Question on Zoladex

[Mav]

My husband was diagnosed with Prostate Cancer last October 2018.How long will Zoladex work as Primary Treatment

2018 he had  TURP, cancer found in prostate,lymph nodes in groin.right and left hip joint.area going down right leg,small area near right ankle and in T10 in spine. February this year he had one treatment of Docetaxel unfortunately that made him very ill was in hospital for a week in isolation,so at this point of time no more chemo,

PSA level was point 7 three months ago....so that seems quite low from which i understand is very good

Next Injection is in a week....so anything we should be asking oncologist next visit

Will add my husbands health seems O,K, at moment...but his history is 

20 years ago a stent...December 2017 heart attack blockage is small artery unable to place stent as other arteries are thinning and hardening with calcium.he also has Rheumatoid arthritis that`s under control with Methotrexate

What can we expect in future if Zoladex stops working or if it can work for many years...

 

[Charles (Chuck) Maack]

Hello May,

Recognizing from your explanation the extent of metastases, your post is a difficult one to provide an adequate answer.  Perhaps chemotherapy at a reduced dosage might help, though I suspect his treating physician is having second thoughts.  Hard line is that with the extent of metastases Zoladex or any LHRH agonist or even the antagonist degarelix/Firmagon is unlikely to have a long effect.  Chemotherapy with docetaxel is the usual route with extensive metastases, and as I remarked, discussion with his oncologist whether reduced administration of docetaxel might be considered.  What comes to mind in reading the other health issues your husband has and is experiencing, particularly his heart issues, is the concern that any androgen deprivation drugs may have on his well-being.  Of important awareness are these other issues for which to be concerned taken from one of the papers I have written:

Recognizing that ADT has an effect on bone health as well as contributing to osteonecrosis of the jaw, imaging should be performed with Quantitative Computerized Tomography (QCT).  QCT imaging can distinguish vascular calcifications and degenerative joint disease as not being bone, thus providing a more accurate bone mineral density (BMD) result.   The supposed “Gold Standard” Dual-Energy X-ray Absorptiometry (DEXA) imaging falsely reads calcification and calcium in blood vessels close to bone as being bone density, giving the false impression that all is well when it is not.  Whether or not the imaging identifies bone issues, treatment to prevent issues occurring should commence with ADT.  Understanding these issues and recommendations for treatment can be reviewed here: https://tinyurl.com/3m78ymg.

 

PLEASE NOTE: Medications involved in Androgen Deprivation Therapy (ADT) are known to increase cardiovascular risk.  Thus, IT IS IMPORTANT that prior to prescribing any form of ADT medication the patient’s other health issues, that would include already present cardiovascular issues, are determined.  As noted in:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516188/  

 

“Androgen deprivation therapy (ADT) has been the mainstay of treatment for advanced prostate cancer for decades and has been shown to control disease and improve symptoms. In addition, for men with high-risk localized or locally advanced prostate cancer, short-course ADT in combination with radiotherapy improves survival. There is evidence that ADT increases cardiovascular risk, particularly in men with preexisting cardiovascular disease. This increased risk may apply even with short-course ADT. In an individual patient, the benefits of ADT should be balanced against the risk, and patients who require ADT should have risk factors for cardiovascular disease optimized. There is some evidence to suggest that more contemporary methods of delivering ADT may reduce cardiovascular risk.”

 

Dr. Matthew Roe, a Professor of Medicine at Duke University’s Clinical Research Institute (DCRI), the Faculty Director of the Global Outcomes Commercial MegaTrials program, and the Director of their Fellowship Program, remarks: “If a patient who has advanced prostate cancer and known cardiovascular disease is being considered for androgen deprivation therapy, it is important that he speak with his cardiologist. (Presumably, both a cardiologist or cardiovascular specialist and a urologist or oncologist would treat him.) He needs to ensure that all the providers have a discussion about what the best and safest treatment would be before therapy begins. Obviously, this trial (the PRONOUNCE trial regarding which is safer for patients with cardiovascular issues, the GnRH agonist Lupron or antagonist Firmagon (or neither?) https://tinyurl.com/yxnw5kb6 ) is not completed yet so we don’t have any answers. In the meantime, it is certainly in the patient’s best interest to ensure that his providers are communicating and trying to jointly determine the right approach.”

