Antiandrogen prior to receiving HT injection to prevent PSA flare?

Can anyone provide more insight regarding the suggestion mentioned in the below excerpt:


(from the "MaleCare Recurrent Prostate Cancer" book thank's to Joel's recommendation):

At least ten (10) days prior to starting a GnRH agonist, take an antiandrogen (see below). When you first start the GnRH agonist your body will start a cycle and over produce testosterone. This flooding of testosterone will enhance and encourage the prostate cancer to grow in leaps and bounds. For men with very advanced disease this can result in a significant disease progression and increased pain. (When this happens there will be what is called a PSA flare, the PSA will shoot up marking the increased growth and progression of the disease).


How strict is this 10 day period? From reading the forums and other blogs, it seems like the length of time between starting the antiandrogen (like biacalutamide) and getting the first injection varies from person to person (probably based on their disease profile and discussions with their doctor). I have read at least one account where someone received the injection first and then started taking the drug. I'm asking because my dad is considering getting his first shot in a much shorter time period than 10 days (EDIT - 4 days actually). (my dad is an intial diagnosis, PSA 4.6, GS 8, bone met).



Additionally, can anyone provide a medical reference for this set of facts (or at least point me in the right direction), specifically in regards to the notion that without this 10 day (or other length of time) pre-period of taking the antiandrogen, there will likely be an over production of testosterone and resulting significant disease progression / increased pain? The source where I read this doesn't provide such citations. This would be helpful in presenting the information to my dad, in order to convince him to ask his docter about it before deciding for certain to get the shot.



Thanks so much for any additional advice you may be able to give! This forum has already been extremely helpful. What a great resource!

Post Edited (hotpink2) : 12/20/2011 7:42:36 PM (GMT-7)

There is biochemical flare and clinical flare. You will always have biochemical flare when an LHRH is initiated; this can be detected, but in low volume cases does not have much significance. A clinical flare is when an advanced patient has a tumor burdon at a significant site. In this case flare will cause clinical symptoms as the tumor volume increases. There is no reason to subject a patient to any type of flare because there is no biochemical reason to ever stimulate tumor growth. Clinical flare can result in very severe complications such as spinal cord compression and kidney failure.
Dr Strum in "A Primer On Prostate Cancer" does an excellent job of discussing flare and how it works and how to prevent it. Casodex is usually given 10 to 14 days in advance and any oncologist with any experience with Prostate Cancer will always follow this protocol.
JohnT

hot:  There is a new HT out there that doesn't spike the testosterone and it is made specifially for patients like your dad.  The name is Degraluix(sp).  Lupron and other like HT therapies spike the testosterone in males for a period of 2 weeks give or take a few days the spike was documented to average 65% above your normal testosterone reading which could be dangerous for people with mets or fast growing PCa.  I have heard of some Docs who just have you superload Casodex for a few days 150 mg for 2 or 3 days, some docs believe thats enough to stop the spike. 

With your Dad's stats there's no reason to take a chance, do 10 days of casodex and there's no question about the testosterone if you stick with Lupron.

If you google Lupron vs. Degraluix I'll bet you'll find plenty of information.

Good Luck

David

its interesting to hear the different experiences. For clarification, my dad is only taking 50mg, and will have taken it for 4 days (not 3 as I initially stated) at the point when he receives his injection. Also, he is completely asymptomatic (his one met is in his arm/shoulder area and he reports no pain there whatsoever).

I did just read an article (more like a literature review of research updated in September 2011) on "UpToDate" (provided by my uncle that's a GP), that says:

The flare phenomenon can be effectively prevented with antiandrogen therapy, which blocks the effect of the increased serum testosterone [12]. A placebo-controlled trial demonstrated that antiandrogens decrease bone pain at the initiation of GnRH agonists for patients with metastatic prostate cancer [24]. In practice, antiandrogen therapy is often started seven days prior to GnRH agonist initiation for men at high risk of flare symptoms, or concurrently for asymptomatic patients. Antiandrogen therapy is then continued for two to four weeks.

12. Loblaw DA, Mendelson DS, Talcott JA, et al. American Society of Clinical Oncology recommendations for the initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer. J Clin Oncol 2004; 22:2927.
24. Kuhn JM, Billebaud T, Navratil H, et al. Prevention of the transient adverse effects of a gonadotropin-releasing hormone analogue (buserelin) in metastatic prostatic carcinoma by administration of an antiandrogen (nilutamide). N Engl J Med 1989; 321:413.

There definitely doesn't appear to be a strict consensus on this issue, which makes it a worth while question to ask the doctor. Hopefully his response will jive with everything else we know!

Thanks so much for everyone's feedback/contributions!

Good news! My dad just went back to his urologist today. He did NOT get his first shot. The Dr. has now decided he wants to do a bone biopsy of the hot spots on his clavicle and upper arm, and mentioned that the HT injection might mess up the biopsy - which will hopefully be done next friday (thanks to the xmas holiday, and my parents trip out to AZ to visit me!)

I'm not sure why the Dr has decided he now wants a biopsy - he has a bone scan, xray, and MRI - though i'm thinking it has to do with the fact that my mother asked why he hadn't done one, and has also scheduled appointments with medical oncologists at both the cleveland clinic and ohio state for the first week in January.

Either way, i'm happy because I was worried about the potential for flare since he had only been on casodex for 4 days. Also, now they can get 2nd opinions regarding the general diagnosis as well as the best course of HT. I'm particularly interested in discussing ADT3 and the possibility of Degraluix(sp) - which recent research appears to show some promise regarding additional positive effects compared to Lupron.

The two medical oncologists that my mother tried to schedule appts with (at CC and OSU respectively) both had very full schedules - OSU told her they would have to wait 2.5 months to get in to see the person she asked for. So at this point they do have appts, but not necessarily with our "first" choices.
So two questions - 1. any advice regarding how to get in more quickly with the "top dogs"? and 2. In addition to the two appts that my parents have set up with CC and OSU, do you all see additional value from a phone consult with one of the "well known" doctors of advanced prostate cancer - like Dr Strum, Dr Myers, Dr Lam, or Dr Sholtz? Has anyone participated in the p2p mailing list?

Thanks again for everyone's insight and advice. It is all so helpful! My parents arrive tomorrow for xmas and I'm excited to give and get lots of hugs. I hope everyone has a fantastic holiday season!