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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="DarkGreen"]Hi Rhonda,

I'm sorry you were not able to get where you wanted to be. At least you and Irv have planted some ideas that may bear fruit among the doctors. As I think back, it took me more than half a year from the time I started discussing triple blockade and bone density attention until I found a doctor who would help me with those issues. I'll respond in green to your immediately preceding post.[/COLOR]

[QUOTE=srhonda61;4675041]Jim, I'm so convinced about the idea of triple blockade and, you'd be right in thinking that it isn't well accepted here.

We saw the radiation oncologist today and it seems that, in Irv's case, radiation would give an extremely low chance of cure which isn't worth the risk of the radiation having a terribly adverse effect on his colitis.[/QUOTE]

[COLOR="darkgreen"]That's kind of where I was with radiation, but for different reasons. I did not have to worry about GI or urinary issues, but the strategy was to include aggressive pelvic radiation.[/COLOR]

[QUOTE]The bone scan was negative (no surprises there) and the ct scan showed an enlargement of one of the lymph nodes which is sort of off to the side. This could either be due to the cancer, which would account for the 1.19 PSA or it could be due to the colitis. There is no way to know for sure. Irv's case was discussed by a team of doctors and there was some disagreement on the likelihood of the enlargement being due to the cancer or not.[/QUOTE]

[COLOR="darkgreen"]Actually, there probably is a way, but it may not be practical for you. The Netherlands was doing a steady stream of Combidex scanning, a technique that was highly effective for finding mets in the lymph nodes. It used an iron oxide contrast agent that would migrate to non-cancer cells in nodes but not cancer cells, so the cancer cells would stand out during the scan. The company making the agent ceased production. However, a new company, in Florida, is now making a similar agent that is supposed to work even better. I think Irv would have to go to Florida to get the scan, however. I suspect this will catch on fast and become more widely available. You might want to contact some of the leading and pioneering Canadian researchers, such as Drs. Klotz and Fleshner, or perhaps Vancouver, to see if they are aware of Canadian facilities that are experimenting with the technique. [/COLOR]

[QUOTE]So, now we wait for his second PSA result which he had done today. We pray that it hasn't changed much. There are several clinical trials being done by the medical oncologic team. My concern is that triple blockade is something they don't believe in.[/QUOTE]

[COLOR="darkgreen"]Here's a thought. Irv could ask to try triple blockade for a six months period. During that time his PSA is almost certain to drop to below 0.05 using an ultrasensitive test, hopefully one capable of a reading of <0.01, and the extent and rapidity of the decline should impress the doctors. Such declines are common with triple blockade, but, while they do happen with single and two drug blockade, are not common, as I understand it. Monthly or bimonthly PSAs would be wise to document the rapid decline. It will probably happen within the first three months, but the additional three will allow leeway. It often takes those of us with very high PSAs many months longer, but Irv is starting with a relatively low PSA. Many men with PSAs like his have experienced that very rapid and profound decline.[/COLOR]

[QUOTE]Are there men out there who didn't do well on triple blockade?[/QUOTE]

[COLOR="darkgreen"]There are a [I][U]few[/U][/I], and the weaker than normal response is an indicator of either substandard delivery and management of the drugs or unusually aggressive disease. In the latter situation, triple blockade adds valuable information in staging the disease and indicating the need for trying advanced drugs like Leukine. It seems to me those who truly fail well-done triple blockade fall into two groups: those with rare types of prostate cancer, such as some "small cell" and "endometrial" prostate cancer (named because the cells resemble the shape of female cells), or because the patient is already hormone refractory (androgen independent); that's quite unlikely for Irv at this point. The key to assuring well-done blockade is monitoring, at least with tests to assess the PSA, testosterone and DHT levels, and with a liver function test for the first few months to make sure the bicalutamide is not causing liver problems (a rare issue).[/COLOR]

[QUOTE]I still have to see specific clinical trials which support triple blockade and share those with the medical team here. [/QUOTE]

[COLOR="darkgreen"]Unfortunately, there simply are no completed formal clinical trials to offer as evidence. What I gave you a few days ago is about the best you will find. Frankly, I believe that doctors who insist on clinical trial evidence for pioneering advances are often copping out, hiding behind the "clinical trial evidence" excuse in order to avoid having to move out of their comfort zones. Hopefully, we will have evidence from Dr. Sartor's trial in the near future, but it could be one, two or even three years til we see those results. In the meantime, ask what is the harm of adding the third drug? To me, the high likely benefit and minimal harm balance is persuasive.

Another option is to commence two drug ("combined") blockade, which has been well accepted for years, and keep trying to get on triple blockade. In effect, that's what I did. I started with single drug blockade in December 1999; Casodex was added by the radiation doctor in early March 2000; and I was able to have Proscar added (and Fosamax) in mid-September 2000. I did not even realize that there were such things as two-drug and triple blockade when the doctor added the Casodex. The PSA is unlikely to fall as fast or as far on two-drug blockade, but it still may eventually reach <0.05.[/COLOR]

[QUOTE]Then, we went to our support group and there was a man who failed after 5 years of hormone therapy.....NOT triple blockade, and now he's got cancer all over with a prognosis of six months.[/QUOTE]

