My husband was diagnosed in the last month and has only has a Firmagon shot and ~10 days of Casodex. We know he has a high volume of mets. Curious if anyone else has gone right to chemo instead of Zytiga/Xtandi or used it in conjunction as a first-line treatment?
Also, are there any trials or studies right now for using these drugs prior to demonstrated castration-resistance?
Newly diagnosed hormone sensitive metastatic prostate cancer can be treated with ADT plus Zytiga/prednisone or plus docetaxel. Docetaxel is only effective if there is a large number of metastases. Both treatments have similar results.
ncbi.nlm.nih.gov/pubmed/295...
Thanks! I was reading this one:
urotoday.com/center-of-exce...
Guess the Peace1 study will show which is the best bet.
If the patients can survive the combination of chemo, anti androgens and radiation.
CHAARTED and STAMPEDE have shown that docetaxel has maximal benefit in men newly diagnosed with multiple metastases.
pcnrv.blogspot.com/2017/06/...
Yes, I think I read that blog post earlier in the week - - thank you for the very nice summary. It just seems like we're going to need to make a guess. My husband has many metastatic sites (including a possible liver tumor) so jumping right to chemo sounds like it wouldn't be totally crazy.
BTW, you have a typo: "less time if a high-vulume met patient begins with docetaxel." 
I never make tyops...
Happy Eastern Orthodox Easter.
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 04/28/2019 6:04 PM DST
I agree - liver tumors usually respond especially well to chemo. Thanks for catching that!
Lupron and chemo right out of the gate, lupron for a month and then 10 rounds of chemo I pushed doc for more as I was handling chemo very well yes some side effects but manageable. After new scans in January 2019 my prostate has shrunk from a baseball to a big walnut and my lymph nodes from golf balls to peas my Mets are all but dark on bone scan so with my experience I say go for it. Now on Zytiga and lupron my original PSA January 2018 was 1780 now 0.54 i feel hitting it hard as fast as possible to beat the beast back good luck and best wishes 👍
Thank you - - very helpful. If you don't mind my asking, what are the notable side effects? Also, are they giving you an adjunct for neutropenia?
Sure first the funny side effect I lost All of my hair and I mean ALL, kind of weird looking in the mirror as I have sported a full beard since high school but it’s only hair, minor neuropathy between treatment but always cleared before next treatment, some fatigue but never missed work and exercised 4-5 days a week and played hard also, I’m 61 years young but after chemo my skin turned 90 very thin and cuts easy but getting tougher as time passes, I got to my chemo treatments 60 miles away by motorcycle weather permitting the day after was a hoot, at first until treatment 3 when I had them cut the steroids in half as I was driving everyone crazy as I was wired to the max, my finger and toenails got thin and flaky but never lost any. I had some fatigue and when I felt fatigued I would go for a walk or do yard work and that would help and no on the neutropenia I have found that standard of care is not the same for everyone depending on your personal situation many different drugs may be added to your particular cocktail. Again good luck and best wishes to you and your husband
Thank you! And LOL about the motorcycle. Bad ass.
My husband did. Lupron plus 6 rounds Docetaxel from start. Two months after last round started Zytiga plus Prednisone. He had very few side effects. Lost all of his hair- like bhr17- all hair. He was bald on his head but always had a beard and mustache. His moustache and eyebrow hair really hasn't come back. He had some fatigue towards last round and dry skin/lips but overall not a lot of side effects. My husband was 49 at diagnosis with multiple mets and >677 PSA. Gleason 9.
Thank you - - my husband has already lost most of his hair so I doubt that part would bother him.
Did you guys ever pursue stereotatic irradiation?
Not yet. Our MO really wants the PSA lower before surgery or radiation. My husband has no pain yet. I'm building my research library to send our team They're very open to discussion with me. Which I love.
I am also a no, no pain to date but probably down the road
Yes, that's exactly what I did. First Lupron shot almost immediately after Dx,
then started Docetaxel about 5 weeks later, on the recommendation of my
oncologist at MD Anderson. I was pushing for it anyhow on the basis of having read results from the CHAARTED and STAMPEDE studies showing increase in life for metastatic patients with early chemo. I was G10, with several mets, and currently undetectable PSA. I'm only 22 months in, so time will tell, but so far, it looks like that approach worked well. I expect that Zytiga and/or Xtandi is in my future.
