Thursday, August 1, 2024

Good News: PSA Drops Nearly 60% After The First Month Of Firmagon (ADT) Treatment

 Well, it hasn't been easy but after a month- plus of hot flashes, sleep turmoil, back aches and general low energy (plus cognitive 'fuzz') the PSA - in the most recent lab test (7/23)-  went down from 19.2 to 8.0 ng/ml.  At the same time, the testosterone went from 82 down to 8.5 ng/Dl.

The double shot (12o mg each) into opposite sides of the belly - was delivered by a Urology Nurse Practitioner (Kayleigh) - who carefully laid two needles down on a tray next to the exam table - where I sat with my shirt up. Janice sat just across from me next to the office wall watching the spectacle unfold. I was amazed that 1/2 hour after the shots, when I had the same day's uro lab results,  to see the testosterone had already dived to 82.  

No PSA was taken at the time because it takes at least two weeks for it to lower from Firmagon. The T (testosterone) dive always precedes the PSA dive.

Showtime arrived quickly when Kayleigh swabbed each side of my belly with antiseptic then proceeded to first stick one needle in the right side, taking nearly a minute to deliver the Firmagon.  She then brought forth the second loaded needle and stuck it into the left side - again taking nearly a minute for the injection. Afterwards proclaiming "You took those two like a real champ, a lot of guys at least wince after the second." 

But within an hour both injection sites swelled up like twin hornet stings, forming small lumps.  But this is how Firmagon works in the wake of the injections - quickly forming a semi-solid "depot" under the skin, e.g.


Firmagon 'depot' formed after injection

The depot then is a storage 'lump' of the Firmagon solution that quickly forms after injection.   The lump then supplies a continuous release of the Firmagon over time, as opposed to one massive (240 mg) dose which could have more adverse side effects. (All future monthly injections are "maintenance" only, at 80 mg per shot.)

 Janice was also impressed by my tolerance of the physical insult, but as I told her - I kind of learned to tolerate the pain from the time (July, 2012) of my first prostate biopsy in 2012 (12 needle grabs of prostate tissue with no sedation),

 Then high dose radiation therapy two months later. Especially after a med student at UCSF (where I got the HDR treatment) drove 3 needle sticks into my spine before she found the right place to deliver the epidural.

It is what it is, and you learn that when dealing with any type of cancer. 

 Firmagon, far less any other androgen deprivation treatment (ADT), was not my choice as I will admit. But a PSMA scan in March showing the spread of lesions (with greater SUV intensity) to pelvic region and lymph nodes changed that. (Intensity of  uptake of radionuclide by cancer cells is defined by the SUV or standardized uptake value.  

Where: SUV = C(T)/[injection dose (MBq)/patient's weight (kg)] 

So the sole remaining option was to go on ADT which consequences I've  elaborated in ancillary links from previous blog posts, e.g.


 I had originally hoped to start Orgovyx, the newest (and ‘greatest’) ADT medication which had the benefit of: a) being taken in pill form as opposed to regular injections - which usually leave massive swelling at the injection site, 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., covered by Medicare) Firmagon E.g.

Firmagon | PCFA

 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 lowered and hence there is less havoc caused by tumor growth - including metastasis.   Let me quickly add here the ADT regimen is rarely used for early prostate cancer.  But there are more sites now that will, when PSMA scans show suspicious SUV values, deliver radiation (usually SBRT) with ADT.  I also had the option but declined the radiation given I already had high dose brachytherapy 12 years ago, 

And didn't want to run the risk (20%) of a bowel obstruction.

So for now I will deal with the irritating swelling - like bee stings - after the injections, along with the night sweats, back aches and low energy - if it means postponing the time the cancer 'mets' get into my spine, brain, legs or other places. 

The good news, according to a recent (Nature) paper by my former oncologist (Dr. E. David Crawford) at UC Health and co-authors,  e.g.

Androgen-targeted therapy in men with prostate cancer: evolving practice and future considerations | Prostate Cancer and Prostatic Diseases (nature.com)

is that pronounced lowering of PSA in the first three months is a positive sign for ADT success. Also, rapid lowering of testosterone, especially to below 20 ng/ml which I also achieved. (Also noting that the 20 ng/ml threshold is what is usually detected for those patients who have undergone orchiectomy). As noted therein:

Evidence shows that lowering T levels to <20 ng/dL improves patient survival and delays disease progression

Hence, my low level of 8.5 ng/ml must also involve testosterone from the adrenal glands, which usually must be addressed with ancillary treatments. Meanwhile, the lower PSA of 8.0 ng/ml.  means whatever tumors or lesions are present (i.e. in lymph nodes) will be retreating in size. Again, ADT is not curative, but rather temporarily protective. It works until the cancer cells adapt and resist any further T- reduction. Hence the term "castrate resistant" used by oncologists and urologists. 

In addition, ADT comes with a host of side effects, summarized in the table below:


Nevertheless, I would say for any guy facing advanced metastatic disease, take the ADT rout, as it has the edge over any of the alternatives.

See Also:

Prostate Cancer and Androgen Deprivation Therapy (youtube.com)


  • And:


And:

And:

PSMA PET Scan for Prostate Cancer | UCSF Radiology

And:

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


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