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Suggest Ideal Treatment For Prostate Cancer
Question: Dear Doctor,
Brief:
My father, aged 84, diagnosed prostate cancer after biopsy in Sep 2014. 8 out of 12 specimen positive (4 of 10-20%, 3 of 40-50%, 1 of 60%), all XXXXXXX score 3+3. Doctor said stage 2.
PSA: 12 July 2014 (20.9), 16 Oct 2014 (16.7), 26 Nov 2014 (18), 2 March 2015 (0.06, after 1st ADT shot on 18 December 2014), 20 Apr 2015 (should be 0.06, but not very sure as this level is mentioned by doctor during end Apr consultation, not sure if he has mistakenly read the level of 2 March)
MRI (end Oct 2014) – no metastasis
Bone scan (end Nov 2014)- clear
Flutamide from early Dec 2014 to mid March 2015, 1st 3-monthly ADT shot in mid Dec 2014.
Scheduled radiation therapy (IMRT) in mid-Apr 2015 following androgen deprivation therapy (ADT) shots starting from mid Dec 2014. RT suspended for the time being due to anemia problem found in early March 2015.
Medical history - hypertension, renal impairment, heart disease (pAF, mild AR/TR/PR, LVH, normal LV systolic function and size), gout, TIA in late 2008, insomnia/anxiety followed up by Psy, dementia (features of AD + small vessel disease) diagnosed 4 years ago (now mild to moderate), also enlarged prostate. On long term medication.
Down trending platelets of 150k since 4 years ago
We now need advice on choosing treatment options of PCa ahead
Details:
My father has down trending platelets of 150k since 4 years ago, recently around 100k. Has macrocytic anemia since Feb 2015, after his first injection of ADT shot in mid Dec 2014. His pre-ADT Hgb in Nov 2014 is 14.5 but dropped significantly to 9.5 in mid Feb 2015. Because of this anemia issue, we stopped his 2nd ADT shot and Hgb then improved slightly to 10+. His RT is also held up for the time being for investigation of his anemia problem. Other tests for anemia e.g. serum B12, folate, lactate dehydrogenase (LDH) are normal, but he has hypersegmented WBC. He also has high MCV (rang from 103 – 107 since mid Feb 2015). His creatinine level has always been high for several years and is about 180+ currently. Doctor said that impaired renal function can cause anemia. But since his Hgb has always been within normal range despite high creatinine, I wonder why suddenly there is such a sharp drop. Could it be due to ADT or my father has bone marrow disease? Our doctor (internal medicine) did not suggest bone marrow biopsy for the time being as he said even if my father has MDS or other bone marrow disease, he cannot tolerate the treatments and hence not much can be done. On the other hand, the oncologist said that his PCa needs to be treated, and we can choose RT for curative purpose or just ADT in view of his medical history. The decision is left to us. However, the urologist seem prefer more conservative treatment of ADT or even watchful waiting. Different doctors have different opinions.
We are now stuck in making treatment decision for PCa. We initially chose RT because we want “cure” as we primarily do not want father to suffer from great pain at the cancer terminal stage (not because we expect his life expectancy would be more than 10 Years). But now the anemia problem pops up, we are in a dilemma and hesitant whether to proceed with RT, which seems to be a more aggressive approach than ADT. However, ADT seems to have quite some side effects on my father (he felt rather tired, lost some muscle mass after the first ADT shot, and I thnk may partly account for his anemia). If we choose RT, we are afraid that it may suppress his bone marrow and further worsen his anemia problem, or even trigger bone marrow disorder or aggravate it if he actually already has bone marrow disease. We also worry that the side effects of RT (e.g. urinary stricture, urination urgency, incontinence, bladder or rectum inflammation etc.) may persist and impact his quality of life. If we choose ADT without RT, we worry about the side effects of continued ADT. Our thinking is that if he really has bone marrow disease, we would choose more conservative treatment options such as ADT or active surveillance rather than RT. Our primary consideration in choosing the treatment option is to prolong his life expectancy with quality of life, not simply seeing him live longer. We hope that his PCa could be kept under control for 5 to 6 years with quality of life.
My questions are -
1. Could it be the side effect of ADT causing my father’s sharp drop of Hgb from 14.5 to 9.5?
2. Because of his high MCV and hypersegmented WBC, we worry that he may have bone marrow disorder like MDS. Is it possible that ADT could trigger bone marrow problems?
3. What is the likelihood of RT suppressing bone marrow, and the likelihood of triggering bone marrow problems? Our doctor said his RT will be confined to prostate only, not the whole pelvis.