Yes I did. Firmagon and docetaxel for 6 rounds then rad prostatectomy. It was a study at Univ of MN.
I had leuprorelin from the minute I was diagnosed. PSA 348, mets to L3 vertebrae and lymph nodes. Immediately followed by 6 rounds of docataxel. Some loss of hair but no other side effects. Went to work every day until the last cycle when I finally ran out of energy and had 2 days off. Concept seem to be hit it hard and early. Been on Zytiga for 2 years and have had radiotherapy - 20 sessions. PSA undetectable for 26 months straight. Still working 60 hours a week but the gym work has taken a back seat. I have followed trial results at each stage and am glad to have done so.
Hi,
I was diagnosed at the end of 2014 with Stage 4 prostate cancer, my PSA was 100+ with high Gleason scores of 8. Scans showed metastases
in my pelvis, hip joints and ribs. I originally went to the doctor because of hip pain resulting from a pelvis fracture. I was shocked that I had cancer and had never gotten any PSA or other tests previously. Anyway, I went on docetaxel for 18 weeks (6 cycles) and Eligard (ADT). Within 3 months my PSA fell below detection and ongoing scans showed that the cancer progression had stopped. I am still on ADT, and get regular bloodwork and scans. So far so good, though eventually my PSA will rise again as the cancer goes resistant to the Eligard/Lupron. I’m thankful for the good years I’m having now and try to stay as stress free and healthy as possible. Chemo was no picnic, but I believe that in combination with ADT has prolonged my life. At the time of diagnosis I was given 3 to 5 years to live by my oncologist. I’m at 4.5 years now and going strong!
Hang in there....
Doc meant 3 X 5 =15 squared = 225 - 200 = 25 years.
Happy Eastern Orthodox Easter.
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 04/28/2019 6:19 PM DST
Thank you for posting, this really gives me hope. You're first news about cancer is a lot like mine. Having not real symptoms, I was shocked, now thank it's not in soft tissue. YOUR ARE AN INSPIRATION!!
I had the loading dose of degarelix Dec 17, after diagnosis of extensive bone Mets, then 6 rounds of docetaxel Jan-May last year. Apart from hair loss, fatigue is the biggest problem. Just do what he can. I bought a cross trainer from eBay. I didn’t have much of a holiday; PSA started to creep back up and started Abiraterone/Zytiga this January, and seem to be doing well. It took me a year to fully embrace the horror and get in a happy place; ironically, with a chronic/terminal illness, I’ve never been happier. It helped when I swapped from degarelix (which left me with a sore stomach) to decapeptyl, getting a twelve weekly shot instead of four weekly. I found less obsession and better quality of life. Good luck and keep positive.
Yes, same situation. PSA dropped from 2000 to .04 . Reduced bone and lymph node mets. PSA began slowly rising about a year after chemo. Docetaxel was relatively easy to tolerate.
Keep the faith!
Thank you for asking that question. (My husband and I both read and respond to these threads) With that being said, he has the similar situation. Was diagnosed last month, Metastatic no soft tissue spread. He started Cassodex 10 days ago, had his fist Lurpon a week ago along with Xgeva. He sees doc tomorrow to decide between Zytga and Chemo. We are leaning toward chemo for two reasons, doc continues to say her gut feeling tells her chemo may be best option for him after treating men for a decade, but Zytiga is his alternative. After reading the Stampede study, it is my understanding that men with a low metastatic burden have a higher success rate with radiotherapy over those with a high metastatic burden. (But I'm just a layman) So we are leaning toward the chemo due to his high rising PSA count and if doc believes there is any chance of his cancer being the high metastatic burden. His thought is go in and kill the suckers ASAP, rather than risk Zytiga wasting his time. For what it's worth, I hope this is helpful.
Very helpful - - thank you! We'll have to keep each other up to date.
kill those suckers ASAP.... DITTO
Happy Eastern Orthodox Easter.
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 04/28/2019 6:27 PM DST
Stsge 4, PSA at dx was 34. Went straight to zytiga and lupron. Had multiple mets, all to bone, no soft tissue. My PSA nadir was 0.32, started rising again to 1.79, so we did scans. No new progression and all but 3 mets were dark/resolved. The 3 remaining mets have had their activity reduced dramatically. I assume IV chemo is down the road for me. No pain, get to the gym 5 days a week still, and I'm still working.
