Finally Taking The Androgen Deprivation Therapy "Plunge": Firmagon Injections Instead of Orgovyx Pills

 Following  a new PSMA  (PET) scan in March showing my prostate cancer had now metastasized to the lymph nodes and intensified it was time for a new urology and oncology visit.  

To briefly review,  the PSMA uses a more sensitive radionuclide than earlier (axumin) scans, in this case something called  F-18 Pilarify which: "Binds to prostate cancer cells to help localize prostate cancer cells."

It is therefore the property of the agent's binding to specific prostate cancer cells that validates and empowers its diagnostic use in scans.  The cancer cells then will "light up" i.e. experience measurable uptake of the radionuclide  - which helps to identify them and the level of malignancy-  and show up brightly on scans.

The intensity of uptake by those cells is defined by the SUV or standardized uptake value.  Where: SUV = C(T)/[injection dose (MBq)/patient's weight (kg)] 

In my case it was enhanced in the lymph nodes by a factor of nearly 2 from an earlier axumin scan in 2020 and a PSMA scan in 2022, e.g.

PSMA Scan Confirms Cancer Is Metastatic (As Well As Localized) - And Urgent Action Is Needed 

Both my urologist and oncologist delivered a wake up call in terms of what could happen if the cancer migrated from the lymph nodes to the bones, especially the spine.  That is, such bone mets could easily cause a fracture of the spine and have me laid up in a wheelchair. A scan (not PSMA) showing a patient’s spine ‘threaded’ with bone mets is shown below:

If I didn’t want to risk such an outcome I had to choose a treatment option: i) SBRT (Stereotactic Body Radiotherapy) plus ADT (androgen deprivation therapy), ii) SBRT alone, iii) ADT alone.

I declined options (i) and (ii)  in the course of my June 10th oncology (UC Health) visit because one of the primary potential complications recited by the P.A.  was “severe bowel obstruction” – with 20 %  probability.  This arose because I’d already had previous high dose radiation therapy 12 years earlier at UCSF e.g.

• The Longest Day...And Then Some...

 And the tissues in the vicinity of the pelvic region would be susceptible to damage from more radiation. Further, a bowel obstruction would likely require wearing an ostomy bag the rest  of my days. I said ‘no thanks’.  So the sole remaining option was to go on ADT which consequences I've  elaborated in ancillary links from previous blog posts, e.g.

https://www.pcf.org/c/adt-what-you-really-need-to-know/

  I had hoped to start Orgovyx, the newest (and ‘greatest’) ADT medication which has the benefit of: a) being taken in pill form as opposed to regular injections, and b) fewer myocardial infarctions ( by about 43% ) .  But the path to support was scuttled because the company terminated its lower cost  “bridge support”. So I was left with either paying the full monthly tab ( copay) $2,500, or opting for the lower cost ($ 523/ mo.)Firmagon E.g.

Firmagon | PCFA

Well, seeing as  I didn’t wish to see our nest egg cratered I chose the Firmagon, and had my initial double injection June 24^{th .}

 What I forgot to mention was that the urologist suggested – because of my already low testosterone (156 ng/ml) – adding another ADT drug: Abiraterone acetate (Zytiga) which you can read more about at this link (the least technical one I could find):

Abiraterone/Prednisone Combo Linked With Improvements in Fatigue and QoL, But Worsening Metabolic Changes in mCRPC (onclive.com)

 But I wasn’t too gung ho- after reading more about it, the fact is could cause bone fractures (the last thing I need) as well as other unwanted effects including (from the link):

However, abiraterone plus prednisone was associated with higher increases in weight, body mass index, visceral fat, and glycated hemoglobin, as well as the highest incidence of type 2 diabetes,

In any case the SEs from the Firmagon are enough to tolerate for now and include night sweats, back pain, and nasopharynx congestion, some difficulty breathing.  On the good side I learned the results of a blood test twenty minutes after the Firmagon injections showed a testosterone value of 82 ng/ml or nearly half what it was just before the injection.  Both Firmagon and Orgovyx work by blocking the pituitary gland from making hormones called luteinizing hormone and follicle-stimulating hormone, thereby reducing the amount of testosterone the testicles are able to make.   With testosterone reduction the cancer's fuel intake is also lowered and hence there is less havoc caused by tumor growth - including metastasis. 

The need now is to see the PSA also go down, hopefully in another blood test Jul 22nd. (In general the PSA doesn't get lowered much until 2 weeks after the first injection.)

 So for now my choice is just to keep the ADT at the Firmagon level and no more meds.  Another paper – from The New England Journal of Medicine- actually referenced a test trial using the  Abiraterone  and found the average added length of lifespan for patients on regular ADT (e.g. Firmagon only) to be 33 months. But when Abiraterone plus prednisone was added it meant 14 months more.  But really, to me, I can do without 14 more months of added life if it means 14 more months of misery including fatigue, brain fog, worse back pain and possible bone fractures.  So I am ready to go the more conservative route, unless they find bone mets in a new scan. 

See Also:

• ADT: The Only Realistic Treatment Option Left For Advanced Prostate Cancer...
• And:

PSMA PET Scan for Prostate Cancer | UCSF Radiology

And:

https://www.youtube.com/watch?v=GFHUCnwox7o