4. What is the probability of RT causing secondary cancer?
5. If we proceed with RT but cannot be completed (e.g. my father cannot tolerate side effects, or his health conditions do not permit), would it be even worse than if RT is not started at all? Would RT alter the biology of the cancer cells and if RT is not completed, the cancer cells will become more aggressive or spread even faster?
6. If my father get sick in the mid of RT, e.g. get flu, severe cough, neutropenia, etc, can RT be held up for him to recover first and then resume RT after recovery?
7. I understand that usually one will become refractory to ADT after about 2 to 3 years. But is it not uncommon that ADT can be effective for a much longer period, say 4 to 5 years?
8. Taking into account my father’s PSA readings, XXXXXXX score of 3+3, non-metastasis, can ADT keep my father’s disease under control for quite some time, say 5 to 6 years?
9. We worry that RT may suppress his bone marrow or trigger bone marrow disorder. Doctor said this is unlikely as the radiation is locally confined to prostate only. We also worry about secondary cancer of RT as well as other side effects. Though doctor said secondary cancer is very rare and other side effects are often temporary and will subside some time after completion of RT, we still have concern given my father’s age and medical history. However doctor seemed not worried and said that he never saw any patient (including elderly) not able to complete RT and gave up in the mid way. Are we over-worrying? Can you give some advice based on your experience with so many patients?
10. On the other hand, we also worry about the side effects of continued ADT, and so the idea of intermittent ADT or active surveillance come up in my mind. Is intermittent ADT a possible approach for my father?
11. Is it possible to adopt active surveillance approach now despite having one ADT shot? My father already had one shot (3 monthly) for ADT and pending investigation of the anemia problem, we have held up the second shot which should have been taken in mid March prior to RT originally scheduled to start in mid April. If we now adopt active surveillance approach, would the one shot have already “stimulated” or “altered” the biology of his cancer cells in such a way that the cancer cells will spread even faster or become more aggressive.
12. Is PSA a good indicator for metastasis? Which PSA level is a threshold indicating probable metastasis? If we choose ADT only without RT, can we, by monitoring the PSA level, proceed to RT if PSA level rise to a certain level? With XXXXXXX score 3+3, is it likely that the cancer cells will grow slowly so that we have more time to observe before rushing to treatment?
13. At age 84 what are the estimated life expectancy (assuming no other lethal conditions come first) under the following scenario
a. Do nothing = estimated years left
b. ADT = estimated years left
c. RT (EBRT) = estimated years left
14. We are very hesitant and doctors are not patient enough to a listen to and address our views and concerns. . The oncologist doctors focus only on PCa issues. No doctor takes a holistic approach to carefully evaluate my father’s overall health conditions and gave advice based on overall assessment. What would be your recommended treatment ahead in view of my father’s clinical conditions and our views/thinking and concerns mentioned above? What are your suggested way forward and actions to be taken if you were in our place?
Any other advice and insight would definitely be also helpful to us. Thanks a lot.
Brief:
My father, aged 84, diagnosed prostate cancer after biopsy in Sep 2014. 8 out of 12 specimen positive (4 of 10-20%, 3 of 40-50%, 1 of 60%), all XXXXXXX score 3+3. Doctor said stage 2.
PSA: 12 July 2014 (20.9), 16 Oct 2014 (16.7), 26 Nov 2014 (18), 2 March 2015 (0.06, after 1st ADT shot on 18 December 2014), 20 Apr 2015 (should be 0.06, but not very sure as this level is mentioned by doctor during end Apr consultation, not sure if he has mistakenly read the level of 2 March)
MRI (end Oct 2014) – no metastasis
Bone scan (end Nov 2014)- clear
Flutamide from early Dec 2014 to mid March 2015, 1st 3-monthly ADT shot in mid Dec 2014.
Scheduled radiation therapy (IMRT) in mid-Apr 2015 following androgen deprivation therapy (ADT) shots starting from mid Dec 2014. RT suspended for the time being due to anemia problem found in early March 2015.
Medical history - hypertension, renal impairment, heart disease (pAF, mild AR/TR/PR, LVH, normal LV systolic function and size), gout, TIA in late 2008, insomnia/anxiety followed up by Psy, dementia (features of AD + small vessel disease) diagnosed 4 years ago (now mild to moderate), also enlarged prostate. On long term medication.
