Hi-Risk/Recurrent/Advanced PCa Video Chat, Sep 5, 2022
All AnCan’s groups are free and drop-in … join us in person sometime! You can find out more about our 12 per month prostate cancer meetings at https://ancan.org/prostate-cancer/ Sign up to receive a weekly Reminder/Newsletter for this Group or others at https://ancan.org/contact-us/
Editor’s Pick: Great input this week from Advisory Board Member, Richard Wassersug PhD. And right at he end – maybe a touch of African Waterways – ‘De Nile’! (rd)
Topics Discussed
Stick or twist on RT for longtime recurrent older Gent; a similar Peer Survivor comments; man with cribriform intraductal faces immediate recurrence; starting Prolia; leg pains from ADT; Theraworx; looking at IHT; steady as she goes; MSI-H man asks about Immunex test; abi added to treatment but maybe daro would work; is Clinical Trial failing or succeeding?; aggressive disease recurs on Pylarify 3yrs after Tx ends – but man asks if it’s a false positive.
Chat Log
Richard Wassersug (to Everyone): 5:18 PM: Or there were only 6 cores taken
JEFFERSON DURYEE (to Everyone): 7:00 PM: OP GU PROSTATE STUDY IGUP20133 ETRUMADENT ZIMBERELIMAB DOCETAXEL PETER JAY VAN VELDHUIZEN,MD MY CURRENT CLINICAL TRIAL TEN MONTHS THEY ADDED 3 MORE MONTHS YR OLD ORCHIECTOMY A YR A GO PSA HAS RISEN TO 7.006 TESTERONE LESS THAN 5*
Frank Fabish – Columbus OH (to Everyone): 7:04 PM: Got to go guys. Thanks for listening.
Thomas Jacobsen – CO (to Everyone): 7:05 PM: Thanks everyone. Gotta go.
Julian Morales – Houston (to Everyone): 7:07 PM: Have to drop. Another great discussion. Glad I could contribute! See you next week!
Richard Wassersug (to Everyone): 7:23 PM: Sorry all. I have to go.
Bob G. Philadelphia (to Everyone): 7:25 PM: Time for me to go. Thanks.
Ben Nathanson (to Everyone): 7:27 PM: Good night, George – good to see you again
George Rovder Arlington VA (to Everyone): 7:27 PM: Good night friends. Stay well.
JEFFERSON DURYEE (Private): 7:31 PM: TY AND GOOD NIGHT
We had a fascinating webinar on August 29th, a debate on whether transrectal biopsies or transperineal biopsies are better for prostate cancer patients.
Don’t know the difference? No problem, this webinar will give lots of food for thought, and plenty to take back to the doctor’s office with you!
Deborah Kaye, MD, Assistant Professor Duke University Division of Urology and Duke Clinical Research Institute Margolis Policy Center, argued for transrectal biopsies. Arvin George, MD, a urologic surgeon specializing in the diagnosis and management of genitourinary cancers at University of Michigan Health, argued for transperineal procedures.
We have been reading all your feedback and taking it to heart, you want more information on this topic. To quote Rick Davis- “we hear ya!!”, and we are working on it.
Watch here:
Special thanks to Janssen, Pfizer, Bayer, Foundation Medicine, and Advanced Accelerator Applications for sponsoring this webinar.
We are working on slides – check back later.
To SIGN UP for any of our AnCan Virtual Support groups, visit our Contact Us page.
(Editor’s note: This is a ‘master’ list of books related to death, dying, and grief. We hope you will find this to be a helpful resource in your journey, no matter what it is. If you would like to share a book that has helped you, please email alexa at ancan.org. Amazon links here for your convenience and ease of purchasing the book. Remember, you can help AnCan with absolutely no cost to you by purchasing through AmazonSmile. Read how to here. Special thanks to Dr. John Antonucci.)
“We face fears of death and dying, and at times turn to authors who have thought deeply and written about the topic. I offer here a short bibliography on the topic. Ideally it would be an organic list, onto which readers could add suggestions or comments.” – Dr. John Antonucci
AnCan has an ongoing interest in issues around heart health for men on hormone therapy – especially if it involves androgen deprivation with an LHRH drug. We speak about this often in our High Risk/Recuirrent/Advanced meetings where many men are impacted, including our Moderators.
