three months into treatment. Update on outcome and next step please.

[Juliane314]

My dad has been on ADT+Zytiga for three months since diagnosed in Aug 2019 . He receives treatment in China His initial PSA was 39 (G10) with 3 bone mets (pelvic area). Last PSA (end of Oct) was 0.02. Bone scan and MRI showed improvements on all mets. He is also BRCA2 positive.

We consulted with two top oncologists in China for the next step, on top of ADT+ Zytiga: one suggested radical surgery on prostate, the other suggested radical surgery on prostate + radiation therapy on mets.

It's very common for doctors in some large institutions to perform radical surgery on oligometastatic patients in China. I read a few retrospective Chinese studies showing positive data on it. But I am still very hesitant about surgery. Based on what I see in this forum, RS is rarely performed by western doctors on metastatic patients, even if they are oligometastatic. However, I am also concerned if we don't do surgery,we might not do all what we should do if my dad could eventually benefit from the surgery. His cancer is very aggressive, and the oncologists said 3-4 months into the initial treatment is an excellent timing for surgery

We also asked the Chinese doctors' opinion on using PARP inhibitor now, we were advised that there is no evidence to show benefit to use it before Zytiga fails.

Can you please share your thoughts on the next step for my dad? What would a western doctor suggest if he was here in the USA?

Thank you!

[Tall_Allen]

He can have radiation to the prostate, pelvic lymph nodes and bone mets. Docetaxel or cabazitaxel with carboplatin followed by a PARP inhibitor may be a good strategy given the BRCA mutation. He can follow that with Zytiga.

[Juliane314 in reply to Tall_Allen]

My dad is on Zytiga now and it's working very well, for next steps, aside from the radiation, do you suggest to switch to chemo + carboplatin now then PARP inhibitor then switch back to Zytiga? Just want to make sure that I understand your suggestion properly.

I mentioned adding PARP inhibtor to his treatment now to his oncologist, but he said no evidence for benefit at this stage. So basically his approach is to wait till Zytiga fails then try PARP inhibitor. Do you know of any researches supporting early introduction of PARP inhibitor (as first line treatment) as opposed to introducing as a second line of treatment?

[Tall_Allen in reply to Juliane314]

No, I know of no studies on early use of PARP inhibitors.

[nycrunner]

Contact Dr Song in Xiangtan.

[GP24]

A recent prospective study in England showed that radiating the prostate will be beneficial for you dad: esmo.org/Press-Office/Press...

They did not test surgery in this trial but there is no obvious reason why surgery will not work just as well.

If they did test it and found BRCA2, they probably suggested a PARP inhibitor like Olaparib.