Testosterone check after Radiation and lupron

Posted by borudds @borudds, Oct 6 6:17pm

I am 73 and am ( was ) in good shape. Worked our pretty hard 6 days/ wk. for over 40 years. I had been on TRT for approx.18 months with a T level between 490 and 510 the past year. I was diagnosed with prostate cancer via a prostate biopsy in Feb. of '20. Prostate biopsy had 1 positive out of 12. It was a 3+3 Gleason score of 6. I had a 16 week Lupron injection on April 14th and started 39 radiation treatments on June 10. I had a 12 week Lupron injection on Aug. 4 and the last radiation treatment of Aug.5. My nuclear bone scan, Prostate MRI, Spine MRI and Pelvis/Abdomen CT scan were all negative. I just had my first follow up blood work last week. My PSA was 20 and it is now .2. My medical oncologist gave me orders for my next PSA in 6 months and said that my next Lupron ( 12 week ) shot on Oct. 27 will be the last one. He originally indicated I would be on Lupron for 18 months but this will just get me to 40 weeks. ( fine with me ) My question concerns the fact that he told me he doesn't believe there is any need to check my testosterone level. I thought that was the key reason for the Lupron injections. Has anyone else gone through this process without knowing what your testosterone level has become?

It has just been a month over a year since my last Radiation Oncology treatment.. They did the 20 treatments in the summer of 2019. I had only one shot of the Lupron at Mayo MN in about April of that year.. then we waited 2 months before radiation. After my Radiation and PSA around o.5 the Oncologist optioned for NOT giving me a second Lupron shot.. I am 83 now.. My Oncologist is at a central Iowa Clinic but he had trained with the Mayo MN Doctor.. The Machines were to be similar so I opted to do the daily Radiation in Central Iowa.. I never knew what my Testosterone levels were either from Mayo or the Central Iowa Clinic.. I had not bothered to inquire.. but I will go on My Chart and ask.. perhaps you are being treated at a clinic that uses Epic and you can simply email you doctor with a non-emergency question.. Ken

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@ken82

It has just been a month over a year since my last Radiation Oncology treatment.. They did the 20 treatments in the summer of 2019. I had only one shot of the Lupron at Mayo MN in about April of that year.. then we waited 2 months before radiation. After my Radiation and PSA around o.5 the Oncologist optioned for NOT giving me a second Lupron shot.. I am 83 now.. My Oncologist is at a central Iowa Clinic but he had trained with the Mayo MN Doctor.. The Machines were to be similar so I opted to do the daily Radiation in Central Iowa.. I never knew what my Testosterone levels were either from Mayo or the Central Iowa Clinic.. I had not bothered to inquire.. but I will go on My Chart and ask.. perhaps you are being treated at a clinic that uses Epic and you can simply email you doctor with a non-emergency question.. Ken

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Ken, I have sent a message to my medical oncologist (sent on late afternoon this past Monday ) and have not received an answer at this point. I'm not looking to do something that will negatively affect me but I want to know the testosterone level. By the way, I went daily for my 39 sessions of radiation. I was lucky that the cancer center is only 15 minutes from me. Good luck.

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Hi Ken! I am same age and have been on Lupron for 30 months. I declined on radiation and take Rick Simpson Oil daily in the evening as a natural alternative. I take my PSA monthly along with my Testo. I do this to keep track on the effectiveness of the Lupron. All is well but if it were me I would not wait 6 months. I would do it at least every 3 months and demand from your Dr that you want both tests. It’s your right to advocate for your own health and be insistent. If you have objections from your Dr find a new one.

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Time to throw the BS penalty flag on your medical team.

When I was doing 18 months of ADT, six cycles of taxotere and 25 more IMRT after a C11 Choline scan in January 17 showed four PLNS but no organ or bone activity (I had surgery in March 2014 and SRT in March 2016) my urologist did not want to measure my T. I threw the BS penalty flag, explained why it was important and he said ok.

