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Stopping Casodex due to nipple soreness

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Posted 9/19/2017 1:06 PM (GMT 0)
Anyone experience early onset of nipple soreness from use of Casodex for PSA increase and then be told to stop the Casodex? Hubby started 50 mg six weeks ago and has been having sorenes since about 4 weeks out. Called his onc today who wants him to stop the Casodex and get a PSA on Friday. PSA was 6.6 on July 12, Casodex started July 28, PSA down to 2.6 on 9/1 so it is working (doctor said it was a "partial response").
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Age 58 at surgery
Sep 2013 PSA 3.7, clinical stage T1c, 3+4
RRP 10/31/2013, path stage pT3bN0Mx
SVI bilaterally (direct, not distal), LVI, pos margin at apex (3+3), EXE at base
4+3 w/ tertiary 5 (65% 4, 35% 3, 5% 5), tumor involved 15% of gland
12/2013 PSA 0.02; 2/2014 PSA 0.03; 3/14 PSA 0.02; 4/2014 PSA 0.02; 6/2014 PSA .03
MRI/bone scan negative
7/01/14 to 8/27/14 - 40 sessions adjuvant radiation
11/26/2014 PSA .03 - three months after radiation (same as before radiation)
2/25/2015 PSA .05 - six months after radiation
5/21/2015 PSA .17 - nine months after radiation (referred to Med Onc at Moffitt)
7/20/2015 PSA .41 - more than doubled, classified "incurable, micrometastatic"
10/5/2015 PSA .47 - slowed down considerably; MSK opinion same as Moffitt, wait and see
1/6/2016 PSA .62 - only half increase
3/30/2016 PSA .93
08/08/2016 PSA 1.7 - med onc says wait and see
11/02/2016 PSA 2.82 again wait and see; bone and CT scan negative
02/12/2017 PSA 3.86
05/04/2017 PSA 6.07
07/12/2017 - bone scan (normal); CT scan abdomen/pelvis (small slightly increased bilateral iliac lymph
nodes, doc not stage as Stage IV, said not considered measurable yet for mets)
07/12/2017 PSA 6.6 (slight increase from previous May PSA)
07/28/2017 Started 50 mg Casodex
Posted 9/19/2017 3:28 PM (GMT 0)
mbock,
My experience was about the same as your husband's. I was on Casodex 50 mg for 3 months during SRT 7 years ago. Nipples became sore after 6 or 8 weeks. Soreness went away about a month after I finished the 3 months course of Casodex.

The good news for you and your husband is that the Casodex was working so you know his PCa is hormone sensitive. I'm curious about your MO's treatment decisions so far because I am also PT3N0Mx and am now having rising PSA which began about 5 years after SRT. PSA reached .2 last October and was .9 in June. I switched my care to an MO in January. I see your husband's doubling time is about 3 months and he started Casodex when his PSA reached 6.6.

Has the MO given a reason why he chose Casodex rather than Lupron and why he waited until PSA reached 6, even with a somewhat fast doubling time? Was the Casodex meant to be the primary treatment or was it meant to be in preparation for starting Lupron? I'm not criticizing the MO's judgment -- just trying to figure out what I will do next.

My MO says he thinks my doubling time (now around 6 - 7 months) may slow down, in which case he'd be inclined to postpone ADT. My next test in a few weeks may show if his hunch is correct.

My former RO said he would want to put me on Casodex rather than Lupron when the time came because of the milder side effects (other than nipple pain and breast enlargement, which may respond to tamoxifen). When I discussed Casodex as monotherapy with my MO he disagreed because in his knowledge/experience he thinks it is less effective and the side-effects though different than Lupron, can be just as bothersome in their own way.

Just curious about the background of your and your MO's choices re Casodex and timing of start of treatment - because I have to confront choice of my own next steps soon.

Best of luck with your next appointment.
Jim
Posted 9/19/2017 4:26 PM (GMT 0)
Hubby goes to med onc at Moffitt in Tampa where we live. We have also been consulting with Dr. Slovin at Memorial Sloan Kettering. The two docs seem to be on the same page with treatment options/timelines. Both agreed to have the PSA increase between 6-10 before any therapy was started. Moffitt med onc was wanting 6-8, Slovin was at 8-10, but each said the doubling time will determine start time as well. Dr. Slovin said she always starts her patients out with Casodex monotherapy and the reason she waits for higher PSA is to get proven results that the Casodex is working. Moffitt med onc had discussed starting on Lupron but said he had no objections to going first with Casodex since it would have lesser side effects. Hubby's only other side effect other than the nipple tenderness is an occasional hot flash but nothing that has interferred with every day life. Fatigue doesn't seem to be an issue either. One thing I do know is Dr. Slovin's expertise is prostate cancer. Our Moffitt doc is their genitourinary oncologist dealing with all cancers including prostate. He had mentioned that he does not deal with the large number of prostate cancer patients as Dr. Slovin and welcomes her recommendations. Currently, our Moffitt doc has taken hubby off the Casodex starting today and we're not sure what the outcome will be on Friday. He had mentioned that when the PSA gets to a certain low level hubby could take a break from the Casodex. Who knows where hubby's PSA will be on Friday, and if the doc is temporarily stopping the Casodex to address the breast issue and see if gynecomastia is an issue. Hope this info helps.
Posted 9/19/2017 4:59 PM (GMT 0)
breast soreness/enlargement is a very common side effect of Casodex. The solution is simple - 10 mg tamoxifen everyday. 20 mg can be used to reverse any gynecomastia already there.

But based on the limited response to 50 mg Casodex, bigger guns are surely required. That may mean 150 mg Casodex (with tamoxifen) or it may mean Lupron or more. There is little agreement among even the best prostate oncologists on the best ADT strategy. One POV is to get a maximal response as early as possible (using Zytiga if insurance will approve it) in order to lower the tumor load and enjoy a longer ADT vacation. Quality of life is an important consideration, so there are no easy answers.

As long as he's stopping Casodex, this may be a good time to get an Axumin PET scan (if his insurance will cover it). If you can identify one or more of the larger metastases, and they are in a safe place for spot radiation, they can be zapped with SBRT. The hope is that that, when combined with ADT, may slow the cancer's progression. No one knows if that really accomplishes anything, but if it is safe to do so, why not? A secondary "benefit" (if it can be called that) of detecting a metastasis is that it may qualify him for some clinical trials.
Posted 9/19/2017 7:23 PM (GMT 0)
Interesting. I asked the doc about the decrease from 6.6 to 2.6 in five weeks and he said it was about average for what he was seeing. He believed that by his next appointment November 1 hubby would be below the threshold to stop the Casodex for about six months. Again, from his experience. We are all, including the med onc, not convinced the slightly enlarged lymph nodes (which doc felt were too small to be measurable) are metastatic cancer. Reason being is that John had total knee replacement for both knees (February for left, June for right) and developed lymphadema and still continues to have swelling. Hence the slightly enlarged nodes. So, although there has been consistent rises in PSA, our hope is that it is not metastatic, the PSA this coming Friday will be even lower than the 2.6, he'll go back on the Casodex at the current dosage of 50 mg and add Tamoxifen to treat/prevent gynecomastia. That's our hope. This disease is all about hope.
Posted 9/20/2017 10:21 AM (GMT 0)
I had soreness for a while but it went away in a couple months . I take Cabergoline.
Bob
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