Down trending platelets of 150k since 4 years ago
We now need advice on choosing treatment options of PCa ahead
Details:
My father has down trending platelets of 150k since 4 years ago, recently around 100k. Has macrocytic anemia since Feb 2015, after his first injection of ADT shot in mid Dec 2014. His pre-ADT Hgb in Nov 2014 is 14.5 but dropped significantly to 9.5 in mid Feb 2015. Because of this anemia issue, we stopped his 2nd ADT shot and Hgb then improved slightly to 10+. His RT is also held up for the time being for investigation of his anemia problem. Other tests for anemia e.g. serum B12, folate, lactate dehydrogenase (LDH) are normal, but he has hypersegmented WBC. He also has high MCV (rang from 103 – 107 since mid Feb 2015). His creatinine level has always been high for several years and is about 180+ currently. Doctor said that impaired renal function can cause anemia. But since his Hgb has always been within normal range despite high creatinine, I wonder why suddenly there is such a sharp drop. Could it be due to ADT or my father has bone marrow disease? Our doctor (internal medicine) did not suggest bone marrow biopsy for the time being as he said even if my father has MDS or other bone marrow disease, he cannot tolerate the treatments and hence not much can be done. On the other hand, the oncologist said that his PCa needs to be treated, and we can choose RT for curative purpose or just ADT in view of his medical history. The decision is left to us. However, the urologist seem prefer more conservative treatment of ADT or even watchful waiting. Different doctors have different opinions.
We are now stuck in making treatment decision for PCa. We initially chose RT because we want “cure” as we primarily do not want father to suffer from great pain at the cancer terminal stage (not because we expect his life expectancy would be more than 10 Years). But now the anemia problem pops up, we are in a dilemma and hesitant whether to proceed with RT, which seems to be a more aggressive approach than ADT. However, ADT seems to have quite some side effects on my father (he felt rather tired, lost some muscle mass after the first ADT shot, and I thnk may partly account for his anemia). If we choose RT, we are afraid that it may suppress his bone marrow and further worsen his anemia problem, or even trigger bone marrow disorder or aggravate it if he actually already has bone marrow disease. We also worry that the side effects of RT (e.g. urinary stricture, urination urgency, incontinence, bladder or rectum inflammation etc.) may persist and impact his quality of life. If we choose ADT without RT, we worry about the side effects of continued ADT. Our thinking is that if he really has bone marrow disease, we would choose more conservative treatment options such as ADT or active surveillance rather than RT. Our primary consideration in choosing the treatment option is to prolong his life expectancy with quality of life, not simply seeing him live longer. We hope that his PCa could be kept under control for 5 to 6 years with quality of life.
My questions are -
1. Could it be the side effect of ADT causing my father’s sharp drop of Hgb from 14.5 to 9.5?
2. Because of his high MCV and hypersegmented WBC, we worry that he may have bone marrow disorder like MDS. Is it possible that ADT could trigger bone marrow problems?
3. What is the likelihood of RT suppressing bone marrow, and the likelihood of triggering bone marrow problems? Our doctor said his RT will be confined to prostate only, not the whole pelvis.
4. What is the probability of RT causing secondary cancer?
5. If we proceed with RT but cannot be completed (e.g. my father cannot tolerate side effects, or his health conditions do not permit), would it be even worse than if RT is not started at all? Would RT alter the biology of the cancer cells and if RT is not completed, the cancer cells will become more aggressive or spread even faster?
6. If my father get sick in the mid of RT, e.g. get flu, severe cough, neutropenia, etc, can RT be held up for him to recover first and then resume RT after recovery?
7. I understand that usually one will become refractory to ADT after about 2 to 3 years. But is it not uncommon that ADT can be effective for a much longer period, say 4 to 5 years?
8. Taking into account my father’s PSA readings, XXXXXXX score of 3+3, non-metastasis, can ADT keep my father’s disease under control for quite some time, say 5 to 6 years?
9. We worry that RT may suppress his bone marrow or trigger bone marrow disorder. Doctor said this is unlikely as the radiation is locally confined to prostate only. We also worry about secondary cancer of RT as well as other side effects. Though doctor said secondary cancer is very rare and other side effects are often temporary and will subside some time after completion of RT, we still have concern given my father’s age and medical history. However doctor seemed not worried and said that he never saw any patient (including elderly) not able to complete RT and gave up in the mid way. Are we over-worrying? Can you give some advice based on your experience with so many patients?
10. On the other hand, we also worry about the side effects of continued ADT, and so the idea of intermittent ADT or active surveillance come up in my mind. Is intermittent ADT a possible approach for my father?
11. Is it possible to adopt active surveillance approach now despite having one ADT shot? My father already had one shot (3 monthly) for ADT and pending investigation of the anemia problem, we have held up the second shot which should have been taken in mid March prior to RT originally scheduled to start in mid April. If we now adopt active surveillance approach, would the one shot have already “stimulated” or “altered” the biology of his cancer cells in such a way that the cancer cells will spread even faster or become more aggressive.
