testosterone "flare"

Posted a few weeks ago seeking information on radiation treatments and what to expect.  Well,now I have  met with urologist 8 weeks post op and since my pathology post surgery was not so great (Gleason (4&5) 9, seminal vesicle involvement and positive margins it was decided to go with hormone therapy and radiation.  Post op PSA was 0.07.  Next stop was radiation oncologist in Cleveland.  He initiated hormone therapy on 6/24 with a Lupron 45 mg injection that is supposed to last 6 months.  He wants radiation to begin by at least August.  He talked about a testosterone "flare" but decided against a drug called casodex.  Is this because my prostate was already gone and that I am asymptomatic physically other than incontinence?  I know he must have explained it but after awhile it all sounds the same.  Any insight?

When you take a GnRH-agonist type drug like Lupron, the way it lowers your testosterone (T) level is by raising it first. When your brain detects the T surge, it shuts down any further production of T from your testicles, in a process called "negative feedback." Because T can stimulate cancer growth, some like to take the precaution of blocking the ability of the cancer cells to use any available T with Casodex for up to a couple of weeks during the surge period. Others argue that the T surge doesn't really stimulate the cancer any more than your baseline T level because its androgen receptors are already saturated. There's no clear right or wrong.

- Allen

My uro says the flare only is a problem when it is known there are bone mets in the spine that could bring on a compression.

Thank God there can still be some sense of humor in all of this! Hopefully side effects stay minimal for all of us. Was shocked at $3000 price tag for the injection. Hopefully insurance covers. Has anyone had any issues with that? Grateful for this site.

Thanks for the response. Like I said, Doc only gave me the Lupron trying to avoid negative side effects of the Casodex so just have to be positive. Learning one had to have a lot of trust..,

I had not heard that before. Was under the impression that the radiation oncologist does handle the HT. My urologist basically has turned me over to the Radonc until treatments are over and then said he would monitor PSA's again. A medical oncologist has never been mentioned and I am working with guys from Cleveland Clinic. Certainly food for thought...

Anyone else have their Radonc handling both radiation and HT?

Thanks everyone for the invaluable input.

digger1948-

Your primary need right now is radiation oncology, not medical oncology. Cleveland Clinic is among the best and they certainly know what they're doing. You do not need a medonc while you are still pursuing curative therapy, which is outside of his area of expertise. He would add nothing to the process and only confuse the issues. My RO gives Lupron shots too.

- Allen

Tall Allen said...
You do not need a medonc while you are still pursuing curative therapy...

Allen, as someone under going RT with adjunct ADT, at what point am I no longer pursuing curative therapy? Would that point be when a raising PSA or imaging indicates systemic disease? Is that the proper time to begin talking to a medonc?

For the duration of the adjunct ADT is the RO the authority on the timing and duration of the ADT?

Digger:

As a fellow G9 with high risk statistics, I am firmly with Ed-Bar's opinion that you need a medical team that , at a minimum, includes a highly experienced RO, MO, Urologist and internist. Once you are through the radiation, it is a good idea to have the MO tracking your psa on a pretty tight schedule, at least for a while. The MO is the right guy to be advising you on the HT duration as well.

Digger,

There is a lot of wisdom for prostate cancer patients to be had in the sad story of the mule who starved standing in indecision exactly half way between two piles of hay.

I can reliably start an argument here by saying that one sort of treatment is pretty much as good as another (and they all get better every year). Guys will pipe up to point out studies that show that their favorite treatment works 90 percent of the time while some other treatment only works 86 percent. Usually that slightly-better treatment turns out to be the one they themselves had -- which makes sense because somebody talked them into it once so of course they think it's better. And they are right, provided that the particular endpoint their study was based on is important to you. But we sometimes get so wrapped up in that couple of percent difference that we miss the fact that the 86 percent (or whatever) is really pretty good.

It's worth your time to do your homework but once you do you gotta pick a machine, pull the lever and watch the cylinders spin. We all do. There are no guarantees.