 

I wish I had more positive answers to your concerns.  As I noted as I started this post, "Recognizing from your explanation the extent of metastases, your post is a difficult one to provide an adequate answer." Importantly, your husband's cardiologist, and any other physician treating our husband for any condition, should be informed and should be in contact with your husband's oncologist to work together in determining the best strategy of treatment given these several health issues.

 

[Mav]

Thanks Chuck for your reply. 

Yes oncologist has referred to heart specialist. As originally when prostate caused problems TURP couldn’t be performed as he was on Brilinta (blood thinner ) heart specialist wanted him to stay on it for 12 months but finally agreed he could come off it after 10 months.  

They did at first think they would reduce the Chemo but after his oncologist reading all the emergency reports of hospital. And seeing the rash my husband had down legs and face. Decided not to proceed at this time with anymore. 

 

All I can do I guess is hope and pray things keep working for few years so he can see our grandchildren all reach teenage years. 

[Charles (Chuck) Maack]

With your husband experiencing coronary artery disease, this, too, becomes an ailment requiring close attention.  This paper by Mayo Clinic here in the U.S. describes this condition, how it is checked, treatments, and, also importantly, past daily practices that may have been your husband's norm now having to be changed. https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/diagnosis-treatment/drc-20350619.   I know this must be a burden on you, May, and just know that we readers on this forum deeply appreciate those spouses and loved ones who take charge and reach out to seek better understanding of health issues - in this case more than just prostate cancer - in order to help make certain treating physicians are providing appropriate attention and treatment to their spouse or loved one.  I suspect that even if we were physicians who are skilled in treating prostate cancer, we would not have enough knowledge to encompass all that must now be closely reviewed, monitored, and made certain that whatever treatment is determined; so many competing issues must be included to make certain this or that drug is not counter to one or the other drugs that could then add to worsening current conditions.  Never give up hope, and it is at least somewhat comforting to know that your husband is currently not experiencing any undo distress.  Feel free to enter this forum anytime with any questions that may come up regarding your husband's prostate cancer, and for that matter any other health issues.  We have participants here who delve into research and study of more than just prostate cancer, and several who are pretty good in research for most any issue - as I tried to do here regarding your husband's other health issues. My email, if interested, is maack1@cox.net. 

[Mav]

Thank you Charles...I have been reading this Forum for couple Months...it has been a Help in understanding Prostate Cancer...

Yes my husband is not in any pain...so that is a good thing...he walks everyday...to keep bones and heart as healthy as possible...only discomfort he has is the hot flushes...but copes with them now...

Will say this Forum was great help in asking questions...i made list from others and asked the Doctors...His Gleason score was 4+3=7 

PSA..was originally 144  so yes this Forum helped me a lot 

Thank you  

[Geoff Buttfield]

Hi Mav

Still here after 8.5 years, (PSA- 50 @ 50yrs old, Gleason 4+3, Biopsy 12/12)

Stay Active, Keep learning, Ask Questions. 

Perhaps (since chemo is out) a Radiation Oncologist may be able to assist keeping the monster at bay.

Geoff.   

[Patrick Turner]

11 hours ago, Mav said:

2018 he had  TURP, cancer found in prostate,lymph nodes in groin.right and left hip joint.area going down right leg,small area near right ankle and in T10 in spine

Hi Mav,

It is always unknown how long ADT with Zoladex or Lucrin, Lupron, Eligard etc will suppress the Pca progress.

But that's about all it seems to do, suppress by slowing down the life cycle of Pca cell cells, life, so its like putting the Pca into a kind of coma. But even while sleeping, the Pca mutates to be able to grow fast without normal levels of testosterone. I had 6 years of ADT suppression, but recently a friend died because his Pca could only be suppressed by 3 months, and many other things did not work including 10 shots of Docetaxel chemo.

After my Psa began to rise above 5 after my ADT suppression period, I had additional IMRT to PG to increase total RT to 101Grey. I'd had 70Gy in 2010 as primary treatment for Gleason 9, Psa at 8.8, with no mets found, which means there probably were many mets, but too small to be seen in scans. My Pca at PG was inoperable, too much Pca outside capsule.

