A New Prescription Plus a Few Questions and Answers

Dr.. Myers makes himself available to his patients via an Internet "Patient Portal." Patients are able to raise questions about their treatment at anytime. Likewise he communicates with his patients at will. The following Patient Portal exchange (1) introduces a new medication to my treatment plan, and (2) provides a snapshot of Dr. Myers' approach to the treatment of prostate cancer.

Pt.: Why did Avodart appear to work so well for the first four months of treatment then cease to be effective? .

Dr.:Recent studies have shown that prostate cancer can overcome Avodart and even Casodex by picking up LDL cholesterol and converting it to dihydrotestosteron. By lowering your LDL with a statin we can block this. I added low dose Simvastatin (Zucor) to your program. This statin has powerful anti-inflammatory activity and very low risk of side effects,

Pt.:  If Simvastatin effectively controls the progression of my cancer, the Casodex and Metformin may not be needed at this time. If the Simvastatin has little or no effect on the progression, it may not be needed, Do we dare experiment for a month or so?

 Dr.: Cancer is complex and adapts rapidly. This is more difficult if the cancer is attacked from different angles at the same time. If you have 3 drugs each with a 1/100 odds of resistance, the odds of resistance to all three are 1/100x1/100x1/100 which equals one in a million. This is why cancer, tuberculosis and AIDS are all treated with combinations

Pt.: Is "Hormone Lite" likely to  become hormone resistant? If so, when?

Dr.: Sometimes, usually after several years.

Pt.:  Am I now or am I likely to become a candidate for chemo-therapy? Is this an alternative we should have discussed on the 29th?

Dr.: Highly unlikely.

Pt.: What percentage of us on Casodex will experience gynecomastia? Is breast tenderness a precursor to gynecomestia? I believe you indicated these symptoms, if they occur, do not show up for about two years. If I recall you advised me we could address these issues when and if they occur. Does this mean preventive action, e. g., radiation, is contraindicated?

Dr.: It develops very gradually with plenty of time to do something about it..

 Pt.:Are these the only side effects that are likely to occur? .

Dr.: Yes

These questions and answers are virtually verbatim. I exercised editorial prerogative here and there to achieve clarity and continuity.

Stay tuned.

Hormone Lite

Much to my surprise, chagrin and profound disappointment my last two PSAs reversed course and returned to their upward momentum. Specifically September's result came in at 5.04 and October's at 6.27. Consequently my much anticipated discussion with Dr. Myers developed far differently than planned. Rather than a pleasant , mutually satisfying exchange of opinions as to the effectiveness of the treatment plan, we focused on the need for additional, more powerful medications and their accompanying side effects.
In addition to the medications, supplements and diet plan detailed in my  "A Miracle in the Making?" entry, Dr. Myers added the following two prescriptions:
1. Bicalutimide (Casodex). This drug is thought to suppress cancer by blocking the effect of male hormones particularly testosterone.
The Internet describes numerous side effects for this drug, but Dr. Myers thought my primary risks would be breast tenderness and an increased risk for developing diabetes.
2. Metformin. This drug is a first line treatment for Type II diabetes. It works by suppressing glucose production by the liver. Based on an Internet medical site this drug also "exhibits a strong and consistent antiproliferation action on several cancer cell lines including prostrate cancer cells."
It causes diarrhea in roughly fifty percent of its users.
Dr. Myers referred to the above plan as "Hormone Lite."
Repeat visitors to this journal may recall the first oncologist I consulted following my diagnosis of recurrent cancer prescribed Casodex. I rejected this recommendation based on a limited Internet research effort and on the advice of two trusted advisors whose counsel was subsequently confirmed by oncologist #2.
 Its a strange topsy-turvy world of prostate cancer in which I live. The experts rarely agree and treatment plans too often go awry. At this momentous juncture I am prepared to embrace a treatment plan which a few short  months ago seemed totally unacceptable if not irrational.
In retrospect I owe Dr. Cy Fer a cyberspace, Karma inspired apology for the unkind and presumably unwarranted pseudonym I attached to his persona. So be it!

Addendum: The prescriptions have arrived, and I will begin the revised treatment plan on 11/14/13.

