Best treatments for metastaic prostate cancer? (Non-hormone resistant)

[chillpill7]

I have seen various studies that show that xtandi in combination with docetaxol may work better than either of them alone. My grandfather will be undrgoing docetaxol treatment after many years of lupron and radiation. It now has metastisized to bone in lumbar region. There is also some swollen lymph nodes. Is decoetaxol the best treatment option? Should we request the combination of enzalutamide and docetaxol? What about Provenge and Radium 223? Whats the best options for him?

Thanks

healio.com/hematology-oncol...

[tango65]

If he has metastatic hormone sensitive PC the treatment usually is done with ADT plus chemo with docetaxel or ADT plus abiraterone/Prednisone. The results are similar according to the Stampede trial:

ncbi.nlm.nih.gov/pubmed/295...

Docetaxel does not offer an advantage if there are few metastases (3 or less).

ncbi.nlm.nih.gov/pubmed/293...

The combination of enzalutamide and docetaxel has shown some advantage for progression free survival at 6 months in castration resistant PC.

ascopubs.org/doi/abs/10.120...

Provenge and radium 223 are approved to be used in castration resistant PC.

[chillpill7 in reply to tango65]

Are both Lupron and Enzalutamide both ADT? He was on lupron for a while but didnt make him feel good. So he denied further treatment with lupron. Should he stay on lupron at least for the 6 weeks of docetaxol. Would it potentiate it like enzalutamide?

I am bit confused would he be considered castration-resistant ?

[tango65 in reply to chillpill7]

If the cancer is progressing (increasing PSA and/or new metastases) with a testosterone less than 50, he will be considered castration resistant, particularly if his PSA is 2 or higher.

The clinical trials for metastatic hormone sensitive cancer (you said he is non-hormone resistant) showed a survival advantage when ADT (lupron or similar) were combined with docetaxel, or with abiraterone/prednisone.

If he is castration resistant he should continue with lupron (ADT) since castration resistant cancer is very sensitive to the concentration of testosterone.

Some info about castration resistant cancer treatment:

cancer.net/research-and-adv...

[chillpill7 in reply to tango65]

I confirmed he is taking lupron and has started his first round of docetaxel. Do you think he should of did provenge first before going straight to the chemotherapy? Are there any things he can be taking like metformin that can help synergize with docetaxel? In other words what would help it to prevent drug- resistance?

[Tall_Allen in reply to chillpill7]

He needs to stop testosterone production - Lupron, Firmagon,Orchiectomy,Estrogen patches, possibly even Zytiga without Lupron. Everyone in the study you cited, took Lupron (or something like it) too. Radium 223 and Provenge has only been used with it. Radium will do nothing for soft tissue mets.

[chillpill7 in reply to Tall_Allen]

Hello,

Thanks for your response. I did let him know that Provenge is available and should ask his doctor about it? So Xtandi will not help with stopping testosterone production like lupron or the other ADT's you mentioned.

I know he is getting a hormone treatment next week then will start chemo the following week. Im not sure what hormone treatment is but I know he will start chemo the week following it. As far as lupron, he said it costs him a huge out-of-pocket expense of 5k a month and had some side effects. Should I let him know that staying on lupron for at least the next 6 weeks while on chemo is a good idea and worth it no matter the out-of-pocket expenses? I will also let him know about the estradiol patches.

[Tall_Allen in reply to chillpill7]

If he can't afford Lupron, some men have used 150 mg/day of Casodex. It's not as effective, but it's better than nothing.

[CarterW in reply to Tall_Allen]

Yes. My husband has just started 150mg of casodex/bicalutamide because he could not tolerate lupron (suicidal, panic attacks, couldn't add 3+2, couldn't remember anything, etc). It's costing us a whopping $15/month for the pills.

[jmurgia in reply to CarterW]

After 16+ years of no treatment I started 50mg Casodex monotherapy 4 months ago. It has knocked my PSA and Alk Phos down 90%. Improvement in CT and bone scans. Only side effect is some minor nipple pain. Hard to tell if I have gynecomastia. Costs $20.00 for 90 days.

Joe M.

[GP24 in reply to tango65]

Tango,

"Docetaxel does not offer an advantage if there are few metastases (3 or less)."

The STAMPEDE group treats these low volume patients with Docetaxel too. AFAIK they will publish results this month which shall show that this is benefical. Then there will be conflicting evidence for this patient group.

GP

[chillpill7 in reply to GP24]

So then docetaxel would be the best route for him? He is probbaly in the camp of 3 or less. He took lupron last week then did 1st treatment of docetaxel yesterday. Is there anything else he can be doing to maximize the treatments? I do wish he did immunotherapy first but Docs wanted him to start chemo. I read somewhere that perhaps docetaxel and enzalutamide work better than docetaxel by itself. Do you know of any such combinations?

[GP24 in reply to chillpill7]

Tango cited an American study which reports that there is no benefit to add Docetaxel when there are only a few bone metastates and I cited an English study which will soon report, that there is a benefit. I cannot decide which of the two is right, but I think, if you want to maximize the treatment, you should take Docetaxel.

I am afraid that Docetaxel will have side effects so I would not try to add any additional treatments while the Chemo is administered. You can do that when it is finished and your grandfather has recovered from it.

Then you can observe for a while, which is usually done, or radiate the prostate or add Zytiga. I would radiate according to this study:

esmo.org/Press-Office/Press...