Degarelix Monotherapy for Advanced PC?

Hi All,

My father (56 years, diabetic) has been diagnosed last week with Prostate Cancer that has spread to lymph nodes in the abdomen and one suspicious focal marrow lesion detected on MRI near the hip area. Its therefore Stage 4 D2. Biopsy showed four of 12 cores positive with Gleason of 7 (4+3), and PSA of 54. All doctors have prescribed ADT - however, none of the three I visited here in India prescribed ADT3 - one prescribed CAB and one Degarelix only.

For now, he has been started on Degarelix alone with some Calcium supplements - no anti-androgen or Proscar as of now, and no bisphosponate either. Is this the mainstream protocol? Should he not be put immediately on ADT3 OR should we see whether serum T falls below 32 and see how PSA is responding to monotherapy and and then take a call to add an anti-androgen or Proscar? Also, are there any other considerations in deciding ADT3 versus monotherapy - for example, can the cancer mutate sooner is we start an anti-androgen right away?

Looking forward to advice and recommendations. Thanks a ton.

Hi Allen,

Thanks so much - this is certainly clarIfiying for me vis-a-vis ADT.

I had asked the doctor about the CHAARTED study and she said it's a not a good idea right now given dad doesn't have "high volume" metastatic diseases. I then read further details on the study on a Dec 2013 article on NIH ([http://www.nih.gov/news/health/dec2013/nci-05.htm]; relevant extracts below) which seems to say that addition of Taxotere is useful for folks with high volume disease, which they define as the diseases spreading to major organs or four or more bone lesions. Dad has one bone lesion and lymph node involvement but no organ spread, so I am assuming he has "low volume" metastatic and Taxotere addition is therefore questionable now.

Does my analysis sound fair? Would love comments as I am deciding whether to prod the doctor for Taxotere and/or whether its worth getting a second opinion from an oncologist on this.

Thanks, Allen!



"Men received either ADT alone or ADT with the chemotherapy drug docetaxel every three weeks over a period of 18 weeks. In addition to examining whether the study participants lived longer with the addition of chemotherapy, investigators looked at whether the extent of a patient’s metastatic disease was high or low at the start of treatment. Approximately two thirds of patients had a high extent of disease which, according to the study, meant the disease had spread to major organs such as the liver, had a spread resulting in four or more bone lesions, or both.

A significant improvement in the overall survival was noted favoring the participants who had received docetaxel chemotherapy in addition to the ADT compared to the ADT alone (three-year survival rates of 69.0 percent vs. 52.5 percent respectively). Further analysis showed that patients with a high extent of metastatic disease accounted for most of the benefit in the overall survival from docetaxel plus ADT (three-year survival rates of 63.4 percent vs. 43.9 percent for ADT alone). Median follow-up to date is two years."

You are quite right about CHAARTED. The survival benefit for lower volume disease is unknown because survival is so long, it would take many more years to detect a benefit, if there is one.

I should point out there is another study called STAMPEDE that also found an improvement in survival of 22 months in men with any bone mets. They haven't yet published the breakdown for men with high # of mets vs low, but that should be available soon.

- Allen

Hi Sankalp,

You were asking about my experience with docetaxel. It's no walk in the park, but absolutely tolerable.

Let me first explain the procedure / schedule of the treatment. Taxotere chemo is usually an infusion that the patient receives once every three weeks. Normally there are six such cycles, making the whole treatment last a bit less that half a year.

The infusion takes about an hour, it is pain free and the patient receives other drugs in parallel to suppress nausea and other side effects. They usually add Cortisone in this mix. Cortisone is giving the patient's system a strong boost. So usually I could hardly sleep and was slightly "speeded" and full of energy the day of the chemo and the first day after.

The drug is washed out of your system within 24 hours - but the after effects are like you hit a huge gong - the whole system starts to vibrate and needs time to calm down. After 7 days the system is at the low point, the patient will have lost 2/3 of his white blood cells. Usually that is the moment when the patient feels most tired.

From there on the patient's system will start to recover and in your third week after the infusion things are almost back to normal. So the third week will be the best week of such a 3 week cycle.

Now, side effects:
- First the good news: I never had issues with nausea - they give you drugs to suppress that). So don't worry about that.
- I did lose all my hair (head, face, body). This started pretty soon - but that didn't bother me at all. And it all grew back after I had finished the chemo.
- Fatigue: This follow that three week cycle I was talking about earlier. The patient will feel most tired about one week after the infusion. The tiredness - like other side effects - is something that accumulates over time. At the beginning it didn't affect me much, towards the end, during the last two cycles, I had to take long siestas towards the end of the first week of the cycle. Your dad should plan for enough time to rest during those few critical days.
- The two things that bothered me most was that a) I slept pretty lousy due to the chemo and cortisone. I discussed this issue with my doctor and started to take some medication (Remeron, a light anti depression that helps to sleep better). The other thing was that my sense of taste deteriorated continuously. First it was the wine that smelled odd - so I stopped drinking any alcohol (which is probably a good thing). Then other foods began to taste weird. Towards the end I could only eat fruit, steamed vegetables and rice or pasta without any seasoning. That is annoying - but my sense of taste came back, so it is only a temporary issue.

I did one hour of physical activity each day (30 mins running, 30 mins weight machines) and changed my diet (no meat, no dairy products, no eggs, no refined sugar). The diet is really a personal choice, I feel fine with it and it helps me to stay fit despite the hormonal change which can make you gain weight and lose muscle mass. But I would say that the physical exercise is a must - even if it's just a brief walk. It's just very important to keep the system in shape.

- After the chemo it took several weeks to get my sense of taste back, my hair took several month to grow back. I also noticed that I was rather quickly short of breath for about two months after I had finished my chemo. But in general I recovered rather quickly.

At the beginning of the chemo I was amazed and relieved how well I tolerated it. Towards the end I was glad it was over. As I said earlier: most of the side effects accumulate over time and the time you need to recover gets longer. But it was never so bad that I considered stopping the treatment.

Bottom line: Given the very significant effect that the combination of ADT and Chemo had for me I would absolutely do it again. Would I do it if I had a flu? No way! Would I do it if I have stage IV cancer? Absolutely!

One thing I can not comment on: You write that your dad has diabetes. I have no idea how much that might affect the way he would experience a chemotherapy. That is definitely something that he needs to discuss with his doctor.

Hope that helps a bit on your and your dad's way to taking a decision. I wish you all the best - and please just ask if you have other questions.

best, m.

Post Edited (Madagascar_63) : 10/22/2015 2:57:30 PM (GMT-6)