Lupron Inquiry

I was diagnosed in 2012 with PC. My PSA was 37 and Gleason score 7. Since then, I've stated Hormone Lupron treatment at MD Anderson. I've had 3 injections. My PSA went down to 14. Doctor does not want to start radiation until the number is 0. I'm worried because my last lab indicated that my PSA is now 21. How long can I be on Lupron? What must I do? I though they would have started me on Radiation first. Should I seek another opinion? I thought MD Anderson was the best.

Hi Texasblue,

I'm so sorry to welcome you to this board, especially with your troubling diagnosis and even more troubling response to treatment so far.

First, let me assure you that MD Anderson is certainly among the best places in the world for prostate cancer treatment. In fact, you might want to get a consult with Dr. Logothetis who is the head of Urologic Oncology there. There are a few urologic oncologists who are more famous, but in my estimation, none are better.

Let me give you my layman's impressions of what may be going on with you, and you can perhaps bring these up as possibilities to your doctor. I can imagine 3 scenarios, from most likely to least likely:

Scenario 1. Prostatitis

This is the most likely possibility. Your high PSA that is not well-controlled by Lupron may be indicative of prostatitis on top of your prostate cancer. This is especially likely, given that true Gleason 7s typically will not present with PSAs that high. Sometimes prostatitis will respond to a 10-day course of Cipro or other antibiotic, sometimes not. One clue may be in the biopsy you had -- was there any mention of chronic inflammation there? Also, a blood test may show an elevated neutrophil count.

If this is the case, and your prostatitis does not respond to antibiotics, the Lupron may never get your PSA down. In fact, if your true Gleason score is 3+4 rather than 4+3, the hormone treatment may not be useful at all -- only the radiation may be necessary. The reason I emphasize true Gleason score, is because the biopsy is just a sample and may not find high grade cancer that is really there, especially if it is in the anterior part of the prostate.

Scenario 2.Lupron is not enough

This is unlikely but possible. Lupron is usually enough and should have had more of an effect by now, but different people react differently. If it is not controlling your testosterone levels - and a simple blood test will tell you that - you can try Firmagon, which has a different mode of action. Another possibility is to add Casodex, which blocks the prostate cancer from utilizing testosterone. Some doctors add Avodart too, which prevents a powerful anti-androgen, DHT, from forming from the testosterone that is there. Because you have rising PSA after Lupron, you may be able to get Zytiga, which will prevent your adrenal glands from producing testosterone, if that is the source.

Scenario 3. Your cancer is castrate-resistant

This is highly unlikely given your relatively short course of treatment so far. It typically takes many years for a cancer to evolve to the point where Lupron no longer controls it. There are some, very rare, forms of PC that are never hormone responsive, but I think that would have shown up on your biopsy report. In the unlikely event that it has become unresponsive to Lupron (castrate-resistant), adding Zytiga will often control it. This scenario would also increase the likelihood that the cancer has already spread outside of the prostate, and brings up the question of whether the planned radiation would be useful, and, if so, where it ought to be used (e.g., prostate, prostate bed, and lymph nodes).

Length of hormone pre-treatment

There has been some question as to how long it is necessary to continue pre-treatment (called neoadjuvant treatment) before starting on radiation. Then there is even less certainty about how long to continue that treatment (called adjuvant treatment) after radiation starts.

A recent study found that 8 weeks of pre-treatment in intermediate risk patients was as effective as 28 weeks in intermediate risk men.

Fewer Weeks of Hormone Therapy Before Radiation Treatment Reduces Side Effects and Yields Comparable Disease-Specific-Survival for Intermediate Risk Prostate Cancer Patients

Complicating this, however, is the problem that your high PSA puts you into the "high risk" category. However, if your high PSA is mostly the product of concurrent prostatitis, as I suspect, the 8 weeks may be adequate pre-treatment. The other factor that enters into your risk category is the stage, which you didn't mention. The stage is assigned based on how much cancer there seems to be, based on feel or imaging, and whether it has traveled to the seminal vesicles, or has caused a bulge.

If you do have prostatitis, whether hormone treatment is useful or not will depend on your Gleason score and stage. If you have a low volume of Gleason score 3+4 cancer that is apparently well contained, the hormone therapy may be of no added benefit to you.

I hope you will let us know as you explore all this with your doctors.

- Allen

Tex,
Sorry that you are having problems but I think that you have received excellent advice from RalphV and Tall Allen. I recall a vet friend of mine (Deros or Friendly Fire11) who was originally diagnosed and waited for treatment at MD Anderson. His diagnosed psa was 33 and lupron wasn't enough to get his psa to .5 where MD Anderson wanted it before radiation..Casodex really helped in his case but with his PTSD he bailed and had it done locally; at last check he's doing ok with a psa of 1.3 and he said he's done with anymore treatments..he did have a questionable lymph node.
In any event, please review the advice that Tall Allen provided you with; his opinion is respected by (almost) all of us...Hopefully antibiotics and casodex will get the job done..Best wishes and please "pay it forward" by keeping us informed!
Bill

Good info from the veterans on PCa herein, going to add this to consider.

You should have various blood marker tests for biological markers of PCa, like PAP, UnTx (urine test for bone breakdown=mets marker), maybe creatinine (blood & urine tests) and many others. If these types of tests seem indicative of PCa spread, then scannings are needed to establish the extent they can find. You have a strange scenario right now, it needs definings. Do you have a copy of your original pathology report? Might be good to post what it actual says. Best to you.

Did you try antibiotics as I suggested?

My father has been on Lupron for 12 years - during chemo, three different Radiation regimes, Zytiga, Provenge, and now Xtandi and Xgeva. Not sure why they are waiting.

Radiation is only valid when there is a strong possibility that the PCa is limited to the prostate bed. If it appears to be outside that area, radiation is marginally (if at all) useful.

Texasblue-

I have found that I work best with my doctor when we interactively engage with each other. I go in with lists of questions and observations in writing (sometimes I email in advance so he has time to consider it.) I never expect him to have all the answers, especially when there is something out of the ordinary going on. My doctor seems to like it this way -- or rather, I have chosen a doctor who likes it this way. I figure we are there to learn from each other, although the money goes to him ;-)

- Allen

Texasblue-

The imaging you've had is not capable of picking up any but very large tumors in the prostate bed. There are some specialized PET scans that can see smaller tumors in the prostate bed and lymph nodes. Lymph nodes can be treated with radiation as well.

- Allen

Thanks for all of the responses. You guys have truly helped me and you've provided great insight into my situation. I'm glad I found this site.