12. Is PSA a good indicator for metastasis? Which PSA level is a threshold indicating probable metastasis? If we choose ADT only without RT, can we, by monitoring the PSA level, proceed to RT if PSA level rise to a certain level? With XXXXXXX score 3+3, is it likely that the cancer cells will grow slowly so that we have more time to observe before rushing to treatment?
13. At age 84 what are the estimated life expectancy (assuming no other lethal conditions come first) under the following scenario
a. Do nothing = estimated years left
b. ADT = estimated years left
c. RT (EBRT) = estimated years left
14. We are very hesitant and doctors are not patient enough to a listen to and address our views and concerns. . The oncologist doctors focus only on PCa issues. No doctor takes a holistic approach to carefully evaluate my father’s overall health conditions and gave advice based on overall assessment. What would be your recommended treatment ahead in view of my father’s clinical conditions and our views/thinking and concerns mentioned above? What are your suggested way forward and actions to be taken if you were in our place?
Any other advice and insight would definitely be also helpful to us. Thanks a lot.
Brief Answer:
ADT shoud be continued
Detailed Answer:
Hi
I have gone through the history and reports
ADT is causing the drop of heamoglobin as its side effect
ADT does not cause bone marrow problems
Chance of RT suppressing bone marrow is only 10%
RT does not cause secondary cancer
If RT is stopped then cancer can spread even faster
RT can be stopped for few days because of infection and can be started again within 21 days
ADT will be effective for 5 years
I would advise you to continue ADT
ADT can keep your fathers disease under control for 5 years since it is non metastatic prostate cancer
RT is very safe Side effects only occur in 15% of patients
Intermittent ADT is not a good approach
If active surveillance approach is adopted then biology of the cancer cells can change and will spread even faster or become more aggressive.
With EBRT life expectancy around 4 years
I will not advise active surveillance
PSA leve measurement is a good indicator for metastasis
If you do nothing then life expectancy is around 2 years
With ADT life expectancy is around 5 years
I will advise you to continue ADT
Side effects such as anaemia can be treated with packed red cell transfusion
I will advise you to consume pomegranate and broccoli seed extracts, green tea, herbs to prevent spread of prostate cancer
Regards
DR DE
ADT shoud be continued
Detailed Answer:
Hi
I have gone through the history and reports
ADT is causing the drop of heamoglobin as its side effect
ADT does not cause bone marrow problems
Chance of RT suppressing bone marrow is only 10%
RT does not cause secondary cancer
If RT is stopped then cancer can spread even faster
RT can be stopped for few days because of infection and can be started again within 21 days
ADT will be effective for 5 years
I would advise you to continue ADT
ADT can keep your fathers disease under control for 5 years since it is non metastatic prostate cancer
RT is very safe Side effects only occur in 15% of patients
Intermittent ADT is not a good approach
If active surveillance approach is adopted then biology of the cancer cells can change and will spread even faster or become more aggressive.
With EBRT life expectancy around 4 years
I will not advise active surveillance
PSA leve measurement is a good indicator for metastasis
If you do nothing then life expectancy is around 2 years
With ADT life expectancy is around 5 years
I will advise you to continue ADT
Side effects such as anaemia can be treated with packed red cell transfusion
I will advise you to consume pomegranate and broccoli seed extracts, green tea, herbs to prevent spread of prostate cancer
Regards
DR DE
Above answer was peer-reviewed by :
Dr. Pradeep Vitta
Dear Doctor DE,
Thank you for your useful advice. It seems that your recommendation is immediate resumption and continuation of ADT alone without RT, and not to consider active surveillance nor intermittent ADT approach. I don’t quite understand some points in your reply and want to clarify and know more details.
1. You said that ADT is causing the drop of haemoglobin as its side effect. As my father has macrocytic not normocytic anemia, our oncologists consider that it maybe due to possible bone marrow problem rather than ADT. Can ADT cause macrocytic anemia, and what is the likelihood? Do you suggest my father going for a bone marrow biopsy to find out anything wrong with the bone marrow?
2. Will continuous ADT has cumulative adverse effect on the anemia issue? With already a sharp drop after one ADT injection, will the Hgb level continue to drop further if my father resume ADT? Will the Hgb hover at a certain level without further decline?
3. You mentioned “If RT is stopped then cancer can spread even faster” “ and “RT can be stopped for few days because of infection and can be started again within 21 days”. What is the probability of spreading faster if RT is stopped in the mid-way? Or is a faster spread a highly likely consequence if RT cannot be completed? What would be the consequence if a temporary held-up of RT is more than 21 days?
