Help on next step - Chemo or Xtandi?

[dvcarola]

My husband recently had PET PSMA scan last Feb 4, 2019 after 6months of treatment with Zytiga+pred, Xgeva and Eligard. Below is the general impression of the scan and its a mixed result with more positives and MO also agreed with it (we take whatever positive we can get from it)

However, when it comes to the PSA result, from 33 in July 2018, it has come down to 0.889 in December 2018 and slightly went up in Feb 2, 2019 just before PET PSMA scan to 1.05 😔

PET PSMA result (Feb 4, 2019):

Positives:

- Size of prostate became smaller (from 3.4x3.4x3.5cm in July 2018 to 3x2.5x2.6 in Feb 2019)

- Interval regression in size and number of the subcentimeter left paraaortic, bilateral iliac chain and pelvic lymph nodes

- General decrease in number of metastases in the ribs/vertebrae/pelvis

- Still no mass lesions seen in brain, head, neck, lungs

- Gallbladder, pancreas, spleen and adrenals are unremarkable

Negatives:

- one node in lumbar area increased in size and intensity (SUV 91.6)

- Some pelvic lesion and rib lesions increased in size and intensity

Now based on the latest PET PSMA scan results and PSA results, our MO suggested Xtandi or chemo (Docetaxel/Taxotere) if in case husband’s PSA continues to increase in March 2019. He still wouldnt suggest radiation due to a lot of side effects.

Now, my question is, will it be better to do chemo or Xtandi? Would Xtandi still work if Zytiga stops working?

Also, does the side effects of radiation outweigh the benefits which is the reason why our MO doesnt like to include it in our treatment protocol?

Appreciate any inputs I can get please.

Thank you in advance Pca warriors and carers!

[Hidden]

Hi Vicky,

As you know, my treatments: Eligard, daily Zytiga/Prednisone, Amlodipine (2.5 mg) light dose for blood pressure and recently prescribed daily Venlafaxin (37.5) for hot flashes control. Then, daily Vitamin D3 (1000 IU, Dana-Farber recommended) and L-Arginine (2110 mg).

In 4 months, 09/11/2018 PSA 1000+, 10/15/2018 PSA 61.2, 11/09/2018 PSA 2.1, 12/14/2018 PSA 0.5, 02/07/2019 PSA 0.2...

The PSA drops looks great, unfortunately this velocity suggests, a high probability of becoming castrate resistance soonest.

Many "PSA to Nadir velocity" studies, this is a good read:

journals.lww.com/md-journal...

So, I'm in discussions with Dana-Farber team for adding chemo (Docetaxel) now. I don't know if this means dropping Zytiga, will report back. My rationale with chemo now is proactive strategy as oppose to wait and see. Perhaps, this can provide some ideas for you, PCa is just so specific to one's biology...

There's been recent discussions here about PSA bumps, for instance, dying tumors releasing PSA into blood.

Regards,

George

[dvcarola in reply to Hidden]

Thanks George for sharing your journey and hope your psa will continue to go lower with your treatment protocol.

And while Ive read in some posts here that chemo is a good first line of action, im a bit worried about the side effects for my husband who continues to work and drive himself to the office.

And yes i do hope that the rise in PSA is due to cancer cells dying so will have to wait for PSA result next month 🤞

You have a good team behind you and pls do keep me posted if you are to have chemotherapy soon. All the best to you!

Btw, i highly recommend that you watch HEAL Netfllix documentary film, its very interesting how they say that the power of the mind can help our body to heal 😊

[j-o-h-n in reply to dvcarola]

"power of the mind can help our body to heal"

That's why I'm into humor, believe it or not.

I wonder how many here realize that today is A. Lincoln's birthday?

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 02/12/2019 7:27 PM EST

[dvcarola in reply to j-o-h-n]

Thats why Im really glad that you are here bringing light and joy to this site John! You brought so much smiles already so pls keep them coming 😊

I didnt knw its A Lincoln’s bday. Some states must be on holiday, what a treat!

[j-o-h-n in reply to dvcarola]

Thank's.... Not to worry about Abe's birthday, he decided to celebrate by going to see the play Our American Cousin at Fords theater in Washington D.C. I wonder what Booth he'll be sitting in?

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 02/12/2019 10.09 PM EST

[Tall_Allen]

With multiple mets in the ribs and pelvis, taxotere is a good choice. Xtandi usually doesn't work for very long after Zytiga fails, but there is an opportunity to re-challenge with Xtandi after chemo (sometimes it reverses resistance).

Radiation to the prostate has been found in two large randomized clinical trials to afford no benefit when there are multiple metastases.

pcnrv.blogspot.com/2018/09/...

[Hidden in reply to Tall_Allen]

Hi TA,

Yes, I lost my chance 5 years ago for a cure, would have chosen brachytherapy back then, unfortunately my first and second (opinion) docs were Urologist surgeons, they did both wanted RP, the only way for a cure by their definition. They did not referred me to consult RO or MO, I've made it clear to Dana-Farber about it.

I'm going to ask for chemo (Taxotere and Docetaxel the same), next visit with Mark Powermantz, MD, will report back.

I did have a great response with Casodex, so I'm putting Xtandi on the shelf for now, exactly for the Zytiga re-challenged possibility further down the journey.

Vicky, this post was you in mind...

[dvcarola in reply to Tall_Allen]

Thanks TA, now I know why our MO said that radiation will do more harm (SE) than good given that my husband is polymetastatic.

Btw, in case we do chemo (Docetaxel/Taxotere) can we go back to Zytiga instead of Xtandi? I just heard that Xtandi is much more expensive than Zytiga here and there are no generics for Xtandi... So, we would rather prefer the cheaper alternative if Zytiga of course will still remain effective in this case.

Thank you and have a great day!

[Tall_Allen in reply to dvcarola]

It's customary to try the other one when one fails, but if resistance has been reversed, it will probably be true of either. You may want to try a switch from prednisone to dexamethasone with the Zytiga.

[dvcarola in reply to Tall_Allen]

Thanks so much as always for your advise TA! You truly are a gift to all of us here!