New Member - Is This An Expected Short Term Outcome

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Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/23/2017 7:47 AM (GMT -6)   
Greetings from across the pond. I've recently completed primary radiotherapy treatment combined with 6 months of Neo-adjuvant hormone therapy (Casodex - three months prior to radiotherapy commencing).
My first PSA test since completing the therapy has come back at 1.47.
Is this a typical initial outcome? My oncologist seems happy and expects my PSA to track downwards towards 1 but I was of the impression that it should be much lower due to the ongoing effect of the Casodex>

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/23/2017 8:06 AM (GMT -6)   
Sincere apologies, I forgot to tick the box when I submitted my post which would have included my signature.
Significant history/background:
Age 59
February 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

George_
Regular Member


Date Joined Apr 2016
Total Posts : 487
   Posted 12/23/2017 9:19 AM (GMT -6)   
You did not mention when you completed the radiation and when you stopped using Casodex. What was the PSA value while using Casodex before the radiation?

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/23/2017 9:29 AM (GMT -6)   
Thanks for the reply George. Last PSA test came back at 25. I started the Casodex at the end of June and started radiotherapy at the start of October. Last fraction of radiotherapy on the 4th of November. First blood sample post-radiotherapy taken 6 weeks after last fraction. Just completed the course of Casodex.

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 8618
   Posted 12/23/2017 9:35 AM (GMT -6)   
Welcome to HW.
Likely it's a bit early for a PSA test, but your results are just fine and are looking good. This RT plan is the slow road and you'll need a few more PSA tests to establish a pattern. Lower is good.

It's possible that your T-levels never got to castrate level or that your T-levels are recovering faster than expected. In any case, I don't think you should be too concerned about it.

You're going to do just fine.
Andrew
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/23/2017 9:51 AM (GMT -6)   
Hi Andrew. Thanks for your reply and kind words of reassurance. I imagine that you're correct about this being a long road. Happy Christmas.

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2812
   Posted 12/23/2017 11:24 AM (GMT -6)   
At this point, you're looking for the trend to be downward, which it is. Unlike the surgery guys, radiation patients don't get the benefit of a quick non detectable PSA. Also, you should know that some guys treated with radiation have PSAs that bounce around--that can be frustrating in tracking it, but again it's the longer trend you need to look at.
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 12/23/2017 4:23 PM (GMT -6)   
I don't think there is an ongoing effect of Casodex. It has a halflife of about a week, so it is cleared pretty quickly. It was blocking your androgen receptors while you used it, but testosterone was produced normally all the while. Now testosterone and DHT are activating your androgen receptors. I'm actually surprised that your PSA is this low this quickly, given how high it was before.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/27/2017 4:02 AM (GMT -6)   
Thanks for the responses folks. There seems to be a different approach in the UK to what you guys see in the US. For example, my PSA was not measured again from when I had a test done in March until after my radiotherapy had ended. My oncologist seemed to regard the clear Ga68 PSMA PET CT scan as the strongest indicator that my cancer had not spread outside of the organ and seemed not to think that measuring my PSA again prior to the start of treatment as being necessary.
On reflection, the most arduous part of the treatment has been the side effects from the Casodex. Hopefully they will clear pretty quickly although I have been advised that they may take as long to clear as I have been taking it (6 months). Does anyone out there have specific experience of this?
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 12/27/2017 11:43 AM (GMT -6)   
In the US, the first post treatment PSA is usually 3 months after the last radiation treatment. Earlier testing is meaningless because radiation increases the dead prostate cells that leak PSA into the serum. All of that has to clear. Then the cancer cells slowly die off, releasing lower levels of PSA. They will then track your PSA every 3 months until it eventually reaches a low nadir value.

Unlike Lupron, which blocks the testicles from producing testosterone, Casodex only blocks the cells from receiving testosterone. The testosterone is still there all the while. Now that the Casodex is gone, that testosterone is activating your androgen receptors and creating benign sources of PSA. It can take years for PSA to diminish to a nadir value.

As for the side effects of Casodex - the most frequent one is gynecomastia. If breast tissue has already developed, you may be able to still get rid of it using 20 mg of Tamoxifen daily.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/28/2017 4:06 AM (GMT -6)   
Tall Allen, thanks for your reply. Your knowledge of all things PCa is quite astonishing and extremely helpful to the uninitiated like me.
The Casodex has indeed caused some breast tissue development and tenderness in the nipple area. This has only really manifested itself in the last 6 weeks of the 6 month treatment period. Is this side effect naturally reversible? I'd like to avoid having to take any further course of treatment.
Also in the UK doctors seem to have a variable approach to the treatment of gynecomastia. Some will prescribe a short course of radiotherapy, others Tamoxifen and others no treatment at all! Presumably my hormones will be getting back to some degree of normality, so I was hoping that maybe a natural reversal may occur.