4. You also mentioned “if active surveillance approach is adopted then biology of the cancer cells can change and will spread even faster or become more aggressive.” Do you mean that because my father has started ADT, this has already “stimulated” or changed the biology of the cancer cells such that discontinuing ADT will make the cancer cells grow faster or become more aggressive? Do you mean that once treatment has started, be it ADT or RT, the treatment cannot stop otherwise disease progression would be even faster than if no treatment has started at all?
5. You said “With EBRT life expectancy around 4 years” and “With ADT life expectancy is around 5 years”. Based on our doctors’ advice, life expectancy is probably longer with EBRT than with ADT, and that’s why one doctor recommended RT. Why do you think my father’s life expectancy with EBRT would even be shorter than with ADT?
6. You advised that ADT will be effective for 5 years in my father’s case. After ADT become ineffective, are there other treatment options available that are suitable for my father taking into account his age and medical history?
7. Why “Intermittent ADT is not a good approach”? Can this approach delay the time of becoming refractory to ADT?
8. You advised that for RT, side effects only occur in 15% of patients. Is 15% referring to temporary side effects which will subside a few weeks/months after competing RT? Or 15% refers to side effects that will persist for long? What is the likelihood of getting more serious complications such as urinary stricture that require surgery, permanent incontinence, serious bowel or rectum inflammation etc.? If RT is confined to prostate only, will the side effects be much milder and short term only, and what is the probably of experiencing long term side effects ?
9. My father’s current medication is shown in the attachment (medicines currently taking are circled) . Apart from those, he is also taking allopurinol for gout. Will pomegranate and broccoli seed extracts or green tea interact or interfere with these medicines?
For my better understanding, would appreciate very much if you could kindly give some details and elaboration of your considerations underpinning your advice/recommendations. We are keen to know more and get more expert advice to help us make informed decisions on the treatment ahead. Trust you would understand our feelings as a patient and as caregivers of our beloved father. Thanks a lot for your patience and attention.
Best regards
XXXX
Thank you for your useful advice. It seems that your recommendation is immediate resumption and continuation of ADT alone without RT, and not to consider active surveillance nor intermittent ADT approach. I don’t quite understand some points in your reply and want to clarify and know more details.
1. You said that ADT is causing the drop of haemoglobin as its side effect. As my father has macrocytic not normocytic anemia, our oncologists consider that it maybe due to possible bone marrow problem rather than ADT. Can ADT cause macrocytic anemia, and what is the likelihood? Do you suggest my father going for a bone marrow biopsy to find out anything wrong with the bone marrow?
2. Will continuous ADT has cumulative adverse effect on the anemia issue? With already a sharp drop after one ADT injection, will the Hgb level continue to drop further if my father resume ADT? Will the Hgb hover at a certain level without further decline?
3. You mentioned “If RT is stopped then cancer can spread even faster” “ and “RT can be stopped for few days because of infection and can be started again within 21 days”. What is the probability of spreading faster if RT is stopped in the mid-way? Or is a faster spread a highly likely consequence if RT cannot be completed? What would be the consequence if a temporary held-up of RT is more than 21 days?
4. You also mentioned “if active surveillance approach is adopted then biology of the cancer cells can change and will spread even faster or become more aggressive.” Do you mean that because my father has started ADT, this has already “stimulated” or changed the biology of the cancer cells such that discontinuing ADT will make the cancer cells grow faster or become more aggressive? Do you mean that once treatment has started, be it ADT or RT, the treatment cannot stop otherwise disease progression would be even faster than if no treatment has started at all?
5. You said “With EBRT life expectancy around 4 years” and “With ADT life expectancy is around 5 years”. Based on our doctors’ advice, life expectancy is probably longer with EBRT than with ADT, and that’s why one doctor recommended RT. Why do you think my father’s life expectancy with EBRT would even be shorter than with ADT?
6. You advised that ADT will be effective for 5 years in my father’s case. After ADT become ineffective, are there other treatment options available that are suitable for my father taking into account his age and medical history?
7. Why “Intermittent ADT is not a good approach”? Can this approach delay the time of becoming refractory to ADT?
8. You advised that for RT, side effects only occur in 15% of patients. Is 15% referring to temporary side effects which will subside a few weeks/months after competing RT? Or 15% refers to side effects that will persist for long? What is the likelihood of getting more serious complications such as urinary stricture that require surgery, permanent incontinence, serious bowel or rectum inflammation etc.? If RT is confined to prostate only, will the side effects be much milder and short term only, and what is the probably of experiencing long term side effects ?
