Next line of treatment: too many options

[Nettie8200]

Hello all,

I would be so grateful for some advice or thoughts on my dad's situation.

He's 70 y/o, diagnosed metastatic PC in March 2018, with numerous mets to many bones. We were caught off guard--he was (and still is) physically feeling pretty well. At its highest, PSA was 56. He's being treated by Dr. Maha Hussain at Northwestern in Chicago. He has other existing health problems: atrial fibulation, managed type II diabetes, managed high BP, and some vision problems.

Treatment thus far has been 6 rounds of Taxotere in summer/fall of 2018, and Casodex plus Zoladex. Taxotere was tough on him--he got through it but Neulasta especially was painful.

His PSA continued to decline all the way to about 2.5, but about 2 months ago it started to increase. Casodex was removed but PSA and Alkaline Phos is still trending up, despite very low testosterone.

So now we are faced with some options, and feeling overwhelmed by them.

Option 1: Move forward with the standard next line of treatment, Zytiga or Xtandi.

Option 2: Try and be a part of clinical trial EA8153 (clinicaltrials.gov/ct2/show... with placement in one of two groups. Group A has Jevtana and Zytiga simultaneously. Group B just gets Zytiga.

Option 3: Try and be a part of clinical trial 16U05 (if biopsy shows BRCA mutation) (clinicaltrials.gov/ct2/show... which, depending on which arm he is placed in, could mean being treated with only olaparib (Lynparza), or only Zytiga, or both Lynparza and Zytiga at the same time.

There is possible overlap in these options, and a new biopsy may eliminate option 3 for us, but I'm wondering if anyone out there can speak to the experience of Jevtana, or know much about the success of Lynparza.

Many, many thanks in advance.

Annette

[Fairwind]

If it were me, I would add Zytiga / Prednisone right now and see how he responds to that..Try to maintain quality of life while while getting good treatment results..I would save the trials and chemo for when nothing else is working ..We all want to live as long as possible but a few months extra survival might not be worth it if he is miserable during those extra months....

[Nettie8200 in reply to Fairwind]

Sorry, I forgot to mention, if he starts with Zytiga right away, he will become ineligible for the clinical trials.

[BarronS in reply to Nettie8200]

Many combination therapies that I have seen have not added in any type of benefit, just more toxicity. I would just go with standard of care and move on to zytiga and once that fails, try xtandi.

[Hidden in reply to BarronS]

I agree with both Fairwind and BarronS. Zytiga is very effective and proven. There is no reason to go beyond that and add additional toxicity of chemotherapy right now for something that has a chance of not giving him anything. Save the chemo for later if needed.

If he has a BRCA mutation which is unlikely, the PARP inhibitor trial might be worth it since he would get Zytiga in any case.

[Tall_Allen]

I think those both sound like good trials to enter now. Whether option 2 or 3 depends on the biopsy findings, so you can't decide between them yet. Based on his good initial PSA response (albeit short-lived) to the first taxane, you have every reason to believe Jevtana may be beneficial. And if he is BRCA2+, a PARP inhibitor may be useful. Either way, he would certainly get Zytiga, which is the standard next step (so you can eliminate option 1 from consideration). BTW- I think you can't do better than Maha Hussain.

[Nettie8200 in reply to Tall_Allen]

Thank you for your insight!

[Hex40]

I’m receiving treatment from Dr. Alicia Morgans at Northwestern and hope Dr. Hussain’s insights may come into play with me if needed.

[Nettie8200]

Thanks, Bill.

[NPfisherman]

I think you should listen to Tall Allen, and look at the trials because you will be placed on Zytiga, no matter what you do, and it helps add to the knowledge base. For myself, I participated in an apalutamide trial prior to surgery and felt good that I did it. I would participate in a trial now, but my MO states he doesn't want to upend the apple cart--doing well now, thanks be to God......At some point, I will participate again.

While many have this disease, it takes time to enroll people due to willingness to participate, physiological restrictions, treatment restrictions, etc, which leads to slower answers in defining best treatments for the disease and combination therapies. This is how AIDS became more of a chronic disease. First line therapies were figured out and combos, and sequence of treatments. It's what we need.

If you choose to participate in a trial, I salute your father and you in your courage to be part of the answer for all of us.

Fish

[CantChoose]

We also see Dr. Hussein. My husband is getting ready to start taxo, so this decision is down the road for us, but you will also likely have Erleada on the list in a few months as well.

As TA said, you don't really have a decision to make, unless you want to just stick with the Zytiga or Xtandi alone and skip the trial altogether because you are concerned about toxicity or quality of life. If he has the BRCA gene, go with that trial, but that's not likely.

urotoday.com/conference-hig...

[Wongle1]

Hi here we are far more behind I think so a lot of treatments are not available but on e Steve's phosphate levels rose they said there was nothing more as it meant the cancer was spreading and it was in his blood I hope your dad has better luck and finds a treatment to slow it down sorry I have not been much help x

[JuanVV in reply to Wongle1]

I'm sorry to hear that, my husband also has high phosphates, how high did your Steve's go? Nonetheless it has lowered a bit since he started Xtandi.

[Wongle1 in reply to JuanVV]

Over 300 Steve's did go down on the same medication but then started going up x

[JuanVV in reply to Wongle1]

Thanks x

[Mish80]

Can I ask what treatment she organised for you ?

[Braveheart1a]

great to hear you are doing so well! I recently was diagnosed with similar #'s to yours...may I ask what treatment you went through???

Thanks!

Craig