Interim Progress Report

Based on PSA values shown below, it would appear Dr. Myers' protocol has arrested the progression of my recurrent prostate cancer:

A. Prior to beginning treatment:

July   2012   3.1

Oct.   2012   3.96

Jan.   2013   4.7

Mar.  2013   7.3

B. Following treatment:

May   2013   5.25 (30 days into the program)

June   2013   5.26

July   2013    4.90

Aug.   2013   4.73(current)

There can be little doubt that Dr. Myers' treatment plan has extended what remains of my 77 year old slightly battered and moderately tattered quality of life. But for the effectiveness of  his plan, I would be in the throes of full blown androgen deprivation therapy. That is the direction in which I was headed.
USFC issued a brochure titled "Hormone Therapy for Prostate Cancer--A Patient Guide." This publication lists the following possible side effects for this form of treatment: hot flashes, decreased libido, depression, fatigue, reduced muscle mass, breast enlargement, weight gain, hair loss, mild anemia, mental abnormalities, genital shrinkage, abnormal liver function, cardiovascular disease, diabetes and erectile dysfunction. Fortunately I have experienced none of these adverse side effects to date.
Barring unforeseen circumstances my next journal entry will be devoted to my six month checkup with Dr. Myers scheduled for October 29th, 2013. I have begun to compile a list of questions in preparation for this meeting which has the potential for producing some interesting discussion.
Stay tuned.

More Better

 Initially Dr. Myers responded to my "More Drama" entry as follows:
"While radiation induced neovascularization is the most likely cause, a polyp (early cancer) is possible. You need to see a urologist, and he will probably do a cystoscopy."
Shortly thereafter the participant in the internet cystitis discussion undergoing further screening to rule out bladder or kidney cancer reported the findings of his urologist as outlined below:
The cystoscopy revealed only dilated blood vessels in the bladder and prostate, resulting from the proton radiation he had in 2007. This is typical of radiation induced cystitis.
I relayed this information to Dr. Myers who modified his conclusion to: "So yours is almost certainly radiation induced bleeding that will disappear on its own."
As part of my research effort I asked Bob Marckini: "How common is proton radiation induced cystitis?" He replied, "While we have lots of members who have experienced rectal bleeding, we have far fewer who are experiencing hematuria. I would guess that over the past ten years, I've heard from a couple of dozen of our members with this condition. I am not aware of any case that hasn't resolved itself over time."
My research effort on this issue would be incomplete without contacting UFPTI. Accordingly by e-mail I asked my case manager how frequently their patients experienced hematuria. She discussed my inquiry with Dr. Gud E. Nuff and consulted her case manager counterparts . A summary of her telephone response appears below:
UFPTI patients report few cases of hematuria. Rare though it may be it typically occurs between two and four years post treatment and usually happens in conjunction with extreme exertion and/or dehydration.
The consensus of her in-house discussions was that an area of the bladder in close proximity to the prostate gland is radiated to the extent tissue damage results. Subsequent irritation causes sloughing off of new blood vessels in the area of healing. The technical term for this process is neovascularization. In most cases this condition resolves on its own without medical intervention.
As a tennis player I certainly over exert from time to time, and/on those occasions it is difficult to stay fully hydrated. Based on these deliberations I have decided to monitor this condition  pending further development. If indicated I will discuss the matter with Dr, Myers at my next scheduled appointment on October 29, 2013.

More Drama

The following e-mail to Dr."Snuffy" Myers sets the stage for a rerun of the age old dilemma "It Could Be Something or It Could Be Nothing"

"In April of 2012 roughly three years following proton radiation at UFPTI I saw a couple of drops of blood inthe commode after urinating. I contacted my case manager who suggested it may be due to neovascularization which she defined as follows: "New blood vessels form in the treated area which tend to rupture easily and slough off." At the time this made sense, and I thought no more about it.

Twice recently, however, I have had blood spots about the size of a fifty cent coin show up in my underwear. A related discussion is currently underway on a Pca internet site devoted to proton radiation. One of the participants, who described his bleeding much like mine, has been diagnosed with bladder cancer. Another participant has been diagnosed with cystitis and is scheduled to undergo further screening to rule out bladder and/or kidney cancer. The latter gentleman experienced several episodes of profuse bleeding on a single day.

For your information and perspective I have had four screenings subsequent to the initial occurrence of bleeding. A pertinent timetable of events and a summary of findings appear below:

April 2012---Blood drops appear in commode.

