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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="DarkGreen"]Hi Linda and John,

I'm really glad to hear that finasteride (formerly Proscar) is being added and that Casodex is not being dropped :), both of which concerned me from John's previous posts. The reports I've read, the talks I've heard, and the experiences I've learned of from fellow survivors all have convinced me that full triple blockade is the best bet for really challenging cases.

I'll admit to a bias as triple blockade, also known as triple Androgen Deprivation Therapy (ADT3), is what I have been on since 2000. (Hence my screen name; the I in IADT3 is because I am on that therapy intermittently, going off the heavy duty Lupron and Casodex when my PSA gets acceptably low, currently targeting <0.01 but willing to settle (and hoping for) <0.05.

I'll insert some comments in green. Jim


[QUOTE=Johnracer46;3989331]My husband was diagnosed in October with Advanced prostate cancer. ...
We learned today that the bone mets have stayed the same compared to 3 months ago.

[COLOR="darkgreen"]:D Great news! It usually takes a while for changes in bone to register, but Zometa is powerful medicine, and I'm thinking you are already seeing its benefit. :D :cool: When I think of my own experience with more than nine years on a bisphosphonate drug (mostly Fosamax, but Boniva for the past couple of years) that has reversed the decline in bone density and brought me back to close to the healthy range despite years of being on hormonal blockade therapy, and when I learn of experiences like yours with challenging bone mets apparently at least now stabilized with Zometa, I am still awed by the wonders of these drugs! :angel: Without them, hormonal blockade would have a far more serious burden of side effects, and very challenging prostate cancer would have its way more-or-less uncontested with bone mets!

Have you been briefed on how to minimize your risk of getting the one potentially serious side effect, apparently still quite unusual, of Zometa that I know about: osteonecrosis of the jaw (ONJ)? Basically, the program involves making sure you get ample calcium and vitamin D3, determining adequacy of vitamin D by the 25-hydroxy vitamin D blood test - looking for a value between 50 and 100 with closer to 100 better) and being careful about dental work, particularly dental surgery. Also, I've heard Dr. Mark Scholz, MD, and a co-founder and leader of the Prostate Cancer Research Institute, say that in his extensive practice they do not give Zometa infusions any more frequently than every three months, and he thinks that is why they have had no problem with ONJ from Zometa. However, there is probably superior activity against bone mets with more frequent dosing, such as every three weeks or every month. It's of course best to learn what to do from a doctor rather than me, as I am a layman with no enrolled medical education to my credit, unless you count the School of Hard Knocks. ;) [/COLOR]

We also learned that the lymph nodes had a rather large increase in growth which is why his PSA has been climbing over the past 3 months to currently 27.

[COLOR="darkgreen"]It's too bad Zometa does not work on soft tissue too, but at least we have hormonal blockade for that. Of course, blockade also helps against bone metastases (though not with bone density, which it tends to decrease somewhat for many of us).[/COLOR]

We are now going on triple blockade...he was on Lupron and Casodex.

[COLOR="darkgreen"]Are you now on 150 mg of Casodex per day? That would be three pills. I have never been on that dose - only on 50 mg or one pill daily during my "on-therapy" periods, but that's because I've never had detectable mets. The doctors I follow all like to use 150 mg of Casodex if there are detectable mets, and at least Dr. Charles "Snuffy" Myers likes to use 150 even if there are not detectable mets, I believe, and I know Dr. Robert ("Dr. Bob") Leibowitz likes to use 150 mg for all patients if their insurance and finances will cover it. Did doctor Aroujo discuss the dosage?[/COLOR]

Now, he'll be going on Finastride (sp?) as well.

