ADT (androgen deprivation therapy) is no walk in the park as former President Biden will soon learn - having been diagnosed with metastatic prostate cancer. (Like I have). Indeed, the side effects I am experiencing will likely be close to what he will have to endure in the coming months as different forms of ADT are used to try to prevent further advance of bone mets etc.
First some preliminaries: What is androgen deprivation therapy? It originated more than 80 years ago when a researcher noticed that prostate cancers in mice could be reduced by orchiectomy (surgical castration). The reason is that testosterone produced in the testicles is the fuel that feeds the prostate cancer. Cut off the fuel and you slow the cancer’s growth and spread (metastasis) to other organs - especially bones- where bone mets can cause fractures. Since the early work, chemical castration has replaced the surgical, but leads to the same result: namely, castrate levels of testosterone (< 20 ng/ml) and slowing of cancer spread. Basically, ADT is therapeutic and not curative. It can shrink the prostate cancer tumors but not kill them outright.
My ADT journey commenced with a PSMA (PET) scan in March, 2024. It showed my prostate cancer (first diagnosed with a biopsy in July, 2012) had
now metastasized to the lymph nodes and pelvic region. This based on intensified SUV or standard
uptake value clearly denoted in the scan. The intensity of those metastasized cells was defined by
the SUV or standardized uptake value.
Where:
SUV =
C(T)/[injection dose (MBq)/patient's weight (kg)]
In my
case the SUV was enhanced in the lymph nodes by a factor of nearly 2 and in
pelvic region by nearly 3, from an earlier axumin scan in 2020 and a PSMA scan
in 2022,
Mets
are visible throughout the spine as well as the brain and pelvic region. Any or
all of them in the latter can cause bone fractures. Again, these are not bone cells
gone haywire, but prostate cancer cells spread
(i.e. relocated) from the prostate. In my urologist’s parlance: “You
don’t want to end up with a spinal fracture from bone mets and be in a wheel
chair the rest of your days. So the time for ADT is now.”
ADT effects can be horrific, depending on the 'cocktail' of chemo drugs -which is what they are called under the CMS record guidelines - one receives. For example, right now I am avoiding taking the additional ADT drug called abiraterone, which is supposed to reduce testosterone (the male hormone which feeds prostate cancer cells) throughout the body - not just in testes. But side effects can include (in up to 10 % of patients): strokes, mental confusion, myocardial infarction, and liver failure. As I told my urologist, no way I am moving on to that (from Firmagon) unless I actually see bone mets in a PSMA scan.
To even try to temper the effects (like reduced cognition, weight gain and bone fractures) I had originally (in 2023) 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) $2,500, or opting
for the lower cost ($ 800/ mo.) Firmagon. It was the proverbial no-brainer.
To be
clear, 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, though now I do understand
“double therapy” is becoming the norm, i.e. ADT to accompany radiotherapy, or
radical prostatectomy. So much younger men (50s-60s) can expect to be on ADT if
their oncologists prescribe it. And that means expecting the full range of
negative side effects (SEs_, which I will get to.
For me the first Firmagon injection (a double) was the toughest. The double shot (120 mg each) was delivered at the urologist’s office, as I noted in a blog post last year:
Good News: PSA Drops Nearly 60% After The First Month Of Firmagon (ADT) Treatment
While I waited in the exam room, the nurse practitioner (“Kayleigh”) went to get the prepared mixture (always done in office) and the two needles. On her return, she 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.
Within
an hour both injection sites swelled up like 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.
The
depot is effectively a storage 'dump' for 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.)
Three
hours later the first SEs began: hot flashes, back ache, some dizziness, and
sleep disruption, but fortunately no burning (or bloody) urination. Only well
into the second month, after the 2nd injection, would I learn about
the further SEs, including: extreme fatigue, blurred vision, shrinkage of genitals, ED, loss of body hair, nipple
sensitivity – as well as cognitive haze- memory loss. What I was experiencing
were the first elements of androgen deprivation syndrome. Much of which
revolves around psychological distress arising from diminution and loss of male
morphology-characteristics tied to maleness, male identity.
I will examine this syndrome in more detail in
Part 2.
Biden diagnosed with an aggressive form of prostate cancer
- Excerpt:
“Last week, President Joe Biden was seen for a new finding of a prostate nodule,” said a statement from Biden’s personal office. On Friday, Biden was diagnosed with prostate cancer that had metastasized to the bone, it continued. The statement said the diagnosis “represents a more aggressive form of the disease,” but that the cancer appears to be sensitive to hormone therapy, “which allows for effective management.”
- And:
What a Prostate Cancer Diagnosis Like Biden’s Means for Patients - The New York Times
- Excerpt:
Until recently, doctors determined how much cancer was in the bones with scans that looked for inflammation. Now they have a more precise scan, called a prostate-specific membrane antigen (PSMA) PET scan. It uses a radioactive tracer that attaches to a marker on the surface of prostate cells. It allows doctors to spot the cancer much earlier, which means men with prostate cancer cells in their bones often have a much better prognosis — because they can be treated earlier
- And:
Finally Taking The Androgen Deprivation Therapy "Plunge"..
- And:
PSMA PET Scan for Prostate Cancer | UCSF Radiology
Fighting Prostate Cancer At -90 C: My Cryo-therapy Experience At UC Health
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