RRP, then Lupron?

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kbota
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Date Joined Aug 2010
Total Posts : 486
   Posted 9/3/2010 7:53 PM (GMT -6)   
My uro still wants me to begin two years of lupron injections. He states emphatically that doing so is proven to provide a better long term outcome. I really really don't want to do lupron for two years, but will do so if I can find evidence suggesting it may extend my life.

Right now, I feel that it's a lose lose decision.

Is anyone aware of any data that supports using lupron after RRP for high grade PCa? (gleason 8's, 9's, or 10's)


This seems to be my next really tough decision.

k
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 10 RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invastion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)

F8
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Date Joined Feb 2010
Total Posts : 3800
   Posted 9/3/2010 8:01 PM (GMT -6)   

kbota -- i don't have an answer for you but i am VERY happy that you received good news today and that you are considering additional treatment.  it's been a bad news week in general for others and i am pleased to see that you are happy .

i wish everyone the very best cool !

F8


age: 55
PSA on 10/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
ADT, brachy and IGRT

kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 9/3/2010 8:15 PM (GMT -6)   
I know F8. I've read a few of the posts, and I feel horrible for each of them. I also feel guilty for posting my own good news, but I just had to share it with you guys.
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 10 RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invastion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)

Cajun Jeff
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Date Joined Mar 2009
Total Posts : 4106
   Posted 9/3/2010 8:20 PM (GMT -6)   
Kbota never feel guilty for posting good news. We all need the good news to help us from day to day. That good news is also very important to those that got the not so good news.

Thank you for sharing you news. Im sure someone will have info for you about HT.

Cajun jeff
9/08 PSA 5.4 referred to Urologist
9/08 Biopsy: GS 3+4=7 1 positive core in 12 1% cancer core
10/08 Nerve-Sparing open radicalSurgery Path Report Downgrade 3+3=6 GS Stage pT2c margins clea
r3 month: PSA <0.1
19th month: PSA <0.1
Only issue at this time is ED

TryingToStayCalm
Regular Member


Date Joined Aug 2010
Total Posts : 53
   Posted 9/3/2010 8:39 PM (GMT -6)   
Jeff, y ou are so right. Even in the face of bad news it's important to know there is hope and to see that others are struggling with the same decisions on treatment. We must share our experience, strength and hope with each other.

Thanks, K for sharing your good news.
Husband DX on 6/30. Age 56. PSA 5.8 and 1 month later 7.9. Biopsy showed 6 out of 12 Cores Adenocarcinoma. 5 = 50% - 90%, 1 = 10%. Perineural invasion present. Gleason 7 (3+4). RRP scheduled with Dr. David Samadi Mt Sinai. NYC. 8/26.

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6946
   Posted 9/3/2010 8:50 PM (GMT -6)   
k,

The Rad Oncologist was adamant, if not worse, that I should do a two-year round of ADT as I started IGRT after DaVinci (10/09).

I refused, as I do not want the side effects. So far, I am still "undetectable". Next PSA - mid October at the earliest.

Is it the right choice? If not, I'll know to tell about it, but if something else gets me first, I'll never really know.
 
(I was a Gleason 4+5 with multiple positive margins)

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 9/4/2010 5:01 AM (GMT -6)   
kbot, I am a G8 and have had a recurrence. Currently doing SRT and HT. When I found out I was a G8 after surgery, I wanted to do an adjuviant therapy to reduce my chances of recurrence, but my doctors said no. Wait to see if you have the recurrence. I am second guessing myself now and thinking I should have pushed harder with my doctors, or found others. Hindsight is 20/20. You are in the same position that I was post surgery, high gleason and a contained tumor. If you really want to avoid HT I think that many doctors would tell you to wait to see if PSA rises and then take action. Perhaps you should get one or more second opinions.

I think that there is support for adj HT with SRT as a primary treatment. Perhaps others can direct you to it. BB
Dx with PC Dec 2008 at 56, PSA 3.4


Biopsy: T1c, Geason 7 (3+4) - 8 cores taken with 4 positive for PCa, 30% of all 4 cores.

