Advanced Prostate Cancer

Doc + ADT vs Zytiga + ADT

In case you didn’t see this.

If Doc+ADT and Zytiga+ADT have such similar outcomes across different measures, I’d be interested in hearing how MOs decide on one vs the other.

I’d be interested in reading details of the research if anyone has access to it.

practiceupdate.com/c/64908/...

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Most docs go with Zytiga + ADT because of less side effects.....advantage of chemo is that it kills cancer cells which can lead to a durable remmission

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I don’t see either supported in this particular study. Doc is not more effective as measured by OS and PFS, and does not have more severe side effects as measured by grades 3-5 adverse events. Wish I could read the detailed report to see if there were any differences in different arms.

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I think that the decision should be made based on the number of metastases (based on CHAARTED - STAMPEDE did not stratify on this). For men with high volume mets, DOC is probably preferable. For men with low volume mets, abiraterone.

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TA - do you know if there is a way to get access to raw data on these studies?

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You mean the full text (privacy laws prevent access to raw data)? I think this is all that's been published so far (it has a few appendices):

academic.oup.com/annonc/adv...

What information would you like to know that is not in there?

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Thanks TA - I was looking for the raw data. It’s thinking of getting into the weeds of the actual statistical analysis.

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Oddly I had high Vol Mets and started on ADT then after 11 months ADT plus Doc for 8 months. Great results.

2/3 months only ADT then next 18 months Zytiga added and now still ADT+Zytiga with overall PSA @ 0.03 for 15 months.

All Mets (40 bones) disappeared after ADT + Doc./

My MO was part of the STAMPEDE setup and I was asked to join but refused. I see now that my treatment reflected much of that trial, thank God.

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Why did they add in Zytiga?

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I decided this issue for myself, and my MO reluctantly went along. My thought was that Docetaxel is a more short term therapy, that it does kill cancer cells, and that when it is done, I would switch to Zytiga. Oncologist said there is no data showing that using docetaxel and Zytiga sequentially improves outcomes, but he admitted the idea logically makes sense.

For reference, I have known metastasis in pelvic lymph nodes, acetubulum, pubic bone and one rib.

Next for me is RP. Again no studies support the idea that this will improve outcomes, but that’s only because the study hasn’t been done yet. It makes logical sense that debulking, getting rid of as many cancer cells as possible, can only be helpful, the usual risks of surgery notwithstanding. I’ve changed oncologists, and the new guy is always talking about standard of care, while i’m talking about state of the art. But he is young and smart, and my guess is that when I tell him that Mayo and MD Anderson are starting to do this surgery for metastatic patients, he will get on board.

The next item after that will be to get the mets with radiation... it won’t happen for all of us, but IMHO we should all be thinking about cures.

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Sounds like a great plan. I’m in similar shoes. Skipped chemo, but doing RP next month.

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It sounds like a good plan. You are right that the data on debulking are equivocal. The last analysis I looked at found it made no difference. MD Anderson is running a randomized trial that will someday decide the matter. Interestingly, they are leaving it up to the patient and his doctor whether they debulk with radiation or surgery.

Surgery removes the prostate entirely, but it may leave a lot of cancer in the prostate bed. They would do an ePLND with it, but that is far from thorough. Because they have to cut wide to get as much of the cancer as possible, it raised the risk of lasting incontinence, with permanent ED pretty much assured.

Radiation has a much lower risk of lasting side effects. It can treat all the cancer in the entire pelvic area, including all the pelvic LNs and the prostate bed. Also, distant metastases that are safe to treat may be treated during the same sessions. Because of increased radioresistance, it may be advisable to add brachytherapy within the prostate. But that increases the risk of urinary side effects.

Because of the uncertainty of benefit, I would lean towards radiation because it has lower risk of side effects, but I think both options are reasonable.

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I don’t think ED should be the deciding factor. We are pretty much guaranteed it if we are on ADT+Zytiga. There are a lot of back and forth between RT and RP in terms of long term benefits. I prefer to take the mothership out and then do RT selectively. MSK suggested RP for my case.

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It may be easy to say "the usual risks of surgery notwithstanding", but RP procedures also do carry some risks for urinary incontinence. If there is other metastatic disease burden in the body which is still left behind, you may have to come to terms with a personal decision that could possibly leave you with not only continued treatments for advanced metastatic cancer and their side effects, but also the possibility of urinary incontinence for every single day of your future treatments and overall survival time. In the final analysis, all such choices are yours to make, of course, but I would not underestimate the potential Quality of Life impact of possibly unresolvable urinary incontinence for every single day of one's life, on top of advanced metastatic prostate cancer. "Eyes wide open". Etc. Best of Luck in whatever path you choose.

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That’s thought provoking, especially because I thought radiation carried a significant risk of urinary incontinence, and surgery did not. Time to do more research. New scans after the end of chemo will be key, and I do know the difference between being aggressive and being stupid. Thanks for your insight.

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Radiation has a very low risk of urinary incontinence. it may cause temporary urinary retention from the swelling. But as the swelling subsides, urinary function should be better than before.

Here's a list of the side effects associated with IMRT and surgery and their approximate prevalence:

pcnrv.blogspot.com/2016/08/...

prostatecancerinfolink.net/...

And here's a side-effect comparison taken from the only clinical trial where patients were randomized to one or the other (or active surveillance): (Table 1 shows the incidence of incontinence)

pcnrv.blogspot.com/2016/09/...

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I used to tie mine in a knot, but alas it's now come to stapling.

Good Luck and Good Health.

j-o-h-n Saturday 03/17/2017 11:57 AM EDT

(Top of the morning to you all)

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Looked through abbreviated paper a few times. Still cannot find any info on what "standard of care" (SOC) results were; i., did zytiga or docetaxol IMPROVE longevity over plain ole ADT? Did I miss it? Or are they assuming results from pre-existing trials apply?

herb

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Herb,

Look into CHAARTED trial for Doc plus ADT and STAMPEDE/LATITUDE trials for Zytiga plus ADT. All showed significant impact - more pronounced in case of advanced PCa

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Thanks, but while I understand the hi price of added arms in a study, I've never been happy with comparing to an outside study.

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Many tough decisions to be made. I just wanted to mention that I had brachytherapy and I'm tradition combo. The brachy treatment was the highest dose they use. The treatment was unsuccessful for whatever reason but my urinary problems aren't bad. I just have to urinate more often. The longer someone lives, the more that the radiation causes issues but that can be decades for people that live that long.

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