So in 2016 I got PsMa Ga 68 scans which can show mets about 2 years before any CT at that time. In 2017, another PsMa scan showed bone mets and soft tissue mets. I extended testosterone suppression with Cosadex, and Zytiga from 2016 to 2017, but these did not stop an increase of mets being seen in scans. I had 4 shots of chemo, and it made things worse, Psa went from 12 to 45, so doc said it had failed, so I was allowed to buy Lu177 therapy that had arrived in Australia ( where I live ) While waiting for the Lu177, I had a 5th Doca shot but Psa went to 50. But there was a month between last chemo and first Lu177 last Nov 2018, and Psa went to 25. So maybe chemo did something, but nowhere near enough as far as I was concerned. So now after 4 shots of Lu177, Psa is under 4.0, and after No 3 shot, docs put me on Xtandi, enzalutamide, because they said that the chemo plus first Lu177 shots would have made my Pca more sensitive again to hormone blockade / manipulation with and also make it more likely to be killed with the 4th Lu177 shot, so I am expecting a quite low Psa in a few weeks time, and maybe the docs will tell me there's no need for a 5th Lu177 shot. There is is now time for me to have DNA analyzed and then docs might choose their best known drug for whatever Pca cells have not been killed by the Lu177. But not all men respond so well to Lu177. Its not a permanent fix. But side effects for me with all these many treatments I have had so far have been tolerable, and even with chemo, the first week was bad, just feeling awful, but by next chemo I could ride a bicycle 20km across town to hospital to get chemo and I was the healthiest stage 4 cancer patient that attended the hospital, mainly because although I was diagnosed too late for an RP, because I had low Psa for a massive amount of Pca at PG, I insisted docs get on with things as quick as possible, and I'd pay whatever costs happily. But I was diagnosed at age 62, and so fit I could cycle 150km a day with many men half my age struggling to keep up. I am now nearly 72, and Psa is less than 4, and last scans showed no new mets and soft tissue mets negligible, and bone met growth seems to have stalled, so I think I have had a lot of luck so far because until 3 months ago I was cycling 10,000km a year, and able to do a good life, positive while facing possible death any time soon. I have a sore hip now but docs are already saying they can maybe fix that if I get the Pca under control - enough. This means if it looks like I'll live another few years without becoming bedridden with Pca effects, they'll do a hip replacement if need be and they say there is no reason why I could not continue to cycle. In early 2017, when Psa has gone to a low of 0.5, I had both knees replaced. That kept me off the bike for 10 weeks, but I walked a lot with crutches before walking without them, then got on bike and I spent a fabulous 5 months back with a cycling group who did 85km rides on a Sunday. But at that time I was on Zytiga that gave me heart rate  bothers when the day temp went above about 28C so I'd ride alone from 6am on and be home before it got hot. So now though, I can't do much vigorous exercise, but I hope to if its possible in months ahead. My example of how to live with Pca is somewhat exceptional, and for many who are older and with a less robust health profile it could never be the same.

If your husband's Psa goes to real low, say les than 0.2, and stays there for a few years, then maybe he will cope fine with living, but when it rises, he may have Zytiga or Xtandi added to the ADT which might extend the Psa suppression period by maybe a year or more. But while Psa > 5, then its not a bad idea to have him get a PsMa Ga scan to maybe see the fuller extent of his mets. If his mets all show up in PsMa Ga68 scan, its likely that Lu177 treatment will work. Side effects for me with Lu177 were far easier to tolerate than chemo. My doc said one patient of 90 where I live in Canberra drove 300km to Sydney to get his Lu177, which meant about 4 hours sitting in a chair with a canula. Then he drove home same day. OK, a long day for any of us, but that's how some folks cope. I could have done that, but I travelled by a slow train and stayed a couple of nights with my sister in Sydney with whom I get on OK.    

When my initial treatment of 2 years ADT + 70Grey of ABRT failed, I asked my urologist to transfer me to an oncologist to "see me out", and this man said I'd have to stay on ADT for life, and that Pca would kill me if nothing else did, and there was no cure, and he had no idea how long I had, so I said "well how about between 2 years and 20 years?" and he just said, "maybe" and here I am, 10 years after diagnosis. My Pca probably began when Psa was 3.0, about 5 years before diagnosis in 2004. My Pca variety seems to be a slow growing but aggressive killer. 