July 2012---C11 Choline Scan and endorectal MRI at Mayo Clinic. A 1.1 cm nodule of recurrent cancer identified in the upper left quadrant of my prostate. Both scans also reveal what was determined to be renal cysts.

January 2013---Triple Contrast MRI and PET Scan at UFPTI. Revealed a "small focal (non-cancerous) tumor deposit of the prostate and a low density lesion...of the right kidney (that) likely represents a simple renal cyst."

May 2013---Blood spot showed up in my underwear.

June 2013---Same as above."

The screening reports in their entirety are on file in your office. The question at this juncture is should I continue to monitor this issue or should I arrange an appointment with a specialist of one sort or another. I would very much appreciate your advice and counsel."

Stay tuned.

Oh My Gosh; A Glimmer of Hope

Consistent followers of this journal realize my PSA has steadily increased over a two year period. For discussion purposes the results of the past year appear below:
         April             2012           2.0
         July              2012           3.1
         October       2012           3.96
         January       2013           4.7
         March          2013           5.9
         April             2013           7.2
The last entry in the above table represents a treatment benchmark inasmuch as the blood draw occurred in the same week I implemented Dr. Myers' protocol. After following the plan for thirty days or so on May 27th my PSA came in at 5.25. This represents a change in direction and a reduction of nearly two points. Clearly this is a welcome development. Amen and hallelujah!
Oh I know only too well, it is much too early to celebrate. One PSA does not represent a trend. And even if a trend develops there are no guarantees. Even so from a medical standpoint I have had precious little to rejoice about over the past two years. So please understand my inclination to savor the moment.

A Miracle In the Making?

I have been to the mountaintop to consult with the recurrent cancer guru Dr Snuffy Myers. His office is located in the north western region of Virginia; thus the need to ascend the mountain to benefit from his wisdom.
Dr. Myers is a stately, grandfatherly, soft-spoken gentleman. It does not distract that he is super intelligent and possesses a near perfect background for treating prostate cancer. For most of his career he served as a cancer research scientist. When waylaid by a particularly aggressive form of prostate cancer nearly ten years ago, Dr. Myers converted to his current practice to serve out the remainder of his productive life. He has survived much longer than his doctors thought possible. He appears healthy at present following the protocol he now prescribes for his patients. Generally speaking his approach is as follows:
(1) Maximize one's health to enable the immune system to countract cancer
(2) Encourage a healthy diet ; eliminate foods that promote cancer and increase  foods known to have anticancer qualities.
(3) Prescribe medications to restrict and/or eliminate the progression of cancer.
In my case Dr. Myers proposed the following treatment plan:
I. Prescription Drugs
 A. Casodex--An antro antrogen. It works by preventing the actions of male hormones. It keeps testosterone away from the androgen receptor in the prostate cancer cell.
 B. Avodart--interferes with the conversion of testosterone into dihydrotestosterone a hormone known to foster the growth of prostate cancer cells. Dr Myers indicated this drug may cause (1) a 30% reduction in my libido and (2) tenderness of the breast tissue.
 C. Losartan--intended to bring my moderately high blood pressure into the normal range
II. Diet, Over the Counter Drugs and Supplements
 A, Mediterranean Diet--as described in a 306 page handout with the definitive title"The New Prostate Cancer Nutrition Book" and as supplemented by a single page listing of foods to consume and foods to avoid.
 B. Vitamin D3--the bloodwork submitted as a prerequisite for my initial appointment showed that I was marginally low on this vitamin which controls the absorbtion of calcium, phosphate and magnesium.  As I understand it this deficiency interferes with the optimal function of my immune system. Accordingly this prescription is a corrective measure.
 C.Full Spectum Pomengranate extract--this product has been clinically proven to dramatically reduce the doubling time  of PSA in most cases
 D. Super Biocurcumin--an anti-inflammatory antioxident that promotes good health
 E. Optmized Reveratol--an anti-inflamatory antioxident that promotes good health
 F. Lecithin--supports normal cholesterol levels.
This treatment plan looks far superior and is substantially more user friendly than the "full-blown" hormone therapy regimens recommended by oncologists #1 and #2. I am anxious to get started. I am in the process of filling the prescriptions and ordering the supplements. Dr Myers estimated my chances for a favorable outcome at 90% and thought it would be three to six months before we knew one way or the other. He intends to monitor my progress with monthly blood analyses including PSAs. I will update periodically as events indicate.

