What is "Non Metastatic Castrate Resistant" prostate cancer?
My second recurrence was found in a pelvic lymph node via a PSMA scan at NIH. I began ADT (Lupron) 6 weeks ago and will start pelvic radiation next month followed by 2 additional years of Lupron. If the cancer returns again (PSA increase) I will be considered Non-Metastatic Castrate Resistant and will move on to an anti-androgen; Zytiga or one of the "lutamides".
The article via the link below explains the recent FDA approval and further information on this stage of the disease progression. Those in this state will find it interesting in our never ending understanding of PCa.
I haven’t had a chance to read the article and I understand why you call it castrate resistance but wouldn’t it be the metastatic or none metastatic based on imaging findings and not just only psa increase? My MO just told me I am considered high risk pc because of the lesions found by the pelvic MRI and you are totally correct, I keep trying to learn about this disease, never ends
Because it hasn't gone past the pelvic lymph nodes it can still be cured. Anything past the pelvic region would be considered true metastatic. That is why they came up with this new state. It is mind boggling.
You are still contained and will likely need no further treatment except lupron when your PSADT reaches 6 months.
This state is determined with CT and bone scan. Not with a PSMA PET/CT. I have seen a study where about 50% of the nmCRPC patients had mets when diagnosed with a PSMA PET/CT.
In my case I had 2 CT and 2 Bone Scans in 45 days which found no mets but the PSMA scan on the 46th day found a met on my Pelvic Lymph Node. I was classified as having Metastatic Prostate Cancer (hormone naive since I had not started ADT yet).
Met with my MO and she said that the upcoming radiation to the node will kill the met and along with ADT will take my PSA to undetectable (this has already happened). I will then be back to non metastatic. Next step would be if I fail ADT I would then have all the scans again including PSMA and if no mets are found then I would then be non-metastatic castrate resisteant. I would then move on to one of the lutamides or something else that is approved for nmCRPC.
The point of the post was 2 fold; to point out that the FDA has now recognized and approved the nmCRPC state which will hopefully help some folks with insurance approval of the drugs for this condition and also to point out my journey toward this state.
Probably a poorly written post because it's hard for me to understand all the different paths.
What is your objective? Do you want to get into the nmCRPC state to have access to the new drugs Erleada or Darolutamide? Then I would skip the PSMA scan because that will most probably show mets at a PSA value of 2.0 ng/ml. And you have to get at least above that PSA value to be declared castration resistant.
Once you got the desired prescription, you can have a PSMA scan if you want to know where your mets are.
Dr. Hofman mentions that about 1/2 of nmCRPC patients had distant mets (M1) when a PSMA scan is used instead of a CT/bone scan. However, 98% had M1, N1 or recurrence in the prostate bed. So I think the nmCRPC state is just a result of using poor imaging.
Thanks for sharing this. Hopefully very soon the PSMA scan along with the CT/Bone scan will be standard of care for finding and treating recurrent PCa. If I did not have the PSMA scan I would still be waiting for my PSA to rise to a doubling time of 6 months to begin treatment. All the while the cancer continues to grow.
There have been very important studies regarding the early use of Docetaxel or Abiraterone in combination with ADT for hormone sensitive patients. These studies are based on data using CT/bone scan. If you have four or more mets detected with a bone scan, one of these outside the pelvis, these trials show that you will have an advantage of adding Docetaxel to ADT. If you have fewer mets than that Docetaxel will just cause side effects.
If you have a bone scan with two bone mets your doctor should not recommend Docetaxel. However if you have two bone mets detected with a bone scan you will probably have five bone mets with a PSMA scan. If you show this result to your doctor he will recommend Docetaxel. But this is not correct, according to the CHAARTED trial definition you are low risk since the bone scan just showed two bone mets.
I had already six PSMA scans, I think you need no CT/bone scan before that. But the doctor will group you into the wrong state. He will not make a difference depending on the imaging modality used.
This problem will be discussed on the next APCCC conference in Basel.
I assume there will come a time when the CHAARTED trial and recommendations will be superseded by a new trial that will include the PSMA scan with or without the Bone/CT. Thoughts?
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