I'd had yearly Psa tests, and was told as long as Psa was under 5.0, there was no problem and an RP could be done to cut out the Pca before any spread. That was pure bullshit because many men like me will have spread by the time they are diagnosed and although they have an RP that is deemed to be successful, a year or two later the Psa rises, and they then have a fight like mine for many years that can cost a truckload of $$$$ and time.

Men who'll never have Pca, and there are plenty of them, will have Psa >0.7 at 40, > 1.0 at 60, and yet docs say a "normal range of Psa is between 0.55 and 5.5" - more bullshit. If a man has Psa 2.5,he should move heaven and Earth to get a biopsy and have an RP asap, even if no Pca is found especially if most men in his family get Pca when they get old. This does not apply to your husband, but I mention it because other ppl read the posts here because those who are intelligent should expect some bad health diagnoses to occur in the course of their middle age and post middle age. I saw so many die around me from Pca; none thought they'd get it but they did, and once anyone goes over 40, he or she is just not going to live forever, and things will come along to reduce our expectations. 

Its a nice cold sunny day here, and its time to get lunch at my favourite café.

Take care and I hope for the best for your man,

Patrick Turner.  

[alanbarlee]

Hi Mav,

 

With Oct 2018 PSA at 144 and Gleason grade at 4+3, Zoladex has done well in dropping PSA down to the latest level of 0.7. PSA doubling time (PSADT) is an important measure to watch: anything less thn 10 months becomes important, and 3 months or less is a clear signal for a review of treatment. I wonder if a PET, CT or bone scan (hopefully for comparison with a corresponding scan done when the mets were found) would be worth a look, to assess the effect of the combined treatments so far.  

The concomitant use of docetaxel with ADT in cases of intermediate or high risk metastatic disease has become standard of care, following important clinical trials. A possible alternative to docetaxel is cabazitaxel (Jevtana), which, although still a taxane,  it has a different side effect profile to docetaxel. PBS eligibility should not be an issue, since the latter drug clearly was clearly not tolerated. To minimise the risk, a low dose might be tried at the outset. Ask your medonc about the pros and cons.

 

Given the chemo intolerance issue, another possibility could be abiraterone (Zytiga) plus prednisone, or enzalutamide, in conjunction with the Zoladex. There is also good trials evidence of the efficacy of this approach, and if your medonc thinks there may be benefit in this approach, this option may also be available under the PBS.

 

Finally, there are clinical trials with the very promising lutetium-177 (e.g. THERA-P), and your medonc may need to consider eligibility issues earlier rather than later, if this option is to be pursued. A key pre-test is the very sensitive gallium-68-PSMA PET scan, to check that PSMA uptake is positive.

 

Clearly, in spite of there are a lot of possibilities that can help to keep your husband alive and well for along time to come. I congratulate you on you advocacy on his behalf.

 

Best wishes,

 

Alan  

[DavidAbrahams]

Hi Mav,

I was diagnosed nearly 11yrs ago in July 2008 and treated with Zoladex initially with the implant every 3 months then changed to intermittent therapy after 12 months. commencement PSA was 138 and by Feb 2009 it was hovering between 2 & 3. In Feb/ Mar 2009 I had radiation therapy for pain management. (Pelvis and right shoulder).

On diagnosis I was advised that there was no cure for Prostate Cancer, let alone Advanced Metastatic Prostate Cancer and that the ADT would only slow the disease progression. Unfortunately here in Australia there is no uniform treatment for PCa and it basically comes down to the experience and knowledge of the treating Urologist or Oncologist, also the type of Prostate Cancer. Another important factor is the impact of side-effects as everybody responds differently to the treatment.

I have had a great 10/11yrs considering I was given 3yrs to live on diagnoses because of the aggressive nature and type of prostate cancer. Have seen both sons happily married and now have 2 great daughters-in-law and 4 fantastic grandchildren, 2 boys 2 girls. Still enjoy a wee dram and good red wine. 