An afterthought. What's good for this goose may not be appropriate for any other goose. One of the characteristics that attracted me to Dr Myers initially was his individualized approach to the treatment of recurrent cancer. It is necessary to be seen by him to benefit from his expertise. In my particular case, too, the passage of time is necessary to determine the effectiveness of the above-described plan for me and my circumstances,




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Still Another Direction. Really? Yep.

Hormone Therapy (ADP) looms on the horizon. The first of two mainstream oncologists I consulted recommended a modified version of ADP. The second recommended standard ADP on an intermittent basis, but only when my PSA reaches 10 which should occur in a matter of months based on its current velocity and trajectory. This is a fate I wish to avoid for as long as I can or altogether if possible (while maintaining my current quality of life, of course). Accordingly I intend to consult yet another oncologist; one whose counsel and advice may well take me in a different direction. For the time being let's refer to him as oncologist #3.
My next entry will be devoted to this consultation. Stay tuned, but it may take awhile.

Proton Pipedream Up In Smoke

By virtue of a series of mini-miracles, I returned to UFPTI to thoroughly explore the possibility of treating my recurrent cancer with another round of proton therapy. Prior to our meeting Dr Gud E. Nuff ordered a Pet-scan and a a triple contrast MRI. To kick off our "face-to-face" Dr Gud E. Nuff conducted an especially thorough DRE. Our dialog evolved along the following lines (liberally paraphrased):

Dr:  "The Pet-scan, the MRI and my DRE all proved negative. Based on your rising PSA you probably have cancer somewhere in your system, but in my judgement it is no longer active in your prostate gland."

Pt:  "How do you explain  the findings of Mayo Clinic? You may recall Mayo Clinic identified a 1.1 cm nodule of recurrent cancer in the upper left quadrant of my prostate by way of the Choline scan. Mayo Clinic confirmed this finding the same day with an endorectal MRI."

Dr:  "After radiation the prostate gland reacts to technological interventions in unpredictable ways. Based on our test results and my DRE, I am convinced your prostate gland is cancer free. Accordingly you are not a candidate for proton therapy."

Pt:  "Please indulge me; let us assume Mayo Clinic's results are accurate."

Dr:  "Even if your recurrence were restricted to your prostate, you would not be a candidate for retreatment with protons. During your initial treatment your surrounding organs  were bombarded with the maximum prudent amount of radiation. Further radiation could potentially do more harm than good. You would be at risk for causing irreversible damage to your colon. More particularly your colon could be damaged to the extent that you would need a colonostomy. You wouldn't want to wear an external bag for the rest of your life, would you?

Pt:  The latter question did not require a great deal of soul-searching on my part. I responded rather simply, and I suspect, rather predictably, "No" I said, "I would not."

From the get-go I realized my unscientific proposal may be nothing more than a pipedream. Nevertheless I launched my return trip with a fair degree of optimism. One of the mini-miracles preceding my journey put me in contact with the only man on earth (presumably) who successfully underwent proton therapy (at UFPTI no less) following failed IMRT. His very existence stoked my hope.Not only did his existence lend credibility to my grand plan, in addition. this fine gentleman contacted key UFPTI staff in my behalf. Shortly thereafter I received an invitation to return to UFPTI  for the above described evaluation.Unfortunately neither his existence  nor his influence could overshadow Dr Gud E. Nuff's findings and logic.
In the final analysis I pursued my (pipe)dream, that I would have evermore regretted  had I not done so.
 The search goes on.

Protons for Treatment of Recurrent PCa?

 Earlier in my ongoing adventure I proposed the following "Clinical Trial of One" to Dr Gud E Nuff:
 1. Begin with a shot or two of lupron to starve, weaken and shrink the 1.1 cm cancerous nodule identified by Mayo Clinic
2.Kill what remains with proton radiation at whatever volume it takes as determined by UFPTI
3.Reduce the liklihood of a recurrence by adopting a life long regimen of finasteride.
To date UFPTI has not responded substantively to this proposal. An unexpected turn of events has provided me an opportunity to thoroughly explore this option. Although it may take awhile to play out, and I have no way of predicting the outcome, this interim report seems warrented.
Stay tuned.