  I do understand that you would get a much quicker decision on wheter the SRT worked or not by not using HT but because the PSA goes down after SRT with HT whether or not the cancer was systemic to begin with you would need to wait longer to see if the treatment worked.  I don't mind that at all.

David 


 54 y.o.
 Diagnosed 4/10/08
 DRE Normal
 PSA-5.5
 Biopsy- 12 cores, 4 positive highest 4+4=8
 Bone scan, CT scan and Chest X-ray clear 4/16/08
 Urologist suggested surgery 4/16/08
 MRI on 4/24/08 clear no suggestion of lymph node   involvement.
 4/24/08 -Started on Lupron and Casodex preparing for HDRT and IMRT in late July.  This treatment will not preclude me from surgery if I change my mind.
Decide to have DaVinci surgery after another consult with surgeon.
6/19/08- DaVinci surgery at University of Washington.
6/25/08- Path report, clear margins, no noted extension
9/12/08- PSA <0.02 
12/05/08-PSA <0.02 Six months after surgery 
3/02/09-PSA <0.02 Nine months after surgery
5/02/09-PSA .10
8/17/09-PSA .21 Begin HT and set up for SRT to begin in 2 months.
 

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