Oncologist gave bad news about the cancer

[dunde8889]

We were just told that despite two treatments of jevtana the liver metastasis has enlarged. My dad got an ultrasound today which was compared to an Axumin scan at the end of July, and the liver spots are much larger some three times as much. The oncologist is recommending to stop Jevtana and try Keytruda since he has the gene mutation. Liver spots were never biopsied. He says given the high PSA he does not believe it can be neuroendocrine which doesn't produce PSA. He gave a prognosis of weeks if the cancer progresses as is.

He started jevtana on 8/5 and had a second treatment on 8/26. Liver tests were fluctuating.

Liver tests were as follows:

7/26 - ALT 190 AST 130 ALP 513 and bilirubin 0.8. PSA was 79

8/22 - ALT 95 AST 65 ALP 475 and bilirubin 1.2 (abnormal). PSA was 85

8/31 - ALT 135 AST 80 ALP 505 and bilirubin 1.7 PSA 140

9/3 - ALT 110 AST 70 ALP 525 and bilirubin 1.3

Please provide your thoughts on the recommended plan. We are going to have an appointment next week to discuss what we want to do. TIA

[Tall_Allen]

Discuss adding carboplatin to Jevtana. When you say he has a gene mutation, I assume you mean germline BRCA2? Too bad they can't biopsy and do an IHC analysis.

[dunde8889 in reply to Tall_Allen]

Thanks for your input Tall_Allen.

They did a strata NGS test which should MSI high. He recommended stopping chemo if starting keytruda. He also offered alternate chemo if we decide against keytruda. I cannot find anything about both chemo and keytruda together.

Regarding the biopsy - the oncologist feels it would not change management, but if we push for it he may approve it.

I feel like we have only one shot at figuring out what to do because if it doesn't work he may not make it to trying something else.

[Hidden in reply to dunde8889]

If it were me, I would push to get the biopsy of the liver mets so you can find out If the liver mets have neuroendocrine characteristics. If they do, you can add a platinum chemo such as Cisplatin or Carboplatin. If not, adding a platinum chemo probably won't be a benefit. With the biopsy, you have more information and know what your options are. You can make a decision based on that knowlege. That's my opinion.

[Tall_Allen in reply to dunde8889]

So they did biopsy a tumor. The strata NGS test is done on biopsied tissue - no? It's good you had that analysis. Keytruda has excellent results with MSI-hi. Chemo + Immunotherapy is a great combination, imho. What other genetic markers did it show?

[dentaltwin in reply to Tall_Allen]

Do you know if they test prostate tumors for PD-1/PD-L1 expression when considering checkpoint inhibitors?

[Tall_Allen in reply to dentaltwin]

Yes - and 500 other genes.

prnewswire.com/news-release...

But MSI-Hi is the key one to get Keytruda because it is FDA approved for that regardless of the cancer.

[dentaltwin in reply to Tall_Allen]

Great--I'm more familiar with them in the context of NSCLC

[dunde8889 in reply to Tall_Allen]

They biopsied him at diagnosis a few years ago and he had a palliative TURP earlier this year which they also sent to the lab. So I'm not sure which they sent for the strata test. I didn't even know they did it. The oncologist just spoke on the phone with us today after the ultrasound. We will meet him on Tuesday to discuss plans and our decision. I will ask him for the report with the genetic markers to find out about other markers. I do not see them on the biopsy report I have.

Do you still think chemo will be effective with immunotherapy compared with immunotherapy alone? The reason I ask is that so far chemotherapy has not helped.

[Tall_Allen in reply to dunde8889]

It depends upon what the genomic analysis showed. Carboplatin seems to work in the same sorts of situations in which PARP inhibitors work. Let us know what their analysis found. BTW- did your insurance cover the StrataNGS test? I hope they used the most recent tumor tissue.

[dunde8889 in reply to Tall_Allen]

I believe the insurance covered it since we didn't pay any extra for it. I will update once I get the report. Thanks a lot for your insight.

[Tall_Allen in reply to dunde8889]

I think insurance companies have been increasingly covering it since NCCN endorsed it as standard of care.

[dunde8889 in reply to Tall_Allen]

I got a copy of the report, positive genomic findings include ATM, MSH2, RB1, TP53 and MSI-H.

BRCA was negative. Oncologist started keytruda only without chemo or a PARP inhibitor. What are your thoughts? Would a PARP inhibitor be helpful with negative BRCA mutation?

TIA

[Tall_Allen in reply to dunde8889]

He is starting Keytruda because of the MSI-Hi. It is approved for that and sometimes has excellent results.

[CantChoose]

Why wod you not go with Keytruda if he's got the gene mutation? There are people out there getting total responses:

healio.com/hematology-oncol...

[dunde8889 in reply to CantChoose]

I'm scared. The other option is adding carboplatin so I'm not sure which would be a better option if we only got one shot.

Thanks for the article, its giving me hope.

[vandy69]

I also have 20+ liver lesions and being treated with Docetaxel/Carboplatin chemo combo. Key to my treatment was CT guided biopsy of liver. PCa mets In liver caused Med Onc to use Carboplatin. He said that straight up liver cancer is a “better” diagnosis than PCa mets in liver. This was the only time I wished for another type of cancer!

Best Wishes. Never Give In.

Mark, Atlanta

[j-o-h-n]

For the umpteenth time here.... Keytruda is working for my lung melanoma.

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 09/08/2019 11:14 PM DST

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

Glad for you my brother