Here's why…

In the setting of hormone naïve M1 metastatic prostate cancer, is achieving a low testosterone level really important? Up until several years ago, any answers to this question were completely unknown as testosterone levels were rarely measured in the setting of follow-up of advanced prostate cancer patients. In men that undergo bilateral simple orchiectomy, the mean testosterone level was approximately 20 ng dL  However, the traditional testosterone level to define a castrat state has been 50 ng dL−1 .  In fact, all contemporary clinical trials related to prostate cancer have used the level of 50 to define castrate-resistant disease.  In 2007, Morotefurther reported patients that failed to achieve testosterone levels below 20 had a more rapid progression toward castrate-resistant disease  Examined another way Morote et al. found that patients who had a testosterone level above 32 ng dL − 1 had a more rapid course toward castrate-resistant disease. In contrast, patients who achieved a testosterone level < 32 enjoyed an additional 4 years on average until castrate-resistant progression. In 2010, Perachino et al. reported similar findings which the testosterone level measured after 6 months of hormone therapy was a strong predictor of progression to castrate-resistant disease. More recently, Pickles et al. studied 2196 patients treated with LH-RH agonist during and after radiation therapy.  Five to 8% of patients experienced breakthrough testosterone levels above 50 ng dL − 1 . Importantly, young age < 70 predicted higher risk for testosterone breakthrough above 50. Pickles also demonstrated patients that experienced no testosterone breakthrough levels above 50 enjoyed a better disease free survival after external beam therapy treatment. Finally, and most recently, Klotz studied 626 patients on the continuous hormonal therapy arm of PR-7. The PR-7 trial was a Canadian study of intermittent versus continuous hormonal therapy in M1 metastatic hormone naïve prostate cancer. These authors looked at serum testosterone levels and time to the development of CRPC and studied patients after a median follow-up of 8 years. For those men who had testosterone levels that measured > 50 the hazard ratio for CRPC was 1.91 compared to a control group of men who maintained testosterone levels < 20. For the group who had testosterone levels that measured between 20 and 50 the hazard ration for CRPC was 1.41. In summary, these multiple lines of investigation suggest that the level of testosterone suppression during the initiation and early course of ADT for hormone naïve metastatic prostate cancer is a powerful prognostic factor.

In the setting of traditional metastatic prostate cancer, a number of key questions arise with regard to the use of hormone therapy in hormone naïve disease. The first key question: is the PSA response to initial ADT important to predict response and survival? The second question: does the type of ADT matter for maximal response? And the third question: is achieving a very low testosterone level really important in the setting of M1 metastatic prostate cancer?

As early as 1990, it was shown in a small study that PSA declined after the initiation of hormone therapy predicted survival in patients with metastatic prostate cancer. Patients who enjoyed a > 80% PSA decrease in the first month of ADT enjoyed a significantly longer progression-free survival compared to those patients who had a < 80% PSA decrease in the first month.
In a study published by Fowler in 1995, PSA nadir was a very significant predictor of response to hormone therapy. In this study, after patient exclusions, 245 patients with localized and 78 patients with newly diagnosed metastatic prostate cancer were treated with ADT in the form of orchiectomy or LH-RH agonist. PSA regression, nadir and doubling times were calculated for the patient cohorts. For the metastatic patients who reached a PSA nadir < 1.0 ng ml − 1 , they experienced a statistically significant longer time to biochemical recurrence. These authors further stratified PSA nadir on initial ADT from 1 to 1.9, 2 to 3.9, and a PSA nadir of > 4. Patients whose nadir was < 1 enjoyed a much greater disease-free interval compared to patients who experienced a PSA nadir > 4.

The largest and most noteworthy study to look at PSA levels after initiation of ADT for new M1 prostate cancer was published by Hussain et al. in 2006. Specifically in this large Southwest Oncology Group (SWOG) trial, the authors showed that initial PSA nadir 7 months after initiation of LH-RH agonist was a strong predictor of median overall survival . Specifically, patients who enjoyed a PSA nadir ≤ 0.2 at 7 months after the initiation of therapy had a median overall survival of 75 months. In contrast, patients who had a PSA nadir of > 0.2 but < 4.0 had median overall survival of 44 months. Finally, the patients who experienced a PSA nadir at 7 months that were > 4.0 ng ml − 1 had a median overall survival of only 13 months. In my practice, I use these publication data to help counsel patients who I initiate on ADT for traditional M1 prostate cancer. I attempt to defer discussion regarding prognosis with these patients until I have been able to examine a 7-month PSA level. Once the patient and I have the 7-month PSA nadir value in hand, we will use the aforementioned survival data to counsel them on prognosis and future treatment strategies. In fact, many of those patients who have suboptimal PSA nadir > 4 at the 7 months interval after starting ADT will have impending CRPC and may benefit from early novel therapeutic agents. Unfortunately, from this SWOG study in 2006 by Hussain et al., we do not have the serum testosterone levels at the 7-month point. It is possible that a combination of PSA response as well as testosterone response at 7 months or even an earlier interval may provide additional prognostic information to help guide future treat strategies for these patients.

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