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Jun 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31
psa May 10 .50

April 10 MRI and Bone Scan show lesion on lower spine, false positive.

Started HT 5/25/10 with 3 month shot of Trelstar. SRT scheduled for late July

psa July 10 <.01 HT at work

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 9/4/2010 6:23 AM (GMT -6)   
Kbota this is an interesting crossroad in PCa in general, in the past surgery was not a combined protocol with hormone drugs or PCa drugs. Your numbers are high risk which you know by looking at nomograms, high risk for being curative directly from surgery. One guy not long ago posted on P2P to Dr. Strum about his 13 yrs. of clear sailing with surgery only, then had slight psa increases and worry, and started a therapy thereafter, he also was a Gleason 9 patient. This is just fyi-doesn't mean the same would be your situation, we just don't know. There are cases of psa failure in short durations, also.

Here is another school of thought and they have abstracts to support their thinking:
Basically the it makes no difference which drug protocols you take, people live the same time span, is their message (thus they didn't look,ones whom have cases that defied the odds). How that is totally objectively measured is beyond logic to me.

Dr. Fred Lee is the greatest example I have ever witnessed Dx 27 yrs. ago and treated for PCa, failed cure 25 yrs. ago, went onto emcyt drug (most docs would never prescribe it), he has been on this well over a decade and still alive at age 80. There are others, but not this dramatic to witness, but can see have lived alot longer having done additional maybe controversial or weird protocols. Good whom doesn't want to be weird and live perhaps longer or be the anectdotal patient(s) that the abstracts seem to careless about or consider it less noteworthy. (Dr. Lee is anectdotal in results, not cured...that is my point I guess)

Back to your choices, I don't wish to influence your choice, it is yours...questioning it all and looking at your total choices would be a good idea, this is a one time choice right now.
Maybe find out is your doc biased if you say I want Zoladex (it usually is less profittable) or why not go on Degarelix (newly approved this year)-it has no 'Flare up' issues like LHRH drugs and is very comparable otherwise. Why not use emcyt, DES, estradiol or other drugs in this concept of drugs now? (LOL) I know those will be shot down, but actually they cause direct apoptosis on PCa and have less overall side effects(this can be argued so let's forget the idea)....I know the arguments seen them for years...those drugs would not ever be mentioned and especially not in the urologists vocabulary, are in onco-docs vocabulary.

Ok so you do as this doctors says, do you take casodex prior to prevent flare? ask him now. Now Dr. C. a uro-doc recently said it makes no difference basically in using casodex prior to prevent flare(unless known mets perhaps) also doesn't believe ADT3 is worthy(fyi), well micro mets goes undetectable and Dr. Strum whom is miles above this doctors knowledge on overall PCa, says 'No patient should be subjected to Flare'. I prefer the wisdom of this doctor, you don't have to agree...this is PCa...some of the docs don't agree on plenty.

I would avoid flare like the plague if it were my decision and knew of such, you just had surgery and you wish to feed PCa 'T' in the intial Flare up on LHRH which can be for a few weeks before it drops your 'T' levels and goes to real work???? Maybe ask this doc a few interesting questions so maybe you will know his thoughts. One of our brothers herein just had a bout with a flare issue it appears and was not a pleasant thing to have, doesn't mean it will ruin you either, but is unnecessary and known to be unhelpful. Dr. Strum had an example of a patient whom died in complications from Flare issue (proves his point well).