My husband I think is in a similar situation....He started 28 days of Casudex and has 8 tables left to go (to minimise the testosterone flare from the Lupron) . Two weeks ago had the first of his 3 monthly Lupron shots. Not sure if Lupron is similar to Firmagon. No side effects as yet...
Lupron and Firmagon are both androgen inhibitors (hormonal treatment). Firmagon works faster and doesn't cause testosterone flair. Casodex is given with Lupron to tamp down that initial flair.
Loupron and Casodex started Nov. 2017 along with chemo until March 2018 Zytiga started in April 2018 along with the loupron PSA currently at .1 .Cat scan and bone scan last Friday showed a decrease in some mets and the other ones are stable. He is a gleason 10 with ductal prostrate cancer and ATM gene . My advice is hit it hard with all you can.
CantChoose, I did sort of..... the newer treatments were not available in 2004, however a chemo-ADT Trial was...... and, I did more than Taxotere infusions for my Stage 4 with Mets to my spine.
“Each course of chemotherapy lasts for 8 weeks. Patients were treated in weeks 1, 3, and 5 with doxorubicin 20 mg/m2 as a 24-hour intravenous infusion on the first day of every week in combination with ketoconazole 400 mg orally 3 times a day daily for 7 days. In weeks 2, 4, and 6, treatment consisted of paclitaxel 100 mg/m2 intravenously on the first day of every week in combination with estramustine 280 mg orally 3 times a day for 7 days. 30 mg of Prednisone everyday through the three courses of chemotherapy.
As a working hypothesis, investigators suspect that the transformation from an androgen-dependent to an androgen-independent phenotype is mediated by expansion of an androgen-independent clone already present at the time of ADT that continues to grow while androgen-sensitive clones are being suppressed. It is thus desirable to bring treatment to bear on the androgen-independent component while the corresponding tumor burden remains minimal and prolong the time to hormone resistance. Investigators view the androgen-independent component as analogous to "microscopic residual" or "micro-metastatic" disease, for which adjuvant chemotherapy has been shown to be effective in other contexts, even when the same drugs had little or no impact on survival in the setting of more advanced disease.
Chemotherapy for hormone-refractory prostate cancer reduces PSA levels and enhances overall survival (OS), suggesting that administration in earlier disease stages may be beneficial. If expansion of an androgen-independent clone is present during androgen deprivation mediates the transformation from an androgen-dependent to an androgen-independent phenotype, combination chemohormonal therapy could be effective initial treatment for locally advanced or metastatic prostate cancer. This study examined the efficacy and safety of chemohormal therapy approach.”
No co-morbidities, tumor burden minimal and body strong are important.
Gourd Dancer
Wow, that makes so much sense. Kill both subtypes, instead of just selecting for the more lethal one. Thank you for sharing!
Extensive mets to bone, some abdominal lymph nodes. Lupron, Xgeva, 8 cycles chemo, 20 months Xtandi. Psa 59.9 to 0.1 Alk phosphatase from above 200 to normal. Had to take neutropenia shots, had usual side effects but also developed very annoying foot neuropathy after chemo. You may want to look into icing (I was unaware of this). Lymphs nodes now "normal", mets "subtle", next scans June or July. Diagnosed March 3, 2017. Would do the same: chemo 1st (get it over with), and then Xtandi or Zytiga if you have lots of mets. Good luck.
Thank you, very helpful information. My husband started chemo infusion yesterday, right out the gate as someone said. No side effects after 32 hours, just continued fatigue.
For most a general crappy feeling kicks in about 3rd day and lasts about a week. You then start feeling better until its time to do it all over again. By my 8th cycle felt crappy for 2 weeks. But then I was done. The dexamethasone and I did not agree with each other so had insomnia for 3 days each time, used pickle spears for sore throat and midnight snack. I am assuming there are bone mets. I had a spike in alkaline phosphatase after 1st cycle, then gradual downhill trend. A little above 200 to 60's. Now 72. Learned that on this site. Indicates bone activity. Lupron and chemo brought psa from 59.9 to 7 and downward and addition of Xtandi has me at 0.1 Two years 3 months in. 21 months Xtandi. Wishing you well. (I should sail by my 2 and a half expiration date with ease.) Having genetic testing set up this morning. Good luck.
