I was dx 7+ years ago with advanced PC with 3-4 bone mets, PSA in mid-40s and a Gleason score of 9. Was placed on Lupron and Zytiga(Z) with Prednisone(P) on an intermittent basis. Had prostate removed 4 months after treatment and had my "hip" radiated about 1 year after dx. After 5 years of intermittent treatments, that included 3 "vacations" (17, 9 and 3 months respectively), I was placed on Lupron ONLY, continuously a little more than 2 years ago. My doc was concerned about the possible long term side effects of Pred, so she didn't have me on Z for last 2 years. I have always responded well to the medicines, (with <.05 PSA and no progression on scans, UNTIL this week. My PSA is now at .08. My doctor is now ready to start me on Z with Pred. The question I just messaged her, is the question I have for all of you. IF long term side effects of Pred are a concern, why select Z (with Pred) over Apaltamide. It's my understanding that they have similar results and that you don't take Pred with Apalutamide. I appreciate your thoughts.
Zytiga Versus Apalutamide. Which One ... - Advanced Prostate...
Zytiga Versus Apalutamide. Which One Should I Choose?
If prednisone is only the replacement dose, it should not be a concern:
pcnrv.blogspot.com/2019/06/...
Apalutamide seems to be equally effective and has a similar side effect profile to Zytiga. They've never been tested against one another in a randomized trial. Their modes of action are different. There is no data on cross-resistance yet.
Thank you, Tall_Allen.
I was also wondering what you thought about radiating my 3-4 tumors on my 2 verterbre,
my "hip" (again) and my rib (if, in fact I actually have a met on my rib)
I don't know if it really accomplished anything in terms of slowing down the cancer, but maybe it prevented spinal compression.
Tim- I don't think my post regarding radiation was clear. My "hip" was radiated 6 yrs ago. BUT- the other 3 mets were NEVER radiated. The mets on my spine were never radiated. I am wondering if that is something that may be worth doing.
Thx again.
There is no known survival benefit in doing that. However, it may prevent spinal compression later on. Talk to a radiation oncologist about safety.
But- doesn’t the Oriole study indicate a benefit to radiating the tumors?
It showed a benefit in biochemical progression-free survival -- in other words, SBRT to mets reduces PSA, which is not surprising. Most of the PSA in metastatic PC comes from the largest tumors, so ablating the largest tumors reduces PSA. Some have called this "treating PSA." But treating PSA is not necessarily the same as treating the cancer. Will it translate into long-term survival increase? That's impossible to say. Keep in mind that there are many thousands of cancer cells that were not treated. Follow-up was only 6 months (and it included only 36 treated men)- not nearly long enough to detect a survival increase. To me, the most encouraging finding of the trial was that there was an increase in activated T cells. Perhaps those activated T cells will go on to kill remote cancer cells (called the "abscopal effect"), perhaps not (because immune stimulation is short-lived). Here's my analysis of the ORIOLE trial:
pcnrv.blogspot.com/2019/09/...
Your blog post is a lot more positive on the subject than this post. Seems like it’s worth doing if the location doesn’t pose too much risk to adjacent tissue
Schwah
I agree that if safe, why not? I'm just saying the evidence for it so far is weak. Since I made all those points in my blog post, I don't know that one is more optimistic than the other.
Apalutamide is very similar to enzalutamide. Both cross the blood brain barrier and they make cause neurological symptoms such as falls and even seizures. They could also cause significant fatigue in some patients. Apalutamide may also have some negative effects on the liver.
onclive.com/insights/nonmet...
livertox.nih.gov/Apalutamid...
The main side effects of zytiga are different. They are caused by an increase in aldosterone with retention of sodium, increased elimination of potassium which could lead to edema, hypertension and hypokalemia. These problems are controlled by given steroids like prednisone or dexamethasone which could prevent the increase of aldosterone.
Some patients with hypertension and/or diabetes may have problems with the control of the blood pressure or the glucose in blood (glicemia). There are drugs such as inspra which could also help to control the aldosterone effects and they could be used to reduce the dose of prednisone . Abiraterone (zytiga) could also affect the liver:
livertox.nih.gov/Abirateron...
