I have posted a few times about my dad. Stage 4, mets to 8+ bones at time of diagnosis, PSA at 137 (10/22.) Lupron twice a year, Bicalutamide, failed at 7 months, Xtandi failed at 4 months, currently on Zytiga.
We met with my dad’s oncologist on 4/24. My Dad’s PSA dropped from 2.47-1.46 and pain has been improving. MO said that my dad is very symptomatic even with low PSA, and that treatment options have to also take into consideration quality of life. My dad was hospitalized in February for uncontrollable cancer pain when his PSA was only around 2.5 so the decision was made to move him from Xtandi to Zytiga. He talked with my dad about how for some patients he would let the PSA rise a bit more while staying on Xtandi to get a few more months out of the drug, but that sometimes it is not just about quantity.
I was very direct with the MO and said “How long will Zytiga last given my dad’s previous failures?” He said his usual statement, it could last weeks, months, years, or not work at all. My father always hears “years.” I stopped him and said, “Dr. A, do not tell my dad he has years because, with each drug failure, he gets disappointed and tells me he thought he would get more time with this drug.” I then explained I ran my dad’s entire history into three different AI language models and got varying numbers of Zytiga working for his specific case for 3-6 months, and some had concerns that perhaps not at all.” So I need to know not what happens with Zytiga, but what happens next. My dad was not happy with this direct question. But the MO knew why I was asking.
The MO finally had a direct conversation with my Dad and said if he was 50 and walked into his office with advanced cancer my dad had, he would have said five years was reasonable. But at his age each time the cancer comes back it punches harder at him because of his age. Add to that the additional health issues my dad has, the continued falls and hospitalizations, that five years was not reasonable, and that my number for Zytiga failure would be about average in my dad’s case, but we can’t really say until we see how his body reacts.
He talked about what comes next, ADT will still be there and it will continue to block a certain amount of the cancer, but the percentage it blocks will decline. He thinks my dad would do well on Pluvicto, but to get to it we would need to try chemo and fail. He shared that failure can be, not tolerating side effects, response, etc. But we would need to try it and it could be a lesser dose. The MO shared with me privately that the chemo would be harsh on my dad and the GI issues with someone like him could be difficult. My dad has no balance and is dependent on his walker. The MO also shared with me that he sees my dad wanting to exhaust all treatment options.
Zytiga has given my dad an extra pep in his step (I think because of the prednisone.) However, I can see the cancer starting to come back. The urinary incontinence issues are slowly creeping back, he has had some back pain, and shoulder pain where there are significant mets. This is usually his MO and PSA doesn’t seem to correlate with this any more. We moved my dad into Assisted Living in mid Feb and he loves the place, has a great routine, has made a lot of friends, is very involved with the activities, and is honestly more active here than in the last 2+ years.
My question is whether chemo/pluvicto seem reasonable to try. But how long do these last?
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lgutman
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If you have the means and your dad's physical state permitd traveling abroad, skipping chemo and bringing Pluvicto earlier into play, would be my prefered choice. The chemo first, Pluvicto afterwards, sounds in my ears as only satisfying burocratic criteria.
Thanks. He isn't really able to travel. Blind in one eye, very limited vision in the other, hearing aids, and so unstable on his feet. Additionally sitting on a plane would cause intense pressure on his back and spine. Being in different surroundings would be a fall risk. After doing a lot of research I feel Pluvicto is a good option and can add to quality to help with bone pain. I am sure he could stomach a half chemo dose, and who knows maybe he won't have a lot of issues with it and we could use it for longer
Good Call, I should add source. I am preparing myself for docetaxal treatment as well and met my MO he also confirmed that Xtandi works magically for many patients after docetaxal
(Sections 4) I did copied past in case if someone do not want to open
There is some evidence that taxanes (like Taxotere or Jevtana) can reverse one mode of hormonal resistance (AR-V7 splice variance). More evidence proved that Taxotere combined with Xtandi can extend its effectiveness even after it fails. Research continues on methods to reverse resistance (e.g., see subsection - "what's next?"). Although there is known cross-resistance between Zytiga and Xtandi, Xtandi usually works at least for a while after Zytiga.