I have high burden metastatic PCA, diagnosed 9 months ago. I began with Lupron then added docetaxel shortly afterwards. I have not had Zytiga or any other ADT so far. I completed 6 cycles of docetaxel while continuing Lupron. I have been very fortunate to have had a great response. My PSA dropped from 148 to 0.16 and is still going down. Bladder and pelvic lymph node involvement has disappeared on imaging. Bone metastases that were hot on bone scan are no longer seen (the bone changes are still there on CT but the scan suggests that they are not now active. My oncologists all agree that my response has been as good as possible so far. I have a primary oncologist and I have had 2 other opinions at other centers, and they all recommend the same thing - For now, continue Lupron and follow PSA until it starts to rise, unless some new research results suggest I should do something else. I am fortunate to feel well plan to get on with my life for as long as I can. I am realistically optimistic that I have a few good years ahead of me before the PCA rears its head again.
Having said all that, it is only my experience, and not everyone does as well as I have so far. As for which to choose, the evidence is that docetaxel and Zytiga have similar benefit. Docetaxel is done and over after around 6 cycles, but you have to put up with chemo side effects. Mine were not too bad, but again, that was my experience. Zytiga goes on indefinitely, and has to be taken with steroids, so there are other issues to deal with. There does not appear to be a right or wrong choice. It has to be your own, in consultation with the oncologist. Further studies are in progress to see if one is better than the other, and to determine if adding one to the other has any benefit.
Hi, I had Lupron and Casodex, then the first of 15 Taxotere sessions in 2015 two weeks later. PSA @ 840, GL 7(4+3), Mets to L ureter lymph nodes. PSA nadir of 0.1 in 2017 for 3 months. Restarted Lupron - after an 18 month holiday - on 12/14/18. PSA down to 3.8 from 10.2 in 12/18. My best to you both - Randy
We decided to go this route (ADT + Docetaxel) after my husband's latest bone scan revealed multiple mets. Previously we thought he had only pelvic lymph node involvement, and he had started on ADT a few months ago. The onc. proposed doing either ADT + Zytiga or ADT + Docetaxel as options due to the recent aggressive spread of the mets .
Based on everything I have read on this subject, it seems like the chemo may have a chance of killing cancer cells that are not hormone sensitive and early use is showing promise. We are only one round in so we don't have new PSA numbers yet but will in a few weeks, and he will have more scans after the 6 cycles are done. There are side effects from either route to consider. Since my husband is young and in good shape we decided he should do chemo while his body can handle it and not wait to become hormone resistant when it probably will have fewer beneficial effects. Zytiga is still out there as an option if the chemo doesn't work, too.
Hello,
My dad was diagnosed less than a year ago. PSA 1200, lymph node mets and a few hypothesized bone mets. We chose to go aggressive. Casodex 10 days, Lupron and Docetaxel (6 rounds). It wasn't without side effects and I would go into more detail but really.......everyone is different.......everyone's body reacts differently. My dad happened to one who had a side effects to EVERYTHING! But the simple truth of the matter is that he got through it! It wasn't always easy but he was ready to fight. Last weeks PSA, CT, and Bone scans came back........drumroll.........PSA went from 1200 to 0.11. CT scan showed lymph nodes have shrunk to normal size and bone scan can find no cancer. (A few sclerotic lesions on bone which are just scars left behind from treatment) Prior to diagnosis, he was wasting away from cachexia. It was awful! He has put his weight back on and looks so healthy. For him, hitting it hard because of the aggressiveness of the cancer was a great call. He is responding well to the ADT now that chemo is over and the doctor is hoping for YEARS with this protocol. I wish the best for your husband and family. - Linda
Glad it worked out so well for you. Wishing him many years of healthy remission.
Thank you CantChoose. Keep us posted
Great news and very inspirational for those on the same road of treatment. Thank you for sharing, and I wish him many years of healthy remission, too!
Hello. One year ago I was diagnosed with primary PC Gleason 4+5, multiple bone and lymph node mets. ADT +Docetaxel - which provided sufficient margins on the primary so then surgery RP and pelvic lympadenectomy (14 nodes - 5 malignant). This followed by SRT and salvage radiation (38 treatments). Have now stopped ADT and testosterone slowly building again. PSA undetectable for the past three months. If/when it returns I have agreed treatment plan using radionucelear peptides (Lu177 and Ac225 PSMA 617) In summary, chemo + ADT worked for me. All the best.
PSA time to nadir as a prognostic factor of first-line docetaxel treatment in CRPC
Only ADT + Apalutamide as treatment
Strong negative reaction to first Docetaxel treatment
Chemo as first treatment
