Gleason 9 CRPC any thoughts out there

[Bfhahn]

64 yr old very active with no other health issues other than Gleason 9 PC

RP Jan/2016 followed by Salvage radiation 32 sessions.

PSA has bounced around since that time on. Started ADT Zoxidex with Bicalutamide.

Bicalutamide failed Jan 2021 switched to Zolidex and Darolutamide still on, but has also failed.

In less than 2 months psa went from 4.2 to 11.

June 2022 18F PSMA PET impression psma avid recurrent soft tissue mass in the pelvis with metastatic involvement in the liver, multiple lymph nodes above and below the diaphragm, and multifocal bone metastases.

Lined up to start a clinical trial with 50/50 chance of either docataxel chemo or 177 Lu-PSMA-167. If the PC doesn't respond to the first treatment, I will be transfered to the other stream.

Wondering if anyone has any brilliant ideas other than the plan above? I am in Vancouver, Canada, and have been seeing Dr. Martin Gleave but recently transferred over to Dr. Kim Chi for medical oncology.

I'm open to any and all questions and welcome any advice on offer.

Thanks in advance for your time and consideration.

[tango65]

The trial seems a good plan. Both are systemic treatments which will treat the mets anywhere.

Perhaps you could get outside the trial, a PSMA PET/CT and FDG PET/CT to see if the mets had a high PSMA expression (SUV values over the SUV value of the liver) and if there are mets which do not express PSMA (discordant scans).

If the mets have low PSMA expression and/or there are mets which do not express PSMA, then you could consider just to start chemo outside the trial.

I would request a biopsy of the mets to do histological IHC and genetic studies to see if the cancer may respond to olaparib, rucaparib, keytruda or chemo with platinum compounds or other medications in clinical trials.

I would also request Provenge a vaccine which could prolong life.

[slpdvmmd]

IMO there is no perfect answer here. We unfortunately have multiple tumor types as a rule. Having been through both the treatments you are being considered for I would opt for Taxane therapy, repeat PSMA scan and mop up radioligand therapy (Lu177 +/-Ac225 and other developing options off the north American continent). Agree with prior comment that you may have to go out of country at some point to try and optimize your specific treatment needs.

[Teacherdude72]

If no mets see if you can get on Nubeqa. After Eligard failed went on Lupron monthly and Nubeqa. Started T G9 7 yrs ago last June on what I noted and psa undetectable.