Prostate Cancer and Kidney Transplant and can I stop Casodex

Just joined HealingWell. Been reading the posts on prostate cancer and find the experiences of others helpful. I am wondering if someone has a situation similar to mine - prostate cancer dx after having a kidney transplant (complicates treatment as transplant requires me to be on immune suppressing drugs to keep me from rejecting the transplanted kidney). Also I would like to know what others have been told about stopping Casodex. One oncologist says to stay on it and another oncologist says I can stop.

History:
PSA 2.47 April 14
Kidney Transplant 11/3/14
PSA 9.22 7/14/16
Urologist on 9/6/16 ordered another PSA as symptoms suggested prostatitis - PSA 12.7
11/29/16 bladder scope and DRE - urologist said DRE indicated cancer
12/29/16 Biopsy
1/3/17 results - 11 of 12 cores show cancer rated as Gleason 10
1/6 CT scan and bone scan
1/13 - Urologist gave results - cancer in lymph nodes but knot in bones
1/13 started on Casodex another PSA - 28.5 (may have been influenced by biopsy only 2 weeks earlier
1/27 1st 6 month Lupron shot
2/5 Transplant doc eliminated some of immune suppressing drugs.
2/14 PSA 1.14
2/22 2nd opinion with urological oncologist at Univ of Colorado Hospital recommended cryotherapy and said I shouldn't let myself be taken off Casodex
3/15 PSA .24
3/24 Primary oncologist (that insurance is covering) recommends against cryotherapy and says I can stop Casodex
Have read Dr Walsh's Surviving Prostate Cancer,Invasion of the Prostate Snatchers, Anti-Cancer a New Way of Life, and skimmed several other books

That's a lot of complications to deal with. Let me take a stab at some comments for you to consider.

Casodex:
Casodex is often started just before Lupron to prevent a "testosterone flare," but after a couple of weeks that is no longer necessary. Most guys do just fine with Lupron alone. You can try getting rid of it (gynecomastia is a very common SE) and see what happens - if the PSA increases, you can always go back on it - take with 10 mg tamoxifen to prevent gynecomastia.

Cryotherapy:
U of Colorado does a lot of cryo, so it's no surprise they're recommending it. However, whole gland cryo (while it's getting better) is known for lots of complications and poor cure rates. As you can see in the following, the 5-year recurrence-free survival among high-risk men was only 59%. 10% suffered lasting incontinence and 83% were left impotent. 3% required surgical intervention for urinary retention (many more required catheterization) and 1% suffered rectourethral fistulae.

Primary Cryotherapy for High-Grade Clinically Localized Prostate Cancer: Oncologic and Functional Outcomes from the COLD Registry

Potentially curative therapy:
I imagine surgery with ePLND is out of the question because of risk of infection. Ideally, you would have a combination of external beam and brachytherapy boost to the prostate. That has the highest cure rate for high risk men. You should discuss this with a very experienced brachytherapist who would consult with your nephrologist. This kind of combination therapy carries the risk of urinary retention, which may be a concern for your kidneys. Next best would be external beam monotherapy - IMRT, most likely. SBRT may be possible, but I don't know if they would treat a high risk patient (it is experimental for high risk). With any kind of radiation therapy, I'm sure that pinpoint accuracy will be absolutely critical to minimize incidental dose to the ureters.

At U of Colorado, you have Brian Kavanagh who is a very highly respected radiation oncologist. His would be the first opinion I would recommend you seek out. I've also heard patients praise Lee McNeely for SBRT - he may be worth talking to also.

Non-curative therapy:
Another option is to manage the disease. Hormone therapy seems to be working quite well for you, which augers well for long term management. Oddly enough, the corticosteroids you are taking to prevent kidney rejection may actually be helpful in controlling the PC, at least for some time. When Lupron alone is not enough, there are several second-line hormonal therapies, and possibly more by the time you're ready for them.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4023359/

Thanks for the information and doctor recommendations. Unfortunately, seeing doctors at the University of Colorado is very difficult because of Kaiser Permanente insurance. Probably will end up self paying for the second opinion I got there. I saw Dr. E. David Crawford who is head of the Urological Oncology department. He is about 70 and has done lots of research and written lots of papers. Early in his career he started doing research on Combined Androgen Blockage (CAB) - Casodex or similar with Lupron or similar. But most of what I've found indicates there's inconclusive evidence that CAB is better. I feel better being off it. I'll know more after my next PSA tomorrow. If PSA goes up, I'll probably go back on. Cyrotherapy doesn't seem like an alternative to me.