9. My father’s current medication is shown in the attachment (medicines currently taking are circled) . Apart from those, he is also taking allopurinol for gout. Will pomegranate and broccoli seed extracts or green tea interact or interfere with these medicines?
For my better understanding, would appreciate very much if you could kindly give some details and elaboration of your considerations underpinning your advice/recommendations. We are keen to know more and get more expert advice to help us make informed decisions on the treatment ahead. Trust you would understand our feelings as a patient and as caregivers of our beloved father. Thanks a lot for your patience and attention.
Best regards
XXXX
Brief Answer:
2 or 3 units of blood transfusion will take care of anaemia
Detailed Answer:
Hi
ADT can cause macrocytic anemia in 15% of patients
There is no need of bone marrow biopsy
Haemoglobin will not drop to less than 7 gm/dl with ADT
2 or 3 units of blood transfusion will take care of anaemia
If RT is stopped to more than 21 days and cannot be competed then it will not work anymore and the cancer will spread faster
If ADT and RT is stopped suddenly then biology of cancer cells will change and it will spread even faster
ADT kills cancer cells faster than RT and it aso prevents it from coming back or stops recurrence and that is why life expectancy is more with ADT
After ADT stops working there is no other treatment option left other than RT
He will not be able to tolerate chemotherapy at his age
Intermittent ADT is not a good approach as cancer cells become resistant to it and there is chance of recurrence
15% is temporary side effects
5% side effects will persist for long
If RT is confined to prostate ony then side effects will be lesser
Pomegranate and broccoli seed extract will not interact with current medication
Regards
DR DE
2 or 3 units of blood transfusion will take care of anaemia
Detailed Answer:
Hi
ADT can cause macrocytic anemia in 15% of patients
There is no need of bone marrow biopsy
Haemoglobin will not drop to less than 7 gm/dl with ADT
2 or 3 units of blood transfusion will take care of anaemia
If RT is stopped to more than 21 days and cannot be competed then it will not work anymore and the cancer will spread faster
If ADT and RT is stopped suddenly then biology of cancer cells will change and it will spread even faster
ADT kills cancer cells faster than RT and it aso prevents it from coming back or stops recurrence and that is why life expectancy is more with ADT
After ADT stops working there is no other treatment option left other than RT
He will not be able to tolerate chemotherapy at his age
Intermittent ADT is not a good approach as cancer cells become resistant to it and there is chance of recurrence
15% is temporary side effects
5% side effects will persist for long
If RT is confined to prostate ony then side effects will be lesser
Pomegranate and broccoli seed extract will not interact with current medication
Regards
DR DE
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Dear Dr. DE,
Thanks a lot for your quick response. We just learnt that the latest PSA readings are - 20 April 2015 (0.03), 30 May 2015 (0.03)
PSA readings:
12 July 2014 (20.9),
16 Oct 2014 (16.7),
26 Nov 2014 (18),
2 March 2015 (0.06, after 1st ADT shot on 18 December 2014),
20 April 2015 (0.03),
30 May 2015 (0.03)
In view of this latest two readings, one oncologist strongly suggests active surveillance at this stage. His views is that as my father’s PSA level has not rebounded despite stopping ADT since mid March and his XXXXXXX score is 3+3 without metastasis currently, plus his age and medical history, he suggests we can wait and watch the PSA trend. (My father had his first 3 -monthly ADT shot in mid Dec 2014 and has taken flutamide from early Dec 2014 to mid March. We held up 2nd ADT shot and stopped flutamide since mid march because of anemia problem.). Doctor said if PSA rises quickly or reaches a high level say greater than 10 or 20, we can then re-start ADT. He also said that it may not be necessary to take LHRH injection continuously in my father’s case. He also said that it is possible to take antiandrogen pills only, rather than having injection.
What do you think this suggested approach in the light of my father’s latest PSA readings? Worth trying to monitor PSA levels for a period of time, say at least 3 or 6 months to see the trend before deciding to re-start ADT now? Many thanks.
Best regards,
XXXX
Thanks a lot for your quick response. We just learnt that the latest PSA readings are - 20 April 2015 (0.03), 30 May 2015 (0.03)
PSA readings:
12 July 2014 (20.9),
16 Oct 2014 (16.7),
26 Nov 2014 (18),
2 March 2015 (0.06, after 1st ADT shot on 18 December 2014),
20 April 2015 (0.03),
30 May 2015 (0.03)
In view of this latest two readings, one oncologist strongly suggests active surveillance at this stage. His views is that as my father’s PSA level has not rebounded despite stopping ADT since mid March and his XXXXXXX score is 3+3 without metastasis currently, plus his age and medical history, he suggests we can wait and watch the PSA trend. (My father had his first 3 -monthly ADT shot in mid Dec 2014 and has taken flutamide from early Dec 2014 to mid March. We held up 2nd ADT shot and stopped flutamide since mid march because of anemia problem.). Doctor said if PSA rises quickly or reaches a high level say greater than 10 or 20, we can then re-start ADT. He also said that it may not be necessary to take LHRH injection continuously in my father’s case. He also said that it is possible to take antiandrogen pills only, rather than having injection.