On the pluses side of LHRH now, it will mask your psa and look like a cure scenario(we all like those numbers), be anectdotal cure or in results duration, perhaps in so doing (would be a new one for the books), the doc makes alot of additional money on your case (his pluses).
You sacrifice 2 yrs. of side effects but actually do have much longer clear duration which might happen, of course remember the other docs whom believe the it makes no real difference theory...I didn't listen to their theory myself, seems to be good for me. Good hunting and tally ho.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35 normal, ct and bone scans appearing clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off for 1 yr., controlled so well, resumed, using intermittently, pleased with results

livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 9/5/2010 6:36 AM (GMT -6)   
I too spent two years on ADT3 and as much as I disliked it I would probably do it again if needed. I am currently battling rising PSA and will have to make my treatment decision Sept 24th.
Keep us posted as to what you do and please take the time to read what Bob (Zufus) wrote it has a wealth of knowledge.

peace to you
Dale
My PSA at diagnosis was 16.3
age 47 (current)

http://www.caringbridge.org/visit/dalechildress

My gleason score from prostate was 4+5=9 and from the lymph nodes (3 positive) was 4+4=8
I had 44 IMRT's
I was on Lupron, Casodex, and Avodart for two years with my last shot March 2009. I am currently (7-22-2010) not on any medication.
My Oncology hospital is The Cancer Treatment Center of America in Zion IL
PSA July of 2007 was 16.4
PSA May of 2008 was.11
PSA July 24th, 2008 is 0.04
PSA Dec 16th, 2008 is .016
PSA Mar 30th, 2009 is .02
PSA July 28th 2009 is .01
PSA OCt 15th 2009 is .11
PSA Jan 15th 2010 is .13
PSA April 16th of 2010 is .16
PSA July 22nd of 2010 is .71
Testosterone keeps rising, the current number is 156, up from 57 in May

T level dropped to 37 Mar 30th, 2009
cancer in 4 of 6 cores
92%
80%
37%
28%

Putt
Regular Member


Date Joined Aug 2010
Total Posts : 154
   Posted 9/5/2010 12:15 PM (GMT -6)   
I am a Lupron veteran, who is enjoying a 3 year vacation from ADT. My Oncologist follows Dr. Stephen Strum's protocol of requiring at least 1 year of PSA <0.05 and T levels of <20ng/dl, before considering relief from the Lupron routine. Time certainly flys and my recent tests tell me that my PC is coming out of remisson and rearing its ugly head. Since I was a GS 9 and a bad pathology report to start with, it is of no surprise. Therefore my vacation is just about over and I will begin ADT3 sometime after the first of the year. Not looking forward to the SE's but one has to consider the alternative. Later on, after meeting the requirements again, I expect to be enjoying another vacation. Unquestionably, one must consider his QOL while making decisions, and the younger we are, the harder they are to make. It just becomes more difficult if we are Gleason 9's at the starting gate. Good luck to all
PSA at Dx 105 at age 68, 4/04. ADT, RRP, 5/04. Gleason 4+5=9, Staged pT3c N0 MX, 3D rad, 40 treatments, 8/04. PSA 1/05 <0.01. ADT till 7/07. PSA 0.03 12/08, 0.07 4/09, 0.13 8/09, 0.19 12/09, 0.30 4/10, 8/10 0.71. Will start ADT3 after PSA reaches 1.2.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 9/5/2010 1:18 PM (GMT -6)   
Somewhere, there ARE supporting studies that HT after surgery does indeed does indeed extend the time you have before your PSA starts climbing again..But are we just making the surgery look more effective by keeping the PSA undetectable for a longer period of time?? Your prostate came out clean, your PSA is zero...

Yes, your cancer is high risk and G9 tends to reoccur..But I'm with you..I'd wait until I saw something was broken before I tried to fix it...And remember, radiation can STILL be curative, HT can not...But I'm no expert...Just my opinion...
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 9/5/2010 2:49 PM (GMT -6)   
K,
I was in the sane position as you with my Gleason 8. I waited for the pathology report first at it came out "undetectable". So far, I have had PSA tests at 2, 5, 8, 11, and 14 months and they were all zeroes. My suggestion is to wait until you see a detectable PSA before you start Lupron.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005

kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 9/9/2010 4:08 PM (GMT -6)   
A well known urological surgeon from Duke University weighs in directly on my situation. Thoughts anyone?

