Is there anything else after the traditional methods

It looks like the XL 184 is bringing down the Alk Phos at least. With many new therapies there is an immediate PSA spike probably attributable to cancer cells dying and their PSA going into the bloodstream.

Estrogen patches are sometimes used as third line hormonal therapy. Ketoconazole sometimes works, but probably not after Zytiga has failed.

As for chemo... When Taxotere fails, there is Jevtana. Chemo combos can be harsh if his performance status is poor.

He is probably taking Xgeva or Zometa to prevent fractures. He can talk to a radiation oncologist about single-dose SBRT to his bone and visceral mets. It might help with the pain and enhance his QOL.

- Allen

There are dozens of clinical trials for new medicines for mCRPC. If you've browsed clinicaltrials.gov for your area and didn't find any, I wouldn't know of any beyond that. You can ask at your local tertiary care centers if they have any.

The problem with "revisiting" is resistance and cross resistance. Medicines that attack the cancer exert selective pressure on it to evolve. It evolves a way to survive in spite of the medicine, and in so doing, often makes other medicines of that same class less effective. So Zytiga doesn't work nearly as well after Xtandi and vice versa. However, a combination of agents may work longer. There are lots of new hormone therapies in trials: Capesaris, Orteronel, ARN-509, Galeterone, ODM-201, VT-464, and several others. They may be more effective when coupled with growth factor inhibitors, like angiogenesis inhibitors or tyrosine kinase inhibitors. These can also be coupled with Taxotere or Jevtana.

An interesting possibility is a class of drugs called de-methylators that might be able to restore the cancer's hormone and chemo sensitivity. For more information about this and other kinds of medicines that are already approved for other uses and may be prescribed off label, go to this link.

- Allen

Hi winmui,

Dr. Myers has written that Avodart continues to work even when Zytiga and other drugs have failed. The effect will be subtle, but given the fact that it has very mild side effects, it might make sense to add it to the regimen. Apparently, when PC cells become mCRPC, they still require testosterone to function, just very tiny levels of it. DHT just happens to be such a fuel, so blocking access to it could have synergistic effects that might be helpful. Just another part in the battle. Wonder if his oncologist would object to adding Avodart at this point?

There was a recent report from a clinical trial that galleterone seems to be effective for people who have failed Zytiga and Xtandi. So, if your dad can get into a galleterone trial that would be yet another weapon in his arsenal.

When I saw Tall Allen was your advisor I did not comment, as he is my mentor too.

Prayers your way though.

It is good that you did not need his counsel last month as he was on a one month sabbatical to write a novel, but he is back and should be along shortly.

Let's hope the alkaline phosphatase increase was an anomaly and it goes down again next measurement.

LupronJim

Thank you both Tall Allen and Jim!
We will be seeing oncologist this Friday and hoping his numbers are in line. Will be studying the below lists in the meantime.
The xl still puzzles me. It's amazing how his alk phos has declined and kept him pain free. We can see him getting better every day. But how can it be possible that his Psa continues to climb when he is looking so much better. It's so scary to see it at 1,600 not to mention liver levels rising slowly. Meanwhile we will continue to make sure he doesn't lose any more weight.

Will keep you posted on dad. Thank you all!

Just an update, scans were a mixed bag.
Bone mets dramatically decreased from the xl but the good is outweighed by bad. Liver spots not only increased in the two lesions but more spots overall. Lungs also showed increasing from August results.
So the path leads us to Jevtana. Interestingly at today's visit, oncologist also mentioned a phase 1 trial:TEN-010. Belongs to a a group of drugs called bromodomain inhibitor.
He has seen a patient (not his) similar to dad with advanced prostate with Mets and major involvement in liver which in scans responded quite well to reducing the liver lesions. Again, it's only one patient in which he did emphasize. It's decision time again for dad. It's a no brainier with jevtana right?

Hi Winmui,
I am so sorry that you are dealing with this roller coaster and getting such a mixed bag of test results. Our medonc advises that the important thing to pay attention to is not the numbers, but how a person feels. Your Dad's body may be responding to being off the xofigo even though psa is climbing. Gary did not tolerate xofigo well, and was throwing up for days afterwards with little pain difference. But he did very well tolerating jevtana once the vascular reaction was under control. Did you once mention that your Dad had similar reaction to chemo? If so, check into having the administration of the drug broken into smaller portions. Most importantly, don't lose hope, because he is rebounding and the chemo may kick butt on the liver lesions. In the meantime, don't forget to take care of YOU too. It's a crazy time of year and you gotta take a minute to recharge your own batteries to be there for your Dad. Best of luck in your next steps!
Beth and Gary

Dear Winmui,

You have received messages about the medical aspects of your dad's case. I just wanted to let you know that I have been thinking about you and your dad. I am sending my support and prayers and thoughts to you from across the miles. I just wanted to let you know that others are thinking about you and your dad during this time, and I am one of those people.

Sent with caring thoughts,
Cyclone

Hi winmui,

I'm not sure if your medical oncologist has considered this, but DES could yet another treatment to try. It is one of the oldest forms of hormonal therapy, and at very small doses (1mg) it could help in controlling his cancer. Here is more information on a recent study about it:

http://prostatecancerinfolink.net/2014/12/22/low-dose-diethystilbestrol-in-treatment-of-men-with-crpc/

Update on dad:

Its has been an uneventful new year. Dad had received his first does of jevtana. On New years day we brought him into ER with shortness of breath and abdominal pain. He is still hospitalized. Fluid in lungs. Left lung tapped last friday and right lung tapped Tuesday. On Oxygen and many other things. Tests came back and the fluid do contain cancer. He will be getting Pleurx catheter on both the left lung and right lung. Fluid has continue to accumulate. Surgery schedule today.

MO said his next jevtana shot is 1/20/15 and he doesnt believe he will be strong enough to be getting chemo. It has been exhausting and sad for the past week and a half just seeing and hearing bad news as we roll along.

You're going through some tough times. Just wanted to let you know that we are thinking and praying for you, your dad and your family.
Beth

It's a tough road. Dad is still hospitalized since New Years day. I am really sadden as I see his condition worsen. Liver numbers are climbing. Docs said no more chemo no more meds. He continues to drain from his lungs every other day. Pallative care have us a scoop on next steps. After the talk, dad seemed to have lost hope. Not sure if this had helped, but many tears shed today. I'm not ready and I don't want him to lose this battle we fought so hard.