What do you think this suggested approach in the light of my father’s latest PSA readings? Worth trying to monitor PSA levels for a period of time, say at least 3 or 6 months to see the trend before deciding to re-start ADT now? Many thanks.
Best regards,
XXXX
Brief Answer:
PSA is currenty under control
Detailed Answer:
Hi
I have gone through your fathers PSA trend
Your fathers PSA is currenty under control
You can wait for a period of 6 months and you do not need to start ADT at this moment
If after 6 months PSA becomes more than 10.0 ng/mL then ADT can be restarted
If you have no more clarifications then please rate the answer and close the thread
Regards
DR DE
PSA is currenty under control
Detailed Answer:
Hi
I have gone through your fathers PSA trend
Your fathers PSA is currenty under control
You can wait for a period of 6 months and you do not need to start ADT at this moment
If after 6 months PSA becomes more than 10.0 ng/mL then ADT can be restarted
If you have no more clarifications then please rate the answer and close the thread
Regards
DR DE
Above answer was peer-reviewed by :
Dr. Neel Kudchadkar
Thanks Dr for your expert advice. So, taking antiandrogen pills only, rather than having injection, is an option when it is necessary to re-start ADT in future? Is LHRH’s side effect of anemia more severe than antiandrogen pills?
Best Regards,
XXXX
Best Regards,
XXXX
Brief Answer:
LHRH causes more anaemia than ADT
Detailed Answer:
Hi
Taking antiandrogen pills only rather than injection is an option
ADT can be started after PSA rises to more than 10
LHRH causes more anaemia than ADT
Regards
DR DE
LHRH causes more anaemia than ADT
Detailed Answer:
Hi
Taking antiandrogen pills only rather than injection is an option
ADT can be started after PSA rises to more than 10
LHRH causes more anaemia than ADT
Regards
DR DE
Above answer was peer-reviewed by :
Dr. Neel Kudchadkar
Dear Dr DE,
Thanks a lot for your expert advice. I have further queries due to new findings.
New findings told by doctor : Plain chest x-ray done on 20 April 2015 – A small shadow seen. Another plain chest x-ray done on 5 May 2015, similar.
(My father had severe cough and on-and-off low grade fever since 17 April to mid May, and has been on a few antibiotics courses. Much improved after mid May but started to cough a bit more again since a few days ago).
We today just learnt from a doctor (internal medicine) that there is a shadow seen on my father chest x-ray taken on 20 April, i.e. one month after discontinuation of ADT since mid March 2015. While the doctor (internal medicine) will get his sputum for test in the coming days, she raised the possibility of PCa metastasis to lung and said the oncologists will consider this possibility. She did not suggest CT at this moment because my father’s kidney function is not good and creatinine has been always high (about 185+). She asked us to take another chest x –ray in early July to see if there is any change to the spot before deciding on next step.
1. As you see from my father’s PSA readings, since stopping ADT in mid-March, his PSA has not risen, with PSA reading only at 0.03 on 20 April and 30 May. Is it possible that his cancer has spread, and even to his lung, within such a short period of time, given that his pre-ADT PSA, though high, is not too high and XXXXXXX score is 3+3? If there has been metastasis already, shouldn’t the recent PSA readings be so low?
2. Another concern is that my father has lost much weight since mid April, from 54.6 kg to 48.4 kg today. Is it a sign of metastasis? My father has fairly good appetite and no other discomfort.
3. If the prostate cancer spread, what is the usual spreading rate for XXXXXXX 3+3? Which organs are likely to be affected (bone?) first and what are the symptoms?
4. Since his discontinuation of ADT in mid March, his Hgb has improved gradually from 9.5 to 10.2 and then to 12.1 in late May. MCV has also dropped from 107 in early March to 96.2 in late May. It seems that the ADT can explain why his Hgb has dropped so much earlier, but our oncologists said the anemia is unlikely due to ADT. Now with this sudden lung issue, we are further confused and do not know what is the best way forward. Do you have any idea explaining my father’s health picture and progress since his PCa diagnosis till now?
5. Given that the PSA seems under control currently, we want to find out whether the spot on lung x-ray is due to other causes. If the chest x-ray to be done in July is clear or the spot become smaller, then we can rule out metastasis? As such, we intend not to re-start ADT at the moment, but monitor PSA for say 6 months. What do you think?
