Advanced PC, PSA increase after 2,5 years

"1) Since his adrenal gland testosterone is not suppressed, is it possible that Androcur or Casodex can decrease his PSA level again? Or is his PC hormone independent now?"

You can try Casodex - sometimes it helps for a little while. Androcur (cyproterone) is useless because of the orchiectomy - his testicular testosterone production is already shut down. I do not think it does anything about adrenal production, but since it is steroidal, I'd be afraid it might paradoxically feed the cancer. It is not used at all in the US. He should have his serum testosterone level checked to make sure it is at castration level.

"2) What about non hormone medicine like Metformin and Ketoconazole? Can they be used in such advanced cases?"

Metformin is of questionable efficacy. Ketoconazole can be used to stop adrenal production of androgens - but check his serum level first. Zytiga is more powerful than ketoconazole but may not be available to you in your country. If you can get zoledronic acid and celecoxib, that is a useful combination.

"3) Can 2d line hormone therapy like Premarin be used if orchiectomy took place?"

I doubt it, but perhaps - but, again, the first step is to see what his serum level of testosterone is.

"I am afraid his oncologist will suggest chemo, but I am not sure this is the best choice taking into account the above mentioned options."

Don't be afraid of that. It was his best option and should have been started long ago. It adds markedly to survival if started sooner, but adds much less if you wait.

Hi PavelNovak,
Your questions sound like the ones my husband asked at his last appointment. He had an orchiectomy almost a year ago and is currently castrate resistant. He is taking Casodex which is holding his psa at about 10.5. He asked his doctor about adding metformin and (in his case) Avodart. It was suggested that metformin is used only if you have diabetes or pre-diabetes, and that metformin and Avodart won't do much anyways if he already had the orchiectomy and is on casodex. The doctor's quote was something like, "If you already are using the big guns, those drugs are like using a pea shooter."
His highly regarded prostate oncologist said he's been using estrogen for advanced prostate cancer with good results for those who don't want to incur the high costs of Xtandi and/or Zytiga. With copays of almost $5000/month on top of high health insurance premiums in excess of $2000/mo (here in the US), some patients are looking for less costly options. My husband's oncologist uses estrogen until a patient is on medicare because costs for the new drugs are a lot less after turning 65. Hope this helps.

Hi Tall Allen,
I don't know the science behind why that particular treatment is advised, but I did a quick search and found this article that may be helpful: bmccancer.biomedcentral.com/articles/10.1186/1471-2407-10-244
We really like DH's oncologist because he appears to have seen it all and doesn't just go by the standard of care treatment algorithms DH's urologist uses.

Tall Allen,

I believe mtnwife's husband had orchiectomy a year ago.

He hasn't started it yet but that's the plan. His psa didn't go up very much (still under 11) when tested two weeks ago, so he's waiting until his psa starts moving again before adding anything else.

PavelNovak,
My husband (83 yrs) was diagnosed over a year ago with stage IV - D2 (wide spread mets). He did not have an orchiectomy but had chemical castration first with Casodex (2 mos), then Lupron injections which lowers testosterone levels from the testicles. His PSA dropped from 20 to 1.33 over an 8 month period, then started to rise.

His oncologist then added Xtandi (enzalutamide) which prevents additional testosterone (produced by the adrenal glands) from bonding. As a result, his PSA dropped again to 0.07 over 5 months. We could not afford to buy Xtandi even with drug coverage insurance, but qualified to receive it free from the drug company.

The only side effects are extreme fatigue and neuropathy in his hands, but my husband has a preexisting very rare autoimmune neuropathy (CIDP antiMAG IgM) related to a mantle cell lymphoma. This means his nerves are stripped of their myelin covering and are likely more sensitive than most to drugs with neuropathic side effects. ... so I'm a fan of Xtandi.

Hope your dad's situation improves.
Hugs, Carol

Norb age 82 at diagnosis 9/15
Biopsy - Adenocarcinoma 10/15 bone scan & CT w/contrast
Gleason - 4 + 5
Metastases - 22 wide-spread (bones-9, lymph-6, lung-5, liver-2)
PSA:
9/15 - 20.59 started Casodex, then switched to Lupron
2/16 - 01.39
5/16 - 01.33
8/16 - 02.07 added Xtandi to Lupron
10/16 - 01.98
11/16 - 00.20
1/17 - 00.07

PavelNovak - I've added you to the Gleason 9 Crew roster, on the thread we have on this forum for those facing this diagnosis. You can find others here with similar situations, and perhaps something may be of help. It's organized by a G10 group, a G9 5+4 group, and a G9 4+5 group, all sorted by diagnosis date. Where I could find them, I have also posted links to each person's initial post.

The Gleason 9 Crew -- Part 2, continued.