On the downside I had to give up work about 5yrs ago because of the impact of side effects. Still walk most days and go to Hydro therapy twice a week if I'm able.

All the very best to you both. Any questions please do not hesitate in contacting me.

David

 

[Mav]

Thank you all for your reply’s.  I now have couple of more things to ask his Oncologist next week. 

Especially of further treatment if current one fails. That has been my greatest fear. What happens if does 

now I know there is more options. 

[alanbarlee]

Mav - one other thing to add to your list of items to review with the medonc is the need to monitor and protect bone health while on androgen deprivation - especially if supplemented with second generation hormone blockade like abiraterone or enzalutamide. A DEXA scan to measure bone mineral density is important to get done early in the treatment journey as a baseline. Any tendency to osteopenia or osteoporosis that may be induced by low testosterone, or worse, the risk of spinal compression that loss of bone and vertebral metastases can exacerbate, can often be effectively managed with denosumab (RANK ligand inhibitor)  or 'Zometa' (bisphosphonate), both of which strengthen cortical bone, if administered early.

 

The list gets longer - but that's a good thing!

 

Alan   

[Mav]

Thanks Alan,

Will add that to my list

He does have Rheumatoid Arthritis and is under specialist for that,,,But will ask about bone density now as well...seeing he has it in T10 in spine...Oncologist did say originally no sign of spinal compression at first diagnosis

 

[Mav]

I applaud you all so much...You have been through so much already...you are all fighters.

Hope you all have continual good prospects with your treatments

I can see my husbands journey is not going to be short lived (i hope)

I will fight for him to get a lot of years survival yet

Have to make our 50th Wedding anniversary only 3 Years to go..

Good luck to you all...i will let you know of his progress..

Thank you again for your information...

[Mav]

Update on my husband

He visited the Oncologist last week

I asked about heart and Zoladex he said there is a risk but mainly if a person puts on to much weight and doesn't keep relatively fit..and diet is important...So husband is doing O.K. on all those things

His P.S.A. was .04 this time so has reduced further...I also asked whats next if Zoladex stops working....he said they have another option a pill...he didn't say the brand..or type

Future Chemo is unlikely as even if they reduce the dosage he had such bad reaction to first one all chemo apparently have the same profile..Was discussed with heart specialist and she thought not a good idea...

He is testing for some Mutant Gene..and if he has the gene there is another treatment he can go on in future..Husband still does't have any pain still walks everyday...Yes will have further scans to see how Mets are going...I also ask that...

Doesn't have to go back now till August so i'm thinking that is a good thing...

 

[alanbarlee]

All good, Mav!

Alan

[Mav]

Haven`t updated since my very first post...Husband is still having Zoladex P.S.A.  hasn`t risen or gone down...so nothing has changed since my last post

He has been to heart specialist..Heart good well as good as expected

Also Arthritis specialist his Rheumatoid Arthritis also under control

He is a bit Anemic only 2 points below so nothing to worry about apparently..Feb injection will be his 6th,,

Next injection is not till Feb 2020...so all is looking good at moment...

He had test for some mutant gene...but doesn't have the required Gene for that treatment...so that is off list for future

So I am optimistic now for a good future ,we will make our 50th Anniversary in 3 years,,,,

[alanbarlee]

Good news, MAV - thanks for keeping us posted.

 

Could you let us know what mutant genes were the subject of the test, where it was done, and what was the cost? (Genetic testing is likely to grow rapidly in the future).

 

Many thanks,

 

Alan  

 

 

 

 

 

[Mav]

Hi Alan....Will have to find papers that were signed to answer you....It was at Box Hill Hospital...Thats where samples from TURP were collected and sent overseas...plus blood sample  Have not had chance to look

The last few weeks...My husband has had to have 4 skin Cancers burnt off face..

He has to also go 30th December for scan on lower neck as he has a lump...Oncologist is not sure what it is...

On 2nd Jan...he has to go to see a surgeon as he seems to have a Melanoma on side of body..or something that looks like one...I know these things are not connected to his prostate cancer...it has been busy time getting these things seen to...Will catch up soon with life and find all my papers.......Christmas is nearly here....Merry Christmas to you....