Last year AnCan produced a great webinar addressing this issue – yup, we know it says Active Surveillance, but Dr. Darryl Leong did a great job addressing LHRH implciations too. Watch it here. We are now particpating with Drs. Leong and Narayan at Penn who were just awarded a research grant to address heart health. We followed this up by nominating Dr. John Antonucci to appear on a CureTalk Panel addressing cardio-oncology issues. Listen to Dr. John talking with UCSF’s Dr. Javid Moslehi here. And recently Professor Herb Geller PhD spotted a good ASCO journal article reviewing the state of play. Herb and Dr. John, who himself has cardio considerations, worked together to summarize this piece, that follows. (rd)
The first line of treatment for recurrent and advanced prostate cancer is Androgen Deprivation Therapy (ADT). ADT is known to promote metabolic syndrome that has adverse cardio results. One controversial issue is whether an agonist Leutinizing Hormone Releasing Hormone (LHRH) like Lupron (and its sisters) or an antagonist LHRH like Firmagon (and its brothers) is safer for our hearts? Most of us with high-risk/recurrent disease are on one or the other and we generally hate them, though they keep our PSAs very low, sometimes for years.
So how do they work? Well, we want to keep our testosterone (T) as low as possible to “starve” out our prostate cancer that feeds on it. The drugs to do this are those that interfere with the brain’s signals to the testes to make T; that signal comes from the pituitary gland. There are two ways to do this:
Goose the pituitary gland in the brain with an “agonist” LHRH that overstimulates it producing excess testosterone. That explains the T. flare we often speak about. The over-signal shuts down this response in the pituitary by flooding and desensitizing receptors over time. The testes may also be complaining to the hypothalmus they are overworked in a separate feedback loop to the pituitary. The whole production of testosterone eventually stops. This LHRH drug is leuprolide; brand names include Lupron, Eligard, Zoladex, and Trelstar (we capitalize brand names and not generic names).
Block LHRH with an “antagonist”. No signal deactivates the pituitary signal to the testes and voila … no testosterone. Antagonists are Firmagon (degarelix) and Orgovix (relugovix).
Both work well, albeit differently, to do the job
No testosterone in your body can result in cardiac implications. There is a vigorous, ongoing debate whether the type of LHRH used mitigates your heart risk. This is of intense interest to us prostate cancer men with heart disease that can take us under.
As our Blog Editor remarked above, AnCan closely follows this debate. Some studies seem to clearly say the agonists are toxic to the heart, and others don’t demonstrate this. Every study has been faulted by the community of scientists, which by this time includes many in the new specialty of cardio-oncology. As a result, researchers are making painstaking efforts to remove all possible flaws from their study designs—a difficult task outside the lab. As these studies are better designed, they have shown decreasing cardiotoxicity for the medications and less and less difference between the two types of medications.
The most reliable study in this review, PRONOUNCE, was a randomized controlled study (the best kind of experiment) that compared an agonist, leuprolide/Lupron, against an antagonist, degarelix/Firmagon. All the men in the study had cardiovascular disease. The outcome measure was major adverse cardiovascular events, and the raters scored these events without knowing what medications the subjects were on. Tisseverasinghe said PRONOUNCE “was ideally conceived to isolate results from confounders and biases”. Results of PRONOUNCE? No significant difference between the two medications in terms of the heart, and very low cardiovascular events overall. So, do we finally have an answer?
Well even PRONOUNCE can be criticized. It tried for 900 subjects to make its statistics valid; it only got 545 – that’s still a pretty good number. Bad outcomes were very low: about 5% – some 3% died in the 1st year, 1.5 % from heart attack, 1% from stroke. It’s very hard to meaningfully compare groups with such small numbers. But the authors of the Tisseverasinghe article argue that even if PRONOUNCE was fully completed the outcome would still be the same. Our takeaway: it was the excellent and modern cardiological and cardio-oncological care that made those numbers of adverse cardiovascular effects in PRONOUNCE so low.
