There are 2 camp forr treating advance pc. One is combining drugs for a kill, the other is sequencing them to manage a chronic disease? Which are you. and is it working for you. Combining only for definitive synergy.
How to fight advanced pc: There are... - Advanced Prostate...
Wow. I don't think my treatment was aggressive enough. It the beginning the just treated with Lupron and then chemo per insurance standards. It only presented in 2 small lesions on sacrum. PSA was 5.67. No nodes involved. Possibly if they had been more aggressive then I might be in a different situation. I
Currently in a trial (Xofigo and Keytruda) but PSA now 26.00 and now have multiple mets on pelvis. It has been 3 yrs for me. But I fear that it will keep advancing until there is soft tissue involvement. Think it may be too late and just a matter of time. You are lucky. Hope you stay in remission. 👍👍👍
For those with advanced metastatic PCa, sequential treatment was the Standard of Care for a long time. The usual path was: Primary ADT (Lupron etc.), then second line androgen blockers such as Xtandi or Zytiga, then chemotherapy, then Radium 223 for those with bone mets along with palliative radiation to bone mets if applicable. Some do immunotherapy somewhere in between, but some doctors don't think it's proven enough for them (like one of mine). Or there were possible clinical trials.
That was before the CHAARTED, STAMPEDE, and LATITUDE trials which showed combining treatments from the point of diagnosis gave a significant survival benefit over the sequential approach. I made my treatment decisions so far based on those trial results.
I started with ADT Lupron shots when I was first diagnosed at stage 4. After one month, I started the first of 6 cycles of Taxotere chemotherapy in accordance with the CHAARTED and STAMPEDE clinical trials. After one year, my PSA started to rise again (castrate resistance) and I recently started Zytiga. I've been on Zytiga for 5 months and now have an undetectable PSA and my bone mets have receded.
I am just trying to understand this approach. You mentioned that that the charrated trials is very good but based on what you wrote and form of treatments as far as I understand it did fail for you after one year, then you went on to second line hormone treatment Zytiga. So my question is what might have happened if you just followed the standard of care approach and stayed only on Lupron and when it became resistance then you went to Zytiga?
I am sorry I am very confused and trying to find a treatment for me. Happy holidays
Unfortunately, you can never know what "could have happened" if you tried a different treatment approach. You have to make your best choice based on the best science and not look back. It's not something you can change anyway so it's not productive. The question is always, "What do I do now?" You always have to be forward looking when it comes to treatments.
It's also very possible that my time to resistance could have been shorter, not longer without chemotherapy. I'd say that's more likely.
At this point, ADT plus Docetaxel chemotherapy or Zytiga is becoming the new standard of care for advanced PCa for those who are fit enough. When I was diagnosed, early Zytiga was not yet approved so I only had the option of early Docetaxel.
Right now, I have an undetectable PSA and receding mets at close to 2 years, so I'd say that my response has been fairly good. But response to treatment is never guaranteed so you just have to make you best choice you can and live with it.
It's going to be hard for an individual to answer the question of whether sequential or combination therapy is best. He will know whether his own treatment is going well or poorly by looking at his own PSA history, but he can't tell whether he would have done better or worse with the other style of treatment, and of course doesn't know whether he would live longer with his treatment or the other one.
alsam and gregg57 appear to be relying on information from the clinical trials - which seem to show that combination therapy works better, at least for men with aggressive cancers. Relying on the trial info seems to me to be the most rational approach - especially since the trials alsam and gregg57 are referencing were big trials conducted by different teams of scientists, but still got pretty consistent results.
Now having said that, I think that your question is still a good one. It's always reassuring to hear that some people you know (we all "know" each other in this group, right?) like alsam really did do well with the recommended treatment. Maybe he would have also done well on Lupron alone. There's no way to know. But at least we know that combination therapy did very well and didn't knock him down.
When you ask "Is it possible to start with sequencing and if it fails you go to combination?" I presume that you are asking if it is possible to try ADT alone and then add chemotherapy or advanced ADT (Zytiga or Xtandi, etc.) when the PSA starts rising in spite of the ADT. The answer to that is, Yes, it's possible, but that's not what the experts mean by combination therapy. What I understand them to mean by combination therapy is that you take the chemo or Zytiga with the ADT (Lupron or equivalent) WHILE THE LUPRON IS STILL WORKING! If you wait until after the Lupron stops working, you don't get the powerful combination benefit.
So, should you take sequential therapy or combination therapy?
I think the answer depends on how aggressive your cancer is. If it's very aggressive - i.e., high Gleason score, high PSA, rapid doubling time - then don't wait for the Lupron to fail. Take the Lupron AND either docetaxel (chemotherapy) or Zytiga (advanced androgen deprivation) both at the same time. The clinical trials say that gives you a chance at a longer life than sequential treatment.
