After Lupron and docetaxel: then what?

[john205]

Fellows of high standing (or at least high PSA):

I am 67 years old. Diagnosis of high volume mPC in July 2018. Gleason 8. PSA 148 at diagnosis. Lupron started in July. Short course or XRT to a bone metastasis. Began docetaxel in mid-September, 2 cycles so far. About to get #3. Last, PSA 3 1/2 months, after beginning Lupron, was 0.87, a nice response. Tolerating treatment without too much trouble. After completing docetaxel with continued Lupron, then what? Any role for Abiraterone? If so, when - now? Or After completing docetaxel? Or when I become cRPC? Or other treatment? My reading of the research is inconclusive. Any thoughts?

[joekaty]

My husband’s experience: diagnosed with PSA 556 and had metastasized essentially everywhere other than organs. Docetaxel started while he was in ICU at diagnosis. Lupron started after discharge from hospital when he was stable. He did 9 or 10 rounds and was taken off at MD Anderson when we consulted them, due to his good response to chemo and concern that more would only damage his organs. That sounds like an excellent PSA response. All that docetaxel only took Joe to 2.5 or so- still a good response I know. He also tolerated treatment with little trouble but at the end he was starting to get fairly beat down. To your question, it was recommended he stay only on Lupron until his PSA started to rise. We had two different recommendations on what threshold to wait for before starting next line of therapy (Xtandi or Zytiga). MDA said wait for doubling. U of Chicago (the other research center we consulted) said that because his cancer was so aggressive- it also needed to be treated aggressively. He said that when Joe had two consecutive small “bumps” in PSA- get in next drug- and that happened the next month. We were directed towards Xtandi and didn’t question that much. Now on month 7 of that, still on Lupron as well as monthly bone shot. Not sure how helpful that is but is our experience.

[joekaty]

Also not sure if this helps at all but next line of therapy will be carbotaxel (I think that’s the spelling- the stronger version of docetaxel) unless he opts to try to get into a trial and save carbotaxel.

[john205 in reply to joekaty]

Thanks Joekaty

[ctarleton]

You might get some ideas for some "Standard of Care" treatment Options to research further/discuss with your Doctor from the latter parts of the NCCN Guidelines for Prostate Cancer (for Patients).

nccn.org/patients/guideline...

Charles

[Fairwind]

He will be on Lupron the rest of his life...That's just how it is...I would try Zytiga just as soon as your Oncologist can get your insurance to pay for it. It seems the sooner you start it the better it works.. The copays for Zytiga can be staggering.. Ask your Onco about getting help with that.

[Hidden]

I think the general recommendation will be to stay on Lupron alone until your PSA is >2 and has doubled at least once along with having some symptom or radiological progression, then moving on to one of two second-line ADT drugs (Zytiga or Xtandi). I had the same treatments as you did. I asked 3 different doctors about starting on second-line Zytiga right after chemotherapy was over and all three said "no". Their reasoning was at that time: early use (before castrate resistance) was approved for either Zytiga or Docetaxel, but not both. So I waited until my PSA hit 26, then started Zytiga. 4 months later and my PSA is undetectable with bone mets receding.

Another option my doctor had suggested prior to starting Zytiga was to do Radium 223. However, both my doctor and I were not comfortable with my PSA doubling time of 3 weeks knowing that Radium would not likely slow it. I would have probably been well over 100 at the mid point of treatment.

These are things to discuss with your doctor. Good luck with your decision.