I was reading on other group and comment. Now days dana farber doing min dosage of 25mg chemo + pluvicto. I did not find any one here. I hope i can find someone and learn from them
The call on whether he can tolerate chemo depends on his frailty and his blood work. If he was a poor candidate for it at diagnosis, he is a worse candidate now.
His oncologist has to look at his performance status and bloodwork and make a determination of what medicines and dosages are appropriate. It's not something anyone can determine on a patient forum.
Thanks! He said at this point he can try chemo and would need to at least once to get to Pluvicto. But his MO warned me that he didn't think my dad would do great on chemo and would want a reduced dose. The MO did say that he would most likely do well on Pluvicto and it would improve QOL from the home mets. But I got the feeling after that there wasn't much else. Today wasn't a good day pain wise for my dad. Pain improved for the first month in Zytiga and now is starting to come back.
My dad is still performance status 2 and can ambulate. Lots of issues with red blood cells. But the MO has told my dad to stop falling because that is going to lead to him injuring himself to the point of not being able to ambulate. He has already broken his hip a year ago and just came out skilled nursing from his last fall, only to find him on the floor several days after getting home. My dad refused to wear his pendant for awhile but now wears it all the time. If I could get him to stop showering by himself and stop cancelling the person that comes to help it would be a miracle.
Many performance status 2 people can still get chemo. The red blood cells may be problematic. I don't think the falling affects the decision. Discuss all this with his oncologist.
Good to know about the red blood cells. I think he said we could do a transfusion first if needed. The problem with a fall is it could move him from performance status 2 to performance 3. This happened to my employee's FIL with pancreatic cancer. While a different beast her FIL fell off a ladder, was hospitalized and everything fell apart when she was two weeks past chemo dated and couldn't get it. He is now in hospice less than a month later. But the MO has told my dad to stop being stubborn, take the help that is given and avoid a fall at all costs because that is what will cause an early death.
Sending all my healing energy your way. Know that you are not alone on this journey. My wife and I both lost our mothers over the past year. It makes me happy to know he has enjoyed some moments in assisted living. Your kindness is a testament to the world being a better place for his being in it.
At some point if the prednisone, taken with the Zytiga, does not seem to be keeping the PSA level, then a switch to Dexamethasone should extend the life of Zytiga.
Maybe he could get Pluvicto without having failed chemo. See the Phase 3 PSMAfore Study.
" The PSMAfore clinical trial was designed to determine if 177Lu-PSMA-617 could also benefit a broader group of patients with mCRPC who have progressed on ARPI but have not received taxane chemotherapy
Patients who enrolled in the trial were assigned to either a change in ARPI, for example from abiraterone to enzalutamide or vice versa, or 177Lu-PSMA-617, a prostate-specific antigen (PSMA)-targeted radioligand therapy. This analysis found that treatment with 177Lu-PSMA-617 prolonged radiographic progression-free survival, improved PSA response rate, and increased objective response rate compared to a change in ARPI, regardless of whether patients had received prior abiraterone or enzalutamide."
You are an Amazing daughter! He is so fortunate to have you. And he is an Amazing Man! His will to live and find joy in life notwithstanding all of his co morbidities is inspiring. I would continue to let him make the decisions.
Lack of balance is one of my issues too. Don't laugh but a friend of mine suggested that I wear a bicycle helmet during the day to protect me from injuring my head from a fall. I do not but that's because I'm known to be hard headed. Anyway keep up your loving and daughterly care for your 81 year old dad. Tell him I said hello........and to use his walker, especially while in the lavatory.
Thank you for everyone who commented and those that made me laugh (especially the helmet one.) My dad's pain has been escalating over the past 8 days and I am having a hard time wrapping my arms around this Zytiga was only started mid March. I have come to learn his pattern very well. I am working with his palliative care doctor to control pain as I think we need to stick with Zytiga even if his next blood draws show a rising PSA because we can't get this window of time back and the Oncologist once told me "we need to milk all the time from the hormone blockers we can." It is just shocking that my dad can experience such pain with a PSA around 2-4.
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what next? Really need your advice. 