However, if your cancer is non-aggressive then the trials found that there is no benefit to combination therapy. You do just fine on sequential therapy - Lupron first then other treatments if and when it fails. Take the sequential therapy and get just as effective a treatment with fewer side effects than combination therapy.
And what should you do if your cancer is halfway between aggressive and non-aggressive. Well for that you need to talk to an expert who knows more than I do.
If your question about PSA progression/imaging means, Can you tell if a treatment has failed based on medical tests, the answer is Yes, you can. However if you are going to benefit from combination therapy, you can't wait until the first treatment fails.
I hope that helps.
One last question Alan please:
I just reread your post a few times and my question is: based on my stats, do you think I have aggressive or non aggressive cancer?
My stats are: failed surgery (2012), g(3+4), failed radiation (2017), current (psa .44), no imaging scans yet, will be done mid February( psma g68a) or the one at NIH trial.
Thanks for your help
OK you started treating with the combination 6 years ago. Have you continued same for the 6 year period and now hoping to continue same as long as possible if no resistance develops? Is this really what you mean?
Your case is very inspiring and I wish you the longest survival benefit from your treatment choice!
I was first diagnosed with a PSA of 5,006 and numerous mets to both bones and lymph nodes almost 4 years ago. I doubt if even combining all the known FDA approved drugs at the same time would totally eradicate all the cancer cells that might still hide away somewhere in my body, assuming that such a treatment didn't kill me first - to say nothing of the combined side effects. Psychologically, I have not considered a definitive, permanent "cure" feasible, in my case. I have, however, imagined finding ways to increase the odds of considerably exceeding the Overall Survival statistics of each and every treatment I will find along the way.
I will "ride the train" for as long as any particular treatment may stay effective, or even partially effective. I will keep an open mind about sequencing treatments earlier, rather than later, balancing quality of life issues with long term overall survival.... subject to other pushbacks I may get from doctors or insurances. I will keep an open mind to combining treatments, especially if they show promise of having a synergistic effect.
using the same rational as active survalense for pimaary treatment, there should be a clear point at which to become more aggressive in the spectrum psa reccurrence with gleason 6 and low 7 to a higher gleason with positive imaging. Side effects ought to be considered and these docs who think overtreatment can lead to early crpc. I would love to blast this disease out of existence with.aggressive treatment early on but we need to know the best timing? Best wishes to all and the docs that treat us. Were learning more evey day. Rocco
I agree. We also need to consider age. I was diagnosed in 2010 at 44, and after reoccurance post both rp and salvage radiation my urologist wanted me to go on Lupron, the traditional next step in the sequence. After Dr. Kwan at the Mayo suggested chemo, I realized that at my age, eventual Lupron failure was a given, and then I would go on to the next treatment, and then the next.
Not willing to be resigned to that fact, I chose to hit it head on and finished my 9 rounds of chemo, with the Lupron, last December. No psa or tumors within 6 weeks of starting. I'm glad I did it. While I know reoccurance is a real possibility, I can't stand the thought of knowing treatment will fail sooner or later.
I am taking a vacation from Lupron at the end of the year, we'll see what happens. In the meantime, we have new information all the time, and promising results from STAMPEDE, CHAARTED, and LATITUDE.
Abiraterone affects different people in different ways. Some people can't tolerate it at all, whilst others like me, have few side effects.
My worst side effect is muscle wastage, which I can't seem to combat. Mind you, I'm getting a double hit of ADT, and my femurs were badly damaged from lesions before diagnosis. I can walk with a walking stick, but not very far. My legs run out of energy after about 20 - 30 yards. I also have to walk slowly as I'm very unsteady on my legs. I've fallen over twice in the last year, nothing serious, just a few bruises, but it's made me extremely careful, and nervous on uneven surfaces.
So what, I can live with that, I enjoy life, I can still lift a drink to my lips!
Good luck all
Total assault appears to be working for me. ADT-5, combined with over a dozen or more Specific Supplements. Very agressive Ductal Cribriform, with a very short OS, under control now past the average DOA date, with undetectability. I still have a few arrows in my Quiver, that I am saving if needed. Docs. and I are now in talks about IADT, or AS. And in the beginning I failed Surgery, and could not receive Radiation, so I failed that modality, and Chemo was out for other various reasons.
So far I've followed a modified standard of care : RT and ADT3 after each recurrence after initial RP. First recurrence was in prostate bed (PSA 0.3); second was in pelvic nodes (PSA 1.2); third was in femur (PSA 2.3); now on ADT3 and xgeva. PSA has been steady at 0.3 for last two months. When I become castrate resistant I'll have another decision to make.
I realize everyone reacts differently to drugs. But I seems that taking the treatment options one at a time worked for me. That how I was able to survive 25 years. With myself I have always been aware that the cancer cells will find a work-around to every treatment. Some treatments worked longer than others.