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Posted 12/23/2017 1:47 PM (GMT 0)
Greetings from across the pond. I've recently completed primary radiotherapy treatment combined with 6 months of Neo-adjuvant hormone therapy (Casodex - three months prior to radiotherapy commencing).
My first PSA test since completing the therapy has come back at 1.47.
Is this a typical initial outcome? My oncologist seems happy and expects my PSA to track downwards towards 1 but I was of the impression that it should be much lower due to the ongoing effect of the Casodex>
Posted 12/23/2017 2:06 PM (GMT 0)
Sincere apologies, I forgot to tick the box when I submitted my post which would have included my signature.
Significant history/background:
Age 59
February 2017 PSA 30
March 2017 PSA 25
mpMRI scan March 2017 - 2 suspicious areas
CT Bone Scan - clear
Template Biopsy: 67 cores in total. Cancer present in 2 cores 3.6%. GS 3+3. Cancer present in 12 cores 26.58% GS 3+4. ISUP 2014 Grade Group 2. No PNI.
Ga68 PSMA PET CT Scan - clear
Hypofractionated IGT/IMRT 20 fractions. 60Gy total dose using Varian Truebeam VMAT.
6 months of Casodex.
Posted 12/23/2017 3:19 PM (GMT 0)
You did not mention when you completed the radiation and when you stopped using Casodex. What was the PSA value while using Casodex before the radiation?
Posted 12/23/2017 3:29 PM (GMT 0)
Thanks for the reply George. Last PSA test came back at 25. I started the Casodex at the end of June and started radiotherapy at the start of October. Last fraction of radiotherapy on the 4th of November. First blood sample post-radiotherapy taken 6 weeks after last fraction. Just completed the course of Casodex.
Posted 12/23/2017 3:35 PM (GMT 0)
Welcome to HW.
Likely it's a bit early for a PSA test, but your results are just fine and are looking good. This RT plan is the slow road and you'll need a few more PSA tests to establish a pattern. Lower is good.

It's possible that your T-levels never got to castrate level or that your T-levels are recovering faster than expected. In any case, I don't think you should be too concerned about it.

You're going to do just fine.
Andrew
Posted 12/23/2017 3:51 PM (GMT 0)
Hi Andrew. Thanks for your reply and kind words of reassurance. I imagine that you're correct about this being a long road. Happy Christmas.
Posted 12/23/2017 5:24 PM (GMT 0)
At this point, you're looking for the trend to be downward, which it is. Unlike the surgery guys, radiation patients don't get the benefit of a quick non detectable PSA. Also, you should know that some guys treated with radiation have PSAs that bounce around--that can be frustrating in tracking it, but again it's the longer trend you need to look at.
Posted 12/23/2017 10:23 PM (GMT 0)
I don't think there is an ongoing effect of Casodex. It has a halflife of about a week, so it is cleared pretty quickly. It was blocking your androgen receptors while you used it, but testosterone was produced normally all the while. Now testosterone and DHT are activating your androgen receptors. I'm actually surprised that your PSA is this low this quickly, given how high it was before.
Posted 12/27/2017 10:02 AM (GMT 0)
Thanks for the responses folks. There seems to be a different approach in the UK to what you guys see in the US. For example, my PSA was not measured again from when I had a test done in March until after my radiotherapy had ended. My oncologist seemed to regard the clear Ga68 PSMA PET CT scan as the strongest indicator that my cancer had not spread outside of the organ and seemed not to think that measuring my PSA again prior to the start of treatment as being necessary.
On reflection, the most arduous part of the treatment has been the side effects from the Casodex. Hopefully they will clear pretty quickly although I have been advised that they may take as long to clear as I have been taking it (6 months). Does anyone out there have specific experience of this?
Posted 12/27/2017 5:43 PM (GMT 0)
In the US, the first post treatment PSA is usually 3 months after the last radiation treatment. Earlier testing is meaningless because radiation increases the dead prostate cells that leak PSA into the serum. All of that has to clear. Then the cancer cells slowly die off, releasing lower levels of PSA. They will then track your PSA every 3 months until it eventually reaches a low nadir value.

Unlike Lupron, which blocks the testicles from producing testosterone, Casodex only blocks the cells from receiving testosterone. The testosterone is still there all the while. Now that the Casodex is gone, that testosterone is activating your androgen receptors and creating benign sources of PSA. It can take years for PSA to diminish to a nadir value.

As for the side effects of Casodex - the most frequent one is gynecomastia. If breast tissue has already developed, you may be able to still get rid of it using 20 mg of Tamoxifen daily.
Posted 12/28/2017 10:06 AM (GMT 0)
Tall Allen, thanks for your reply. Your knowledge of all things PCa is quite astonishing and extremely helpful to the uninitiated like me.
The Casodex has indeed caused some breast tissue development and tenderness in the nipple area. This has only really manifested itself in the last 6 weeks of the 6 month treatment period. Is this side effect naturally reversible? I'd like to avoid having to take any further course of treatment.
Also in the UK doctors seem to have a variable approach to the treatment of gynecomastia. Some will prescribe a short course of radiotherapy, others Tamoxifen and others no treatment at all! Presumably my hormones will be getting back to some degree of normality, so I was hoping that maybe a natural reversal may occur.
Posted 12/28/2017 7:10 PM (GMT 0)
Unfortunately, it won't reverse on its own, and the longer you wait to deal with it, the harder it will be to reverse. You have to begin therapy within 2 months.