6. What do you think all these latest findings and development (e.g. PSA readings, Hgb levels before and after ADT , chest x-ray finding, significant weight loss) together likely point to? Metastasis? Primary lung cancer? Or something else?
7. lf there is really metastasis already, will it make much difference whether we re-start ADT now or a few months’ later until we have found out the cause of his lung issue?
Appreciate very much your expert advice. Looking forward to your reply. Many thanks.
Best regards,
XXXX
Thanks a lot for your expert advice. I have further queries due to new findings.
New findings told by doctor : Plain chest x-ray done on 20 April 2015 – A small shadow seen. Another plain chest x-ray done on 5 May 2015, similar.
(My father had severe cough and on-and-off low grade fever since 17 April to mid May, and has been on a few antibiotics courses. Much improved after mid May but started to cough a bit more again since a few days ago).
We today just learnt from a doctor (internal medicine) that there is a shadow seen on my father chest x-ray taken on 20 April, i.e. one month after discontinuation of ADT since mid March 2015. While the doctor (internal medicine) will get his sputum for test in the coming days, she raised the possibility of PCa metastasis to lung and said the oncologists will consider this possibility. She did not suggest CT at this moment because my father’s kidney function is not good and creatinine has been always high (about 185+). She asked us to take another chest x –ray in early July to see if there is any change to the spot before deciding on next step.
1. As you see from my father’s PSA readings, since stopping ADT in mid-March, his PSA has not risen, with PSA reading only at 0.03 on 20 April and 30 May. Is it possible that his cancer has spread, and even to his lung, within such a short period of time, given that his pre-ADT PSA, though high, is not too high and XXXXXXX score is 3+3? If there has been metastasis already, shouldn’t the recent PSA readings be so low?
2. Another concern is that my father has lost much weight since mid April, from 54.6 kg to 48.4 kg today. Is it a sign of metastasis? My father has fairly good appetite and no other discomfort.
3. If the prostate cancer spread, what is the usual spreading rate for XXXXXXX 3+3? Which organs are likely to be affected (bone?) first and what are the symptoms?
4. Since his discontinuation of ADT in mid March, his Hgb has improved gradually from 9.5 to 10.2 and then to 12.1 in late May. MCV has also dropped from 107 in early March to 96.2 in late May. It seems that the ADT can explain why his Hgb has dropped so much earlier, but our oncologists said the anemia is unlikely due to ADT. Now with this sudden lung issue, we are further confused and do not know what is the best way forward. Do you have any idea explaining my father’s health picture and progress since his PCa diagnosis till now?
5. Given that the PSA seems under control currently, we want to find out whether the spot on lung x-ray is due to other causes. If the chest x-ray to be done in July is clear or the spot become smaller, then we can rule out metastasis? As such, we intend not to re-start ADT at the moment, but monitor PSA for say 6 months. What do you think?
6. What do you think all these latest findings and development (e.g. PSA readings, Hgb levels before and after ADT , chest x-ray finding, significant weight loss) together likely point to? Metastasis? Primary lung cancer? Or something else?
7. lf there is really metastasis already, will it make much difference whether we re-start ADT now or a few months’ later until we have found out the cause of his lung issue?
Appreciate very much your expert advice. Looking forward to your reply. Many thanks.
Best regards,
XXXX
Brief Answer:
No chance of metastasis
Detailed Answer:
Hi
The prostate cancer has not spread to his lungs with such low PSA.
Since your father is having good appetite there is nothing to worry and loss of weight is not a concern.
Prostate cancer spreads to lungs and bones.
Symptoms are dry cough and bone pain.
Spreading rate is 35%.
His anaemia will be alright gradually within 6 months.He needs to continue ADT.
I will advise you to do a CT scan of chest with contrast to rule out lung metastasis.
The latest development does not point towards metastasis.
If there is metastasis then ADT along with chemotherapy needs to be started.
Regards
DR DE
No chance of metastasis
Detailed Answer:
Hi
The prostate cancer has not spread to his lungs with such low PSA.
Since your father is having good appetite there is nothing to worry and loss of weight is not a concern.
Prostate cancer spreads to lungs and bones.
Symptoms are dry cough and bone pain.
Spreading rate is 35%.
His anaemia will be alright gradually within 6 months.He needs to continue ADT.
I will advise you to do a CT scan of chest with contrast to rule out lung metastasis.
The latest development does not point towards metastasis.
If there is metastasis then ADT along with chemotherapy needs to be started.
Regards
DR DE
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