[COLOR="darkgreen"]I'm glad to hear that, but I'm wondering if the doctor explained why he chose finasteride rather than Avodart? Dr. Robert Leibowitz, arguably the earliest advocates of triple hormonal blockade, has always preferred finasteride, but most of his peers among the leaders in triple hormonal blockade prefer Avodart - the other drug in the "5-alpha reductase inhibitor" class, except in men whose genetics can't take advantage of Avodart. (By the way, these doctors were all formerly fans of finasteride, but except for Dr. Leibowitz they moved pretty quickly to favoring Avodart for most of their patients when it became available. It is more expensive because it is not generic, but if finances are not an issue, it's the drug of choice as I understand it.)

I've always been on finasteride (including when it was only available under the brand name Proscar), and in combination with Avodart for a short period, and I'm sticking with it because I've done well. Still, I'm tempted to jump ship and go with Avodart. Did the doctor even bring up the possibility of a choice? If not, that would not be surprising, as our docs with good reason do not wish to overload us, especially toward the beginning of our combat with this disease.

Are you on finasteride twice a day (two times 5 mg = 10 mg per day)? For my first two cycles I was on only 5 mg, but I suspect 10 mg is better, and I switched when I finally realized that that was the dose Drs. Strum and Scholz used routinely, after discussing the switch with my oncologist.

Did either of the doctors measure dihydrotestosterone (DHT)? The finasteride should drive that potent fuel for prostate cancer way down, preventing most of its conversion from testosterone. Mine is now below 3, which is the lower limit of the test and is considered fine. [/COLOR]

They have many clinical trials going on with chemo...and we were handed one possibility today to review incase we need to move to that method if the PSA doesn't come back down.

[COLOR="darkgreen"]Here's another lead to a drug option: first testing for the fasting level of prolactin, and, if it is significant, inhibiting it with a drug like bromocriptine or dostinex. The Primer mentions prolactin briefly on page 137 in Table 11C as the third class of therapy drugs "Prolactin inhibitors." The Primer's index also notes a couple other places where prolactin appears (in the Forms section). Dr. Strum, the medical co-author of the Primer, likes to use a prolactin inhibitor drug at times as the fourth element of hormonal blockade, so you would have ADT4 instead of ADT3. He does this because prolactin increases the ability of the cancer cell's docks for incoming fuels (the "androgen receptors" are the docks) to work with small levels of testosterone.

The drugs mentioned by the Primer for prolactin are Dostinex and Bromocriptine (both brand names as of 2002 - my edition of the Primer). These drugs seem much more part of the game when patients have significant metastases. You can get a flavor of the research by going to PubMed ( and searching for (without the quotation marks): " prostate cancer AND prolactin AND (bromocriptine OR dostinex) ", which should give you at least four hits if you use the Limits feature and call for abstracts, humans, males, and clinical trials. (Without limits, you'll probably see more hits than you want to even think about dealing with. At least that means there is a heck of lot of research going on about prolactin and prostate cancer. :D)

These drugs are not in the usual full blockade regimen because they are not so easy to manage. According to the Primer p. 137, this class of prolactin inhibiting drug "Requires careful dose titration; nausea common, hypotension [meaning low blood pressure] possible." Still, when you look at the research, it's tempting to go for that benefit for cases involving many metastases.

To me, considering adding a prolactin inhibitor would come before a clinical trial or chemo, but chemo or a trial would be reasonable ways to go too.

Dr. Myers would probably want to try second line hormonal blockade, such as with ketoconazole, or try leukine, before going to chemo or a trial. He might also go for that prolactin inhibitor. He devoted much of his newsletter published in August 2000 to Prolactin (Volume 5, #8), and he followed up on a heart valve concern related to Dostinex in his February 2007 issue (Volume 9, #12), basically saying that those on a low dose of the drug probably had a low risk. In that issue he mentions other drugs that are not associated with any heart valve leak (bromocriptine, ropinirole, pramipexole, and lisuride.) Back copies of his newsletter are available.[/COLOR]

There are many options out there...

[COLOR="darkgreen"]Amen! It's nice to have options, but having so many is confusing. :dizzy: [/COLOR]

Take care,
Linda (John's wife)[/QUOTE]

Keep your spirits up,

Jim :wave:

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