Need Advice -- final questions for Scholz/Lam

OK, had some late night get-togethers. I'll look at my PSA results Monday afternoon and announce that here. But I am now working on questions to make efficient use of my telephone consultation with Dr. Lam (Scholz's partner) on Tuesday (12:30). I expect to have a definite plan in place at that time. Here is what I'm thinking. Any additional suggestions:

For Dr. Scholz/Lam:

I really need to talk with you before making any final decisions on the next steps because QOL as well as longevity is important to me.

Quick Review:

DX 12/2/09. Had Surgery 1/25/10. G 4+3, pos. margins, penetrated capsule. PSA started creeping up (it was 4.19 about 6 weeks before surgery). Did SRT and completed that in mid-May, 2011. It failed. PSADT, excluding your result and using all other results since they are all from my local lab, is about 3+ months. [I'll revise this if needed]

1. Where do we go from here based on all the test information/results? More specifically:
2. I had asked Scholz about ADT-3 and he said it couldn’t hurt, but I did NOT request that. I am very concerned about going from no medications to getting hit with 4 things and all the terrible SE. What do you think? Is it not advisable to take ADT-1 (Lupron?) and add the others as needed? What about just waiting until the PSA is higher before starting ANY HT as there seems to be a school of thought to wait. I teach at a University and my term ends in mid-May. Am I screwing myself by waiting until then? What about starting in mid-May and see Scholz or Lam in June or July.
3. How long should I take Casodex BEFORE doing the Lupron shot?
4. Am I correct that I take Femara at the first sign of breast tenderness and/or enlargement? If so, do I just keep taking Femara (assuming I am continuing the Casodex).

5) Given my excellent bone density test results, can I NOT take fosamax or the like and just wait and test bone density again in a year (or sooner?)?

　

6. Will you folks help me in handling the SE? I am in mid-Michigan and my doctors are not PC experts? They will be willing to work with you.
7. Does my short PSADT (about 3.4 months) indicate a poor prognosis for the efficacy of HT? (Any such studies?).
8. Discuss bone scan situation [right shoulder uptake -- local oncologist not concerned given my oft-used right shoulder while teaching]
9. Discuss intestinal problems [possible post radiation complication]

mel

　

i cant think of a thing to add to that question list, all good questions

i do feel that will be a lengthy and difficult list of questions to ask on a phone call, too easy for the doc to cut things short
if he is on a phone vs. being in front of his face.

you may want to prioritirize this list into the top 3-4 questions, and start with number 1, in case the call isn't long enough.

david

Mel

Suggest you send your list of questions to Dr. Lam in advance of your call with him. Than on the call go over those one by one before you move onto anything else.

Bud

Mel,
Prioritize the questions
E-mail the list to them before the phone call
Review the information about ADT side effects at:
tinyurl.com/439bteb

Given the fact that you have failed two localized therapies and you have a PSDT of 3 months, there aren't many therapies available to you BEFORE the application of ADT.
The SEs of ADT can be ameliorated in several ways. The fact that an intermittent ADT protocol with QOL preservation can yield a survival benefit should have significant weight in your decision.

RalphV

Here is my revision:

(Incidentally, I do not like telephone consultations. Maybe this one will go better than the last. I so much prefer face-to-face, especially with this kind of importance. But it's hard to just fly out to Calif. every time..)

For Dr. Scholz/Lam for telephone consultation on 12/27/11 (12:30 PM)

I really need to talk with you before making any final decisions on the next steps because QOL as well as longevity is important to me.

Quick Review:

DX 12/2/09. Had Surgery 1/25/10. G 4+3, pos. margins, penetrated capsule. PSA started creeping up (it was 4.19 about 6 weeks before surgery). Did SRT and completed that in mid-May, 2011. It failed. PSADT, excluding your result and using all other results since they are all from my local lab, is 3.08 months (latest PSA done on 12/22 is 1.97).

