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Sisira

Should I start early chemotherapy?

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Sisira

This is very encouraging for me.

I was diagnosed in February 2015 at the age of 68 with no PCa related symptoms but with elevated PSA of 11.7ng/ml. Needle biopsy confirmed PCa of GL 9. I underwent open RP in March 2015. Post surgery staging : T2c No Mx, GL 4+5=9 and positive surgical margin. 3 weeks after surgery PSA fell undetectable, yet I underwent IMRT and ADT with 50mg Bicalutamide added alongside for a period of 2 years ( continuous protocol ) completing in end April 2017. Throughout this treatment period up to now my PSA checked every 3 months has remained at 0.008ng/ml. My treatment has been adjuvant and not salvage.
According to Gim's article I can be very optimistic about my prognosis and most likely to pass 15 years of recurrence free survival when I come off the present treatment regimen.
But according to the information I have, it is very doubtful because the treatment with ADT + antiandrogen can only suppress the disease progression whereas Radiation treatment is only localized ( focal therapy ) though curative. But the fact remains that there could have been microscopic cancer cell leakage into my blood and lymphatic systems even before surgery whilst the tumour was within the the capsule of the prostate gland ( micro metastasis ). Higher the GS the more will be this vulnerability.
Therefore I am contemplating seriously to go for an early cytotoxic whole body treatment to kill all hidden microscopic cancer cells before they could launch their attack on me. What I really mean is to go for a big hit with Chemo Therapy up front, although my PSA has remained undetectable.All hormone therapies are only palliative and they fail sooner or later and too much dependence on them can deprive us with the early opportunities of taking curative treatments or pushing the cancer into a stable and long term remission.
I would appreciate very much if the wise men in this advanced PCa group comment on my above view points.
 
Sisira

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JimJimJimJim

Sisira

Jim Marshall (not a doctor) said ...

You were referring to the article:

 

If prostate cancer comes back after surgery, adding hormone therapy to radiation helps

 

In this article it is reported that men whose treatment was somewhat similar to yours only had 5.8% chance of dying in the first 12 years.

So, hopefully, you have a low chance of prostate cancer death in the next 12 years.

Early chemotherapy treatment for men with no symptoms has not been found to help. Trials suggest it only helps when there are significant metastases are present.

So, when your doctor advises you to check your PSA regularly, but get on with your life, that is probably good advice.

Exercise and good food may well be the only treatment you need from now on.

And if in the future your PSA increases, there will be a number of options for you before chemotherapy.

 

... end Jim

 

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Charles (Chuck) Maack

Hello Sisira,

You bring up a consideration looked into more often over the past few years whether bringing on chemotherapy in company with ADT medications earlier than absolutely necessary will provide sufficient extended survival to put up with the side effects that can accompany chemotherapy.  You have done well with current PSA 0.008ng/ml as the result of surgical removal, IMRT, and ADT as monotherapy with only the antiandrogen bicalutamide/generic of Casodex.  I can relate with your continued wondering if you should do more than you have to date, but if you have been keeping cancer growth/proliferation under control (as you have), the consideration of bringing on early chemotherapy and the toxicity of docetaxel/Taxotere is questionable; particularly since your metastasis, if present, is apparently low volume.  This article best describes the results of such treatment so can serve as a guide whether there is any merit moving to chemotherapy now rather than waiting to see if ADT with more recent medications now available (Zytiga/abiraterone – Xtandi/enzalutamide) can provide you extended survival prior to the need to move to the more toxic docetaxel/Taxotere chemo medication:  http://tinyurl.com/hvgsp8q

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Sisira

Dear Jim and Chuck,

Thank you very much for your appearance to clear my doubts.

I can find no better mentors/advisers than you with such vast knowledge and experience on this subject.

I am fully aware that chemotherapy ( Docetaxel ) is the standard treatment protocol for CRPC when all the other hormone therapies fail including the latest drugs such as Zytiga and Xtandi. And at this stage in treating PCa, chemo therapy won't be of much use and its toxic effects can be more serious on the patient who has become much unhealthy and weaker by taking various treatments over a considerable period of time.

I would appreciate if you could kindly give simple and direct answers to my following questions :

1. If at all I have micrometastases hidden in my body at this time despite the treatments I have taken ( I believe I may have, based on my risk profile although the PSA is undetectable ) , the cancer burden/volume must be the minimum and the least aggressive ( almost dormant ). Is it correct?

2. Can't I take this as the best opportunity to destroy the smallest volume of cancer cells, now weak/dormant using a cytotoxic treatment such as Docetaxel and wipe them out?

3. Side effects of chemotherapy - Docetaxel are well known and can be tolerated by most if healthy and well prepared.

 So why wait until the cancer becomes CRPC, health deteriorating and struggle to a painful death ? At this stage the cost of drugs too will be colossal!

I am more particular about your answer to my 2nd question - Is it not possible to wipe off completely the minimal volume of PCa now present in my body ( somewhere if there is ) with a well planned 6 cycles of Docetaxel given right now? I can look after the side effects.

Sisira

 

 

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JimJimJimJim

Sisira

The evidence is not yet available to support chemotherapy in high risk patients before metastases are seen.

It seems from the incomplete evidence we have that it may delay progression, but not extend life.

A discussion of the unclear state of the art can be seen here:

http://www.medpagetoday.com/clinical-context/prostatecancer/61476

The position may change as we get more survival data over time from the studies mentioned. 

Jim

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Sisira

Thank you very much Jim.

The position with regard to my case and the specific question is very clear from the web article you have quoted.

I think it is not advisable to jump the gun for benefits not proven as yet. Besides under favourable prognostic conditions of my case.

Sisira

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