k


Just because your urologist and medical oncologist (Dr Sartor) do not agree this doesn't mean they are not both in your corner! In many cases, the management of prostate cancer is controversial and there are several treatment options that may be reasonable. In this case, there are two schools of thought. Your urologist is probably assuming since you have Gleason 9 disease that you likely have micrometastases (small deposits of cancer spread outside the prostate that escaped through the blood or lymphatic vessels before you had your prostate removed. In this case, he believes that adjuvant Lupron hormonal therpy will help you and allow you to have a better chance of beating the prostate cancer for the long haul. On the other hand, your oncologist is probably thinking that you may have low volume Gleason 9 disease and that you probably do not have micro spread. He is also thinking about Level 1 evidence from the medical literature. Level 1 evidence means that there is indisputable evidence from randomized clinical trials showing that some treatment is clearly beneficial to prolong survival or provide some other clear cut disease benefit. In the case of adjuvant hormonal therapy after radical prostatectomy, such as in your case, there is no Level 1 evidence that hormones (Lupron) will help you or allow you to live longer. There is Level 1 evidence from men like you after surgery who have positive lymph nodes but not for a case like yours. It is reasonable to extrapolate from the positive node setting to your setting, but it is speculative if it will clearly benefit you. Frankly, I am not even certain what I would do if I were faced with the same decision. If I was not concerned about sexual recovery, I might take the Lupron to try to increase my odds of cure/long term survival. However, if I was keen for sexual recovery, I might wait to see what my PSA does and only use Lupron or other hormonal medications if the PSA rose.
Best wishes and tell Dr Sartor hello. He is an old friend and colleague from our days together in DC. He was at NCI and I was at Walter Reed, "back-in-the-day."
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 2010 - RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invasion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)
As of 9/3/2010, I'm 99% continent - only occasional stress incontinence !

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 9/10/2010 6:54 AM (GMT -6)   
It's a wild world for us patients, interesting when we get second opinions and comparisons and contrast. Since PCa is basically somewhat illogical in the ways it can act (non-definity and unknowns in so many ways I can't elaborate quickly on), using deductive logic to solve the puzzle is even tainted and actually is beyond total useage of deductive or analyzing logic tools, to come to any type of perfection in the answer. You may have to go with your best guess, gut feeling or summary arguements on a weigh scale approach or flip a freakin coin.
Or play pin the tail on the doctor idea or pickup one with the nicest smile (lol). Wild world. idea
You could take casodex for awhile and still have sex life, then go off of it and monitor and see how good those results actually are (could chose Lupron later), it is another option (few mention it, Dr. Labrie advocated useage-yes I am familar with all the arguements too). This is also a grey area in PCa and most all docs say jump onto Lupron and not the other possible drugs, do we know with certainty they are totally correct??? Do you know this because there abstracts say so or on what basis? Is it more of a generality and accepted practice in the medical community and that is where this comes from? It is yours to try and figure out. Robert Young called PCa the Jungle....we need machette's. Not saying I got it figured out (figured out it is not easy to figure out-LOL), but saying it is best to question everything and all the time, at this juncture in PCa.  You are living this juncture of what to do next, talk about anxiety levels and questions.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35 normal, ct and bone scans appearing clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off for 1 yr., controlled so well, resumed, using intermittently, pleased with results

Post Edited (zufus) : 9/10/2010 7:00:16 AM (GMT-6)


kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 9/10/2010 7:56 PM (GMT -6)   
Thanks everyone for your thoughts and ideas. This is the most maddening and frustrating situation I've ever found myself in. My crystal ball is broke, and the experts cannot agree.

And it's no one's fault. There is no one I can get PO'd at......LOL

Well, I've ordered Snuffy Myers book, and wife and I are planning a little trip to Nashville at the end of this month. Maybe my head will clear by the time I get back.

(I plan to take a little caverject along for this trip.... :0)--- )
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 2010 - RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invasion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)
As of 9/3/2010, I'm 99% continent - only occasional stress incontinence !
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