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 12/28/2017 1:10 PM (GMT -6)   
Unfortunately, it won't reverse on its own, and the longer you wait to deal with it, the harder it will be to reverse. You have to begin therapy within 2 months.

They used to give radiation to the chest to prevent it, but it didn't work that well. 10 mg tamoxifen works much better for prevention. But if you want to reverse what is already there, 20 mg daily dose is required. One HW member found that a related drug, raloxifene, worked as well.

Here's a good review article about it:
/bmcmedicine.biomedcentral.com/track/pdf/10.1186/1741-7015-10-96

The only contraindication I know of is if a patient has a history of thrombosis.

If 20 mg tamoxifen doesn't reverse it, they can inject cortisone directly into the breast tissue around the nipple to break it down. With time that tissue develops a supportive collagen network that can only be removed surgically.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/28/2017 1:36 PM (GMT -6)   
Thanks Tall Allen. I'll see if I can persuade my Doctor to prescribe it. Any thoughts on how long I'll need to take the Tamoxifen for?
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 12/28/2017 1:45 PM (GMT -6)   
I would guess a few months - but you'll have to see how it goes.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Italatin8
Regular Member


Date Joined Apr 2017
Total Posts : 38
   Posted 12/28/2017 3:20 PM (GMT -6)   
Allen, thanks for your post yesterday regarding RT and post treatment PSA. I expect this applies to me as well after I complete my ADT. I completed my SRT in late October and have my first PSA scheduled for next month.

Grumpy E, my MO prescribed 20 mg of Tamoxifen a little less than a month ago to treat my breast swelling and tenderness which began in the middle of the fifth month of my Casodex/Avodart ADT. It seemed to stop the swelling for a while, but not yet completely. Some days they appear more swollen than others, usually in the evening. Nipples are also tender and sore occasionally.

I will be completing my six months of ADT on January 10. However, I expect my MO will have me continue taking the Tamoxifen for at least a couple more months.

Rick
Robotic RP 3-11, GS 7 (3+4), PSA 12
Stage T3a, N1, MO, EPE, Negative Margins & SV, 1 positive lymph node
PSA Undetectable until 11-14
PSA 11/14 0.07
PSA 2/17 .336, PSADT 15 mos., Negative Axumin Scan
PSA 7/17 .441 Started neoadjuvant ADT Casodex 50 mg. and Avodart .05 mg daily
PSA 8/17 .110 Full Pelvic SRT 37 treatments
PSA 10/17 .008
11/17 Started 20 mg. Tamoxifen daily for breast swelling
Expect to finish 6 months neoadjuvant ADT in 1/18

Post Edited (Italatin8) : 12/28/2017 2:23:27 PM (GMT-7)


garyi
Veteran Member


Date Joined Jun 2017
Total Posts : 799
   Posted 12/28/2017 4:41 PM (GMT -6)   
Grumpy Englishman said...
.....My oncologist seemed to regard the clear Ga68 PSMA PET CT scan as the strongest indicator that my cancer had not spread outside of the organ.


Just yesterday, I had an appointment renowned RO, Dr. Anthony D'Amato. He told me that with a G3+4, which I have also, metastases is all but unheard of. FWIW.

Good luck!

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/29/2017 3:12 AM (GMT -6)   
Hi Italatin8. Thanks for your comments and sharing your own experience of using Tamoxifen to deal with the SEs resulting from the use of Casodex. I shall definitely see if I can persuade my oncologist to prescribe Tamoxifen for a period of time to see if that helps with my symptoms.
Have you noticed any specific SEs associated with taking Tamoxifen?
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/29/2017 3:15 AM (GMT -6)   
Hi Garyi, thanks for your reply. The observations from your oncologist are reassuring. As I mentioned, the attitude of my own oncologist seemed to change towards being sure of a positive outcome from my treatment when the Ga68 scan came back clear. I guess time will tell.
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

Italatin8
Regular Member


Date Joined Apr 2017
Total Posts : 38
   Posted 12/29/2017 3:04 PM (GMT -6)   
Gary:

I sure hope this is the case with my G7 (3+4) PCA. However, I did have EPE, negative margins and one positive lymph node.