They used to give radiation to the chest to prevent it, but it didn't work that well. 10 mg tamoxifen works much better for prevention. But if you want to reverse what is already there, 20 mg daily dose is required. One HW member found that a related drug, raloxifene, worked as well.

Here's a good review article about it:
/bmcmedicine.biomedcentral.com/track/pdf/10.1186/1741-7015-10-96

The only contraindication I know of is if a patient has a history of thrombosis.

If 20 mg tamoxifen doesn't reverse it, they can inject cortisone directly into the breast tissue around the nipple to break it down. With time that tissue develops a supportive collagen network that can only be removed surgically.
Posted 12/28/2017 7:36 PM (GMT 0)
Thanks Tall Allen. I'll see if I can persuade my Doctor to prescribe it. Any thoughts on how long I'll need to take the Tamoxifen for?
Posted 12/28/2017 7:45 PM (GMT 0)
I would guess a few months - but you'll have to see how it goes.
Posted 12/28/2017 9:20 PM (GMT 0)
Allen, thanks for your post yesterday regarding RT and post treatment PSA. I expect this applies to me as well after I complete my ADT. I completed my SRT in late October and have my first PSA scheduled for next month.

Grumpy E, my MO prescribed 20 mg of Tamoxifen a little less than a month ago to treat my breast swelling and tenderness which began in the middle of the fifth month of my Casodex/Avodart ADT. It seemed to stop the swelling for a while, but not yet completely. Some days they appear more swollen than others, usually in the evening. Nipples are also tender and sore occasionally.

I will be completing my six months of ADT on January 10. However, I expect my MO will have me continue taking the Tamoxifen for at least a couple more months.

Rick
Posted 12/28/2017 10:41 PM (GMT 0)

Grumpy Englishman said...
.....My oncologist seemed to regard the clear Ga68 PSMA PET CT scan as the strongest indicator that my cancer had not spread outside of the organ.

Just yesterday, I had an appointment renowned RO, Dr. Anthony D'Amato. He told me that with a G3+4, which I have also, metastases is all but unheard of. FWIW.

Good luck!
Posted 12/29/2017 9:12 AM (GMT 0)
Hi Italatin8. Thanks for your comments and sharing your own experience of using Tamoxifen to deal with the SEs resulting from the use of Casodex. I shall definitely see if I can persuade my oncologist to prescribe Tamoxifen for a period of time to see if that helps with my symptoms.
Have you noticed any specific SEs associated with taking Tamoxifen?
Posted 12/29/2017 9:15 AM (GMT 0)
Hi Garyi, thanks for your reply. The observations from your oncologist are reassuring. As I mentioned, the attitude of my own oncologist seemed to change towards being sure of a positive outcome from my treatment when the Ga68 scan came back clear. I guess time will tell.
Posted 12/29/2017 9:04 PM (GMT 0)
Gary:

I sure hope this is the case with my G7 (3+4) PCA. However, I did have EPE, negative margins and one positive lymph node.

Grumpy E:

The only side effects I noticed were a bit more fatigue some days, although this could be the result of the Casodex and Avodart after almost six months of ADT, and on some days a tightness in my breasts. My pharmacist told me I would feel some tightening and tenderness in the breasts after starting the Tamoxifen. I hope this means its working. Today they seem fine.

Happy New Year to you and best of luck in your continued journey.

Rick
Posted 12/31/2017 12:36 PM (GMT 0)
Hi Rick. Thanks for your reply and a very Happy 2018 to you and yours.
Posted 1/1/2018 1:13 PM (GMT 0)

Gary said...
He told me that with a G3+4, which I have also, metastases is all but unheard of. FWIW.

Well, I have a G3+4, determined by biopsy, and several pelvic lymph node mets. I also know of a guy with a G3+3 who has mets and is castration-resistant now. On the other hand I saw a conference presentation and the speaker said "there is a shipload of evidence that there will be no metastases if there is a G3+3. Therefore there is no need to take out any lymph nodes during surgery."

A Ga68 PET/CT currently is the best imaging there is. If that is clear that is better than any nomogram or probability. On the other hand, a PSA value of 30 puts you into the high-risk group. I am afraid the radiation will give you a long break but it will not be the end of your journey.

George
Posted 1/1/2018 6:25 PM (GMT 0)
just my experience with Lupron .....6 months after end of 6 month Lupron shot , my nipple area got very sore ....slight excess fat in breast area too.....soreness lasted 6 months and is now gone completely....David
Posted 1/2/2018 10:11 AM (GMT 0)
George, thanks for your observations. My oncologist has described my PCa as being in the "favourable intermediate" group and shares your view that the clear Ga68 PSMA CT/PET scan provides a better predictor of long term outcomes than a nomogram.
I guess its all a bit of a crap shoot, but hopefully I get a decent run of years with little to worry about and who knows, in 10 years there may be a treatment based on genetics which will be a game changer for all of us?
Onwards & upwards!!!!
Posted 1/2/2018 10:56 AM (GMT 0)
George /Tall Allen, I guess the other thing that has puzzled me is why my PSA dropped from 30 to 25 in the space of less than 2 weeks? Also my biopsy report mentioned the presence of High Grade PIN and also "atrophy, acute & chronic inflammation".
Does the high grade PIN etc. affect the PSA level?
Posted 1/2/2018 6:04 PM (GMT 0)
The HGPIN as no effect, but the acute and chronic inflammation is the culprit. Prostatitis can be a large source of PSA, which goes up and down as it relapses and remits. Your prostatitis may be an ongoing source of PSA bounces, so expect that.
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