These are lists of the side effects of apalutamide and abiraterone (zytiga):
Thank you, Tango. One more thing. Do you have any thoughts about radiating my 3-4 mets (one of which was radiated 6 years ago?
I would discuss irradiating the metastases if it is possible to do it.
Your PSA is very low. You could discuss to irradiate the metastases and then wait until the PSA is over 0.2 without a systemic therapy other than Lupron or similar. When the PSA it is a this level try to get a PSMA PET/CT (Ga 68 or 18 F DCFPyl). There are some clinical trials:
clinicaltrials.gov/ct2/resu...
clinicaltrials.gov/ct2/resu...
If there were new metastases you could discuss the possibility of having Lu 177 PSMA treatment abroad (Germany or Australia), or discuss if it is possible and prudent to irradiate the new mets.
I am in a similar situation. I had many lymph nodes mets in the pelvis and abdomen in 2016. I got treated with Lu 177 PSMA in Germany. The mets were clear of cancer after one treatment. I stayed with castration for the last 3 years. My nadir PSA was 0.05 and it has been increasing, It is 0.5 now. I had a Ga 68 PSMA last January and it was negative for mets. I will have another Ga 68 PSMA at the end of this month. The plan is to do radiation or Lu 177 PSMA treatment if there are metastases depending on the number of mets and their location. I consulted about this plan at the Sloan Kettering Cancer Center and Dr. Morris supported the plan.
The early use of Lu 177 PSMA treatment may offer an advantage in overall survival.
jnm.snmjournals.org/content...
The idea is to delay as much as possible the use of the new anti androgens including zytiga and chemo.
Best of luck on your journey.
Tango- Interesting. But- just wanted to be clear about one thing. When my prostate was removed 6 yrs ago, they did find one dirty met among the more than 30 lymph nodes they removed from me. However- all my other mets, including the one in my "hip" are bone mets. So- are the ideas you mentioned appropriate for someone like me who ONLY now has bone mets? I thought I read posts weeks ago indicating certain treatments being good for mets in lymph nodes and or organs, but that were not good for mets. Was LU 177 one of those?
BTW- I am treated at MSKCC. You said you saw Morris for a 2nd opinion. Who and where is your main oncologist, if I may ask?
Lu 177 PSMA treats all mets, lymph nodes, visceral and bone mets. It is a systemic treatment the same than chemo, anti androgens, lupron etc. Cancer expressing PSMA will be attacked by the Lu 177 PSMA .
What I said is not the standard of care. It is a different approach and you have to discuss it with your doctor if you were interested.
It is not the standard of care to stop zytiga treatment in metastatic patients but your doctor decided to do it . He/she may be opened to different alternatives of treatment.
Tango- I read the article in the link you provided and I think what you said makes sense. I also went to the other link that listed the various clinical trials and have already responded to one at Weill Cornell. I will keep looking to see if I can get the LU 177. Many thanks.
This is a list of clinical trials for Lu 177 PSMA treatments:
clinicaltrials.gov/ct2/resu...
People who can afford it, go abroad (mainly Europe and Australia) to get treatment with Lu 177 or Ac 225 PSMA. I went to the Technical University of Munich. There were not trials about Lu 177 PSMA treatments in 2016.
Were you also on ADT while getting the LU-177? My husband’s doc wants him to try LU177 overseas with a rising psa and no adt.
We are considering Germany now. Can you tell me where you went?
One other thing to consider: Prednisone can be both stimulating and anti-inflammatory. These can be very good effects if you're dealing with fatigue and pain. I've been suspecting that Prednisone is more than offsetting the side effects of Abiraterone in my specific case. I was downright manic at times during the first month or two.
That is such a low dose of prednisone. Now recommended at just 5 mg daily. Shoul not be a problem
Sounds like your doc knows what he is doing with the intermittent therapy as tour response is unbelievable. Just don't do too much Lupron.
Zytiga versus xtandi
Zytiga Side Effects Inquiry
Should I have prostate removed
Hmm... Myelodysplastic syndrome??
in zytiga limbo. 