Grumpy E:

The only side effects I noticed were a bit more fatigue some days, although this could be the result of the Casodex and Avodart after almost six months of ADT, and on some days a tightness in my breasts. My pharmacist told me I would feel some tightening and tenderness in the breasts after starting the Tamoxifen. I hope this means its working. Today they seem fine.

Happy New Year to you and best of luck in your continued journey.

Rick
Robotic RP 3-11, GS 7 (3+4), PSA 12
Stage T3a, N1, MO, EPE, Negative Margins & SV, 1 positive lymph node
PSA Undetectable until 11-14
PSA 11/14 0.07
PSA 2/17 .336, PSADT 15 mos., Negative Axumin Scan
PSA 7/17 .441 Started neoadjuvant ADT Casodex 50 mg. and Avodart .05 mg daily
PSA 8/17 .110 Full Pelvic SRT 37 treatments
PSA 10/17 .008
11/17 Started 20 mg. Tamoxifen daily for breast swelling
Expect to finish 6 months neoadjuvant ADT in 1/18

Post Edited (Italatin8) : 12/29/2017 2:08:20 PM (GMT-7)


Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 12/31/2017 6:36 AM (GMT -6)   
Hi Rick. Thanks for your reply and a very Happy 2018 to you and yours.

George_
Regular Member


Date Joined Apr 2016
Total Posts : 487
   Posted 1/1/2018 7:13 AM (GMT -6)   
Gary said...
He told me that with a G3+4, which I have also, metastases is all but unheard of. FWIW.
Well, I have a G3+4, determined by biopsy, and several pelvic lymph node mets. I also know of a guy with a G3+3 who has mets and is castration-resistant now. On the other hand I saw a conference presentation and the speaker said "there is a shipload of evidence that there will be no metastases if there is a G3+3. Therefore there is no need to take out any lymph nodes during surgery."

A Ga68 PET/CT currently is the best imaging there is. If that is clear that is better than any nomogram or probability. On the other hand, a PSA value of 30 puts you into the high-risk group. I am afraid the radiation will give you a long break but it will not be the end of your journey.

George

Fl Drifter
Regular Member


Date Joined May 2016
Total Posts : 344
   Posted 1/1/2018 12:25 PM (GMT -6)   
just my experience with Lupron .....6 months after end of 6 month Lupron shot , my nipple area got very sore ....slight excess fat in breast area too.....soreness lasted 6 months and is now gone completely....David
67yr.-PSA 10(2016).. 12 Biops 7 of 12 cancer ...Gleason 7-T2c-neg. bone scan and neg iodine MRI - 3+3=6 50% 3+4=7 60% 4+3=7 20% 3+4=7 60% 3+4=7 50% 3+4=7 30% ( all in left apex) then 3+3=6 5% in right apex...Lupron (6mo) shot 6-16... Markers-45 fractions of IGRT,,,81 Gy...starting fractions Oct.2016...finished on Dec.20th ..1st PSA-.4(4-2017)2nd PSA .7(8-2017)

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 1/2/2018 4:11 AM (GMT -6)   
George, thanks for your observations. My oncologist has described my PCa as being in the "favourable intermediate" group and shares your view that the clear Ga68 PSMA CT/PET scan provides a better predictor of long term outcomes than a nomogram.
I guess its all a bit of a crap shoot, but hopefully I get a decent run of years with little to worry about and who knows, in 10 years there may be a treatment based on genetics which will be a game changer for all of us?
Onwards & upwards!!!!

Grumpy Englishman
Regular Member


Date Joined Dec 2017
Total Posts : 20
   Posted 1/2/2018 4:56 AM (GMT -6)   
George /Tall Allen, I guess the other thing that has puzzled me is why my PSA dropped from 30 to 25 in the space of less than 2 weeks? Also my biopsy report mentioned the presence of High Grade PIN and also "atrophy, acute & chronic inflammation".
Does the high grade PIN etc. affect the PSA level?
february 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10125
   Posted 1/2/2018 12:04 PM (GMT -6)   
The HGPIN as no effect, but the acute and chronic inflammation is the culprit. Prostatitis can be a large source of PSA, which goes up and down as it relapses and remits. Your prostatitis may be an ongoing source of PSA bounces, so expect that.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog
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