1. Where do we go from here based on all the test information/results? More specifically:
2. I had asked Scholz about ADT-3 and he said it couldn’t hurt, but I did NOT request that. I am very concerned about going from no medications to getting hit with 4 things and all the terrible SE. What do you think? Is it not advisable to take ADT-1 (Lupron?) and add the others as needed? What about just waiting until the PSA is higher before starting ANY HT as there seems to be a school of thought to wait. I teach at a University and my term ends in mid-May. Am I screwing myself by waiting until then? I would like to start in mid-May and see Scholz or Lam in June or July. Would this be inadvisable?
3. If Lupron, what shot do you recommend: 1 or 3 or 4 months?
4. How long should I take Casodex BEFORE doing the Lupron shot?
5. Am I correct that I take Femara at the first sign of breast tenderness and/or enlargement? If so, do I just keep taking Femara (assuming I am continuing the Casodex). What are the chances of this happening?

5) Given my excellent bone density test results, can I NOT take fosamax or the like and just wait and test bone density again in a year (or sooner?)?

　

6. Will you folks help me in handling the SE? I am in mid-Michigan and my doctors are not PC experts? They will be willing to work with you.
7. Does my short PSADT (about 3.4 months) indicate a poor prognosis for the efficacy of HT? (Any such studies?).
8. How long on HT? IADT?
9. Discuss bone scan situation
10. Discuss intestinal problems.
11. I am scheduled for a routine physical in mid-Februay. I can change that date. Any suggestions on specific tests to do at that time, such as T and ???
12. I will probably think of more questions, probably as soon as we hang up. Can I email them to your office if it is 1-3 questions requiring very brief responses?

New:

#1 covers that although yeah I'm implying that HT is the next step. From everything I've read, it is the next step.  But, I'll see what he says.

Mel

David:

Chemo has worse SE than HT...I think. Could be wrong and that may be the best way to go.

But, also, I remember Scholz's claim that HT can give me 10 years (median) before it fails assuming the PC has not metasticize. But even my bone scan has some non-specific spots so I don't know for sure that I don't have mets.

This is just a trying, frustrating time!

Mel

logoslidat said...
Im, not sure if Chemo works well on the small amount of cancer the psa indicates. I thought that was one of the big guns in advanced cancer when the tumour mass is larger. But than again things are moving fast in Pca{ accelerating at an accelerating rate? } and my knowledge of this is fuzzy at best. I am still in the wait camp on HT tho, especially if you are near and/or over 60., Logo

Why do I want to ask for the expert's opinion: Conventional cancer treatment protocol for many other types of cancer is to use either surgery or radiation to "debulk" the cancer and finish it off with chemo, or if the cancer is caught early enough, just use chemo alone. One example is breast cancer. Chemo works best for fast growing cancer cells. Most prostate cancer cells grow rather slowly except end stage when they become aggressive and hormone refractory. Perhaps, using chemo early would kill off the refractory cells when there are only a few of them in the body and easier to kill. This allows hormone to be effective for a much longer period of time or even curative?

Clinical trials usually only allow new medications to be used for end stage and slowly move the treatment protocol to earlier stages if found useful. Some of us may not have time to wait for the trickle down timing.

Newporter, thanks for the information, Logo

Hello Hotpink2,
It takes 7 weeks of a 50 mg dose of Casodex to achieve a steady-state in blood. Since your Dad has bone mets, you want to be sure testosterone flare suppression is at maximum before the LHRH agonist injection.

Degarelix is a LHRH antagonist and as such there is no testosterone flareup with this medication. Since your Dad is already on Casodex and probably will be on ADT2 while suppressed, he is already halfway there. Wish you and your Dad the very best response to therapy.

RalphV

ralfinaz said...

It takes 7 weeks of a 50 mg dose of Casodex to achieve a steady-state in blood. Since your Dad has bone mets, you want to be sure testosterone flare suppression is at maximum before the LHRH agonist injection.

7 weeks?!?! i'm hoping you meant to type 7 days . . . it seems that there is some slight differences across drs regarding appropriate protocol but i have't read it taking 7 weeks anywhere.

thanks for the quick reply!

Hotpink,
Sorry, my mistake. Had a senior moment. I meant 5 weeks to reach a steady-state in blood. That is some 35 days. Steady-state is reached when the 50 mg dose of the day replaces the initial dose taken 35 to 37 days before. This is due to the 7+ days half-life of the medication.

This is often ignored in patients with no metastases. In more advanced disease, it prudent to reach steady-state or increase dose if time is limited.

RalphV

I am told that the Casodex would start two months before Lupron (my case), therefore 8 weeks. Just comments from my uro, not yet an "on the calendar" plan.