And so what can we conclude? It’s not proven, but it does not look like your doctor has to worry about using antagonists over agonists out of concern for your heart. And given modern cardio-oncological care, it does not look like we have to be terribly frightened for our heart IF we take care of it ….. HOW??
be aware of angina symptoms,
ask about aspirin,
monitor blood pressure,
monitor cholesterol and lipids,
stop smoking tobacco in any form
maintain a good diet (i.e. Mediterranean),
exercise regularly, and
practice weight control.
If there is risk, have a good cardiologist, and if risk is very high or you’re on immune therapy, find a cardio-oncologist.
John Antonucci & Herb Geller (follow up directly at dr.john@ancan.org; herb@ancan.org)
Work cited:
Tisseverasinghe S, Tolba M, Saad F, Gravis G, Bahoric B, Niazi T. Should Prostate Cancer Patients With History of Cardiovascular Events Be Preferentially Treated With Luteinizing Hormone- Releasing Hormone Antagonists? J Clin Oncol. 2022 Jul 21:JCO2200883. doi: 10.1200/JCO.22.00883 https://ascopubs.org/doi/full/10.1200/JCO.22.00883?bid=187952004&cid=DM11125
All AnCan’s groups are free and drop-in … join us in person sometime! You can find out more about our 12 monthly prostate cancer meetings at https://ancan.org/prostate-cancer/ Sign up to receive a weekly Reminder/Newsletter for this Group or others at https://ancan.org/contact-us/
Editor’s Pick: Two supplements catch our attention this week – melatonin, and Vitamin D. And if you’re taking supplements, be sure you run them past your medical team (rd)
Topics Discussed
82-yr old multiple cancer patient needs clear direction for his metastatic PCa; recurrence brings decsion between spot RT and chemo – and the right doc; what’s the origin of a spinal lesion?; why take melatonin?; starting a drug holiday but may need a CT scan baseline; St. Louis GU med onc recommendation; drilling down on v rare testicular lesion and how to treat it; drug holiday brings surprisingly quick relief; supplementing Vit D
Chat Log
Len Sierra (to Everyone): 5:18 PM: Zytiga first approved April 28, 2011.
Peter Kafka (to Everyone): 5:41 PM: What about Dr. Dan George in N. Carolina as a possibility. He is much closer
Rick Davis (to Peter Kafka): 5:43 PM: Dr. E is a better fit. She is very patient with older men. Probably not htat different in distance to Raleigh.
Julian Morales – Houston (to Everyone): 5:44 PM: A most excellent Medical Oncologist! Very personable.
Herb Geller (to Organizer(s) Only): 6:01 PM: What is the linac radiology? A medical linear accelerator (LINAC) is the device most commonly used for external beam radiation treatments for patients with cancer. It delivers high-energy x-rays or electrons to the region of the patient’s tumor. It is coupled with MRI guidance.
Rick Davis (to Everyone): 6:03 PM: 877 582 7011 – GoTo Help Line
Marc Valens (to Organizer(s) Only): 6:03 PM: Thanks.
Rick Davis (to Marc Valens): 6:07 PM: Try calling in …. (646) 749-3129 ID# 222-583-973
Rick Davis (to Everyone): 6:23 PM: Armstrong is at Duke
Rick Davis (to Everyone): 6:30 PM: https://siteman.wustl.edu/doctor/arora-vivek-md-phd/
Rick Davis (to Everyone): 6:33 PM: Picus
Martin Perrotta (Private): 6:36 PM: good evening gentlemen. Thanks for the meeting! Martin Perrotta
Herb Geller (to Everyone): 6:40 PM: There are three important tumor markers for testicular cancer: Alpha-fetoprotein (AFP) Human chorionic gonadotropin (HCG) Lactate dehydrogenase (LDH)
Len Sierra (to Everyone): 6:59 PM: From Mt. Sinai website: The normal range of vitamin D is measured as nanograms per milliliter (ng/mL). Many experts recommend a level between 20 and 40 ng/mL.
Rick Davis (to Everyone): 7:08 PM: Vitamin D3- Hyrdoxy 25
Herb Geller (to Everyone): 7:09 PM: also known as 25-OH-vitamin D