Dads case, psa climbing on zoladex

[paritosh1010]

Hi everyone

This is my first post here. I have found really helpful advice reading this forum.

My dad is a 64 year old male from India. Here’s his history:

In 2014, my father is having CA prostate. Radical prostatectomy done in June 13 with histopathology of T3 N1 M0 disease (Gleason 4+4, extraprostatic extension with clear margins , no SV involved and one periprostatic bed in positive). Over a period of 3 years his PSA rose to .2 from .04 and he underwent IMRT 33 cycles in October, 2016. His pre-RT PSMA scan which was done in Sep 2016 was normal. In January 2017 surprisingly his PSA rose to 0.9 from one lab, and to 1.8 from another lab. He was diagnosed to have a small peanut size mets in right subtrochanteric region of femur. Has been advised adt plus rt ( 10 sittings). The PSA reading was 2.8.

Since then RT and ADT, he has been on ADT (zoladex, every three months) since Feb 2017. His PSA has stable around <0.008ng/mL.

On November 8, 2019, his PSA rose to 0.032 ng/mL. On dec 18, his PSA is 0.064 ng/mL.

We are seeing a couple of docs in the US, but since parents have to travel it makes it a less frequent visit.

We have the following questions:

1. At what frequency should we continue to do the PSA test?

2. Would a scan help? If not, at what point would it help? We are thinking MRI, bone scan, PSMA PET.

3. Should zoladex be continued? His last dose is due in February. ( three year ADT)

4. What other drugs would make sense here, and at what point? We are thinking about Zytiga, enzalutamide and darolutamide.

5. Would gene testing be useful at this time for brca? What about a PSMA scan? I’m asking for targeted therapies at this stage like Lu-177, and parp inhibitors.

6. Any other recommendations on best course of action?

We are talking with dr. Eleni at Md Anderson and dr small at UCSF. The current consensus seems to be to get a pattern for the next few readings (3-4), establish a psa doubling time. The doubling time will then inform our intervention.

[Tall_Allen]

1. f you can, get a conventional PSA test with a lowest value of 0.1 - anything more sensitive will only create anxiety. PSADT is not defined for values under 0.1, and you need to have 3 readings over 0.1 to calculate a PSADT that is valid.

2. Help with what? A scan is only useful if there is a treatment decision to be made. Do not have a scan unless there is a decision at hand - it is another major source of needless anxiety.

3. He has to stay on Zoladex to see if he is castration-resistant.

4. That depends on his castration-resistant stautus. If his PSA continues to rise over 2.0 while on Zoladex, in the US, he can obtain docetaxel, abiraterone, enzalutamide, (but not darolutamide or apalutamide because of his femur metastasis), Xofigo, or Provenge. In India, he may be able to get Lu-177-PSMA if they don't require chemo first.

5. Because his only detectable metastasis was obliterated by radiation, he has nothing to biopsy, (to be useful, you have to biopsy a metastasis, not the prostate) and it is highly unlikely that any new met will show up on a PSMA scan at such low PSAs. He can get a germline test for BRCA2. If it is positive, a PARP inhibitor may be useful, otherwise not. PARP inhibitors are toxic and should not be taken unless they can do some good. I do not know if Lu-177-PSMA has any value at this early stage, and neither does anyone else. This is a matter for clinical trials.

You got some excellent advice from two of the top MOs in the US.

[paritosh1010 in reply to Tall_Allen]

Thanks for your advice, TA. Would we still be able to consider earplugs mode or apalutamide in our case? Even though my dads metastatic, he has fairly low diseases burden. Is there merit to that approach?

I understand both apalutamide and darolutamide have some advantage over Zytiga and xtandi.

[Tall_Allen in reply to paritosh1010]

The amount of metastases doesn't matter, only if he has ever been diagnosed with one on a bone scan/CT.

[LearnAll]

Paritosh,

you have got excellent advice from two of our most knowledgeable forum members.

Nothing much to add. Best wishes to you and your dad .ultrasensitive PSA is useless,

Stick with regular PSA.

[paritosh1010]

Thank you for your reply, Nalakrats. Really worried for my dad for the genetically resistant mutations like arv7 and brca, which fail second line hormonals.

[j-o-h-n]

LearnAll just told you where to LearnAll....

If his doctor is Eleni Efstathiou, he is in good hands...

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 12/19/2019 7:17 PM EST

[paritosh1010 in reply to j-o-h-n]

Thank you, this is comforting.

[LearnAll]

Great info. Thanks. Now I know that BRCA gene test is just a snapshot of the moment the test is being done but does not predict the future.