[COLOR="darkgreen"]Such failure is not unusual with single drug blockade. I was really impressed with a study by Japanese doctors who compared results from various types of hormonal therapy from all over Japan. What it showed for single drug blockade was that the bottom dropped out around the five year point for stage 3 patients. I posted about this on 2/3/9 at 5:46 PM, response number 5 to my thread "So far so good, 2nd PSA, third round, tenth year. I just searched to find it, and you may be able to get there quickly by using this: . I can't help suspecting the unfortunate patient you talked to is being managed by a urologist. There is so much that can be done and that should have been done. However, unless this man finds an expert doctor, that prognosis may prove accurate. Such results do happen with combined blockade too, but it is rare these days, I think.[/COLOR]

[QUOTE]Then there was another guy...he had radiation after surgery and was on Eligard which gave him terrible arthritis. He said he felt like his grandmother. So, he was taken off the Eligard and is now being watched to see what success he might have from the radiation. I was wondering why he was kept on the Eligard if he had such terrible side effects from it. Wouldn't it have been sensible to try another drug, like Lupron on Casodex? [/QUOTE]

[COLOR="DarkGreen"]Bone and joint soreness or pain to some degree is fairly common for a while at the beginning of blockade. Usually it is quite minor. I use glucosamine tablets daily, which probably helps. I'm right with you in thinking that other drugs should have been tried.[/COLOR]

[QUOTE]Then there was another guy who said that hormone therapy causes diabetes, high blood pressure and high cholesterol. One woman said that it causes heart attacks.[/QUOTE]

[COLOR="darkgreen"]It's sometimes hard to think when you are at these meetings, but you know the answers to those statements. All of these appear to be increased risks for men on hormonal blockade, though there is some controversy about the heart attacks. However, only some of us experience, each one; they are often mild and quite tolerable; there are usually effective countermeasures to prevent or minimize each; and, for the many patients able to take a vacation (perhaps permanently) from the heavier duty drugs, the side effects almost always disappear.

It's not really accurate to say that blockade causes these things, as they are far from a certainty. It is accurate to say that blockade increases the risks. Check your Primer for some other side effects; page 153 of my original edition lists the seven most common in the then Strum/Scholz practice, and two others are discussed elsewhere (impotency, p. 151, and bone density, pp. 142-143). Up until I read Dr. Scholz's new book, I too thought there was an increased risk for heart trouble that needed to be countered. However, Dr. Scholz makes a reasonable sounding argument that the reverse is true. If you have his book, read page 81. He concludes the section on hormonal therapy and heart attacks with this sentence: "However, the best prospective study evaluating this question shows that the net effect of TIP [meaning hormonal therapy] is an overall [I]reduction[/I][his Italics] in heart attacks by about 10%. The beneficial effect of thinning the blood is apparently sufficient to offset the known risks from gaining weight."[/COLOR]

[QUOTE]Another man said that you won't get a doctor to prescribe Avodart in Toronto for the purpose of triple blockade.

So, to say the least, the evening ended in frustration for me. [/QUOTE]

[COLOR="darkgreen"]He may be right, but I've learned not to let such statements affect what I try to do. It's one thing to just ask a doctor to prescribe Avodart; it's another to work with him or her to show them why experts think its important and why you want to give the drug a try.[/COLOR]

[QUOTE]Lastly, the radiation oncologist suggested that there are other drugs better than Avodart and when I asked what, he mentioned Abiraterone. But I thought that was second line hormone therapy when the cancer becomes hormone refractory.....So would it be wise to jump straight to the Abiraterone? [/QUOTE]

[COLOR="darkgreen"]I need to learn more about Abiraterone. It's an exciting new drug, but I believe it is better for men with more advanced disease than Irv now appears to have. Also, I suspect the radiation doctor is not that knowledgeable about drugs. Radiation docs are expert in radiation and the drugs that directly support it, but usually they are far less knowledgeable than medical oncologists about the full drug arsenal, which is the oncologists' bag of tricks. For one thing, Avodart as a stand alone would be rather weak, and, unlike Abiraterone, is not normally used by the experts in a stand-alone mode. [/COLOR]

[QUOTE]So....nothing conclusive yet...still waiting....I know that the clinical trial that the doctor's at PMH are thinking of getting Irv into, require three consecutive jumps in basically wait until that happens, which might not take as long as we'd hope it would.[/QUOTE]

[COLOR="darkgreen"]I'll climb briefly up onto one of my soapboxes. One flaw in treatment at a major research center is that the docs there are often hungry for patients for their clinical trials. I fended off several attempts to recruit me. That is probably one of the reasons some docs do not want their patients on triple blockade, or even combined blockade: it will remove them from the pool of patients they can recruit for their own or their colleagues trials. I'm all in favor of clinical trials when patients are properly recruited. I'm strongly against recruiting a patient for a trial when an existing approach, even if still not standard - like triple therapy, appears to offer a superior approach.[/COLOR]

[QUOTE]My feeling is that I just want Irv to be jump on this before it can become more aggressive...but the treatment approaches are different here, it seems.....maybe behind the times.....and we don't have bottomless pockets to deal with go to the states and pay for treatment there.

So, that's it for now. We still have to wait and see.


[COLOR="darkgreen"]So many of us have to deal with these practical issues and work out acceptable compromises that include our wallets and other issues. I've made a few of these compromises myself. I hope you find an approach that works well, and I hope you will keep up your spirits and assertiveness while searching for it.

Take care,

Jim :wave:[/COLOR]

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