Ok so my father’s doctor says to ONLY Do radiation to a recurrent G-9 + most likely bone mets. But the more I read the more I feel like addional early chemo is better? (+ radiation) for example:
He is in good health otherwise so why dont do a more aggressive treatment right away? Am I thinking wrong? I’m going to get a second opition from a doctor of course, but its hard to get in contact with them because of Covid19.
Also: I thought for sure that my father was going to get a new PSA-sample as soon as possible (2 weeks since the last one) but the nurse now told me ”oh ok so you wants that? I’ll try to see to that”. PSA now seems really important?
Greetings from a worried micromanager
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If his bone metastases are spread over his body I don't see radiation therapy as an option. You Father might consider xofigo. It might be better tolerated than chemotherapy.
I have had 2 infusions of 6 without any side effects. So far so good. I must admit zofigo scared me. The physicians give you all the possible effects without saying that most men don't have them.
Had 6 infusions ended in november,no side efffects,actually felt better,they are using it now for early treatmennt
I agree with his doctor if he is non-metastatic.
If he doesn't have detectable metastases with a T99 bone and CT scan he is considered non-metastatic.
For those patients, no benefits for progression-free or overall survival have been proven for adding early chemotherapy. The biggest benefits for early chemotherapy have been for those like me with extensive mets.
The good news is that patients like him already have a good prognosis.
A patient is not considered metatstatic if the mets are small and not detectable with a T99 bone and CT scan. Some of the more sensitive scans like the G68 Pet or Axumin can detect very small mets which may be useful for targeting with radiation.
If he is on ADT (androgen deprivation therapy) and his PSA continues to rise later on and he is still considered non-metastatic, he can add one of three possible drugs to ADT: Erleada (Apalutamide), Nubeqa (Daralutamide) or Xtandi (Enzaluatmide).
Neither chemotherapy or Radium 223 would be indicated for him at this point.
Thank you so very much for your explanation. I’m still a bit lost why very small mets which may be useful for targeting with radiation? If you want to explain more I’m thankful!
As Tall Allen explains below, radiation treatment for Oligometastatic prostate cancer (OMPC), (generally defined by presence of five or fewer metastatic sites on imaging) is controversial and as far as I know still being studied. I think that part of the problem is the patients who would be getting it already live long lives and in many cases die from something else. So why introduce additional side effects for unmeasurable gains?
Here's an article on the subject. It also discusses the different types of imaging scans.
If he has bone metastases, what is the point of radiation? Radiation can be used palliatively if the bone metastases are causing pain or to prevent spinal compression or fractures. But to extend survival, he needs strong ADT or chemo.
He does not need PSA tests every 2 weeks. The normal fluctuations will only serve to drive you both crazy. Like every other diagnostic test, it should only be used to support a treatment decision. If it has been low and stable, and no new treatments are being considered, once every 3 months is sufficient to tell when castration resistance is starting. If a new treatment (like docetaxel) is being considered, he will need a baseline PSA (and bone ALP and liver, kidney and blood panel), and repeat tests 3 weeks after each infusion (before the next one). Any sooner will pick up PSA from killed cancer cells and confuse the findings.
Thank you! I’m also confused about the radiation to be honest. This is the same doctor who said he could cure my father even if he has bone mets (which I made another post about that you replied in). To be fair though the doctor is Finnish and we are Swedish so perhaps its lost in translation (but that is a very worring thing in it self...!)
I assume you are both communicating in English - a second language for both of you. But in addition, there is another language that doctors speak - I call it Medicalese. There is a LOT of room for misunderstanding.
If you die from something else, can we say you were cured? Many of the studies seem to indicate that this approach is useful and it is becoming more popular with the advent of the more sensitive scans as you imply.
That trial did not have long enough follow-up or sample size to determine all-cause survival- 85% survived 5 years across both groups (treated and untreated). There haven't been any studies yet that have shown a survival benefit of SBRT-treatment oligometastatic prostate cancer. So there is absolutely no data that can tell you if it extends survival to the point where one dies of something else.
There is a known use for such treatments in that they do indeed make the patients and doctors feel better about doing something rather than nothing. If it is afe to do so - why not? Unfortunately, I've seen patients shop for radiation oncologists who will do it even when safety is questionable.
I think my article addresses all the false conclusions. You also wrote there that the research suggests that such treatment may "delay the need for hormone therapy." I addressed that in the article, but allow me to expose the circular reasoning.
Metastasis-directed therapy (MDT) does decrease PSA, just because most PSA is secreted by the largest metastases. This is called "treating PSA." ADT has traditionally been initiated when PSA is high enough. So, by artificially lowering PSA with MDT, it keeps PSA below the traditional benchmark for ADT initiation. That doesn't mean, however, that the cancer is not progressing, only that PSA has been artificially suppressed and is no longer a useful biomarker for determining the state of the cancer. One can't treat PSA and then claim that such treatment delayed the need for ADT - it is a self-fulfilling prophesy. As Dr.Ost wrote to me:"MDT does not replace ADT and our results should not be interpreted in that way."
Ah no I this there is a misunderstanding here, this is not MY statement, its me quoting the person who writes the blog as a question (who is a urologist, I do not have that knowledge yet to even begin to form a definite stand poine in anything regarding PC, I’m only desperately trying to understand this because of my father’s new diagnoses). But thank you for your answer! Enlighting to hear the counter-arguments!
Thanks for explaining. I wrongly thought it was an online conversation with you and your doctor. But it does reflect a common misunderstanding of research. Even doctors, who should know better, misinterpret research. I have 20 years of experience in interpreting research and I am still learning. Apart from conceptual errors (like "treating PSA") there are always new statistical techniques that can be used and abused.
BTW, if your father can travel to Radboud University in Nijmegen in the Netherlands, they uniquely offer a kind of MRI called Combidex that is very good at detecting lymph node metastases. I think they also offer PSMA PET scans. The contact is Jelle Berentz. If you aren't overloaded, here is an article that explains about this:
And yes Medicalese is a big problem. When my mother were sick I used to accompany her to doctors and write everything down. And sometimes I would realize that a doctor could give really really bad news without you even noticing (before you start to google what the doctor actually said).
I often go along on visits to doctors with patients (or used to before the pandemic). I take notes, ask questions, and debrief with the patients afterwards. It's amazing how much more I pick up than the patients do. Patients often lose attention when they hear unfamiliar terms, or after hearing emotionally-laden terms like "survival," "mortality", or "cancer". Because I am relatively disinterested and speak Medicalese, I pick up more and can guide the conversation into new territory. I often type up my notes for the patient, and the doctor (along with a thank you note to him).
IMO, if your dad is healthy and feeling great, try the Chemo route first. His body will be able to accept the side effects of the Chemo. Plus most of the side effects can be controlled by following good preps- like fasting before infusion, cold cap for the head, dip fingers n toes in ice during infusion.
Also take pneumonia and flu jabs prior to any infusion. Just my take 😊. Then like TA suggested, follow up by strong ADT and later other blockers.
I’m grateful for all of your opinions!! The doctor suggested only radiation now but I’m getting a second opinion (and getting overwhelmed by all the studies on oligometastatic prostate cancer (PCa)..
I am one of the few that follows the Research Procedure vs Standard Care. In 2010 when my PSA started to rise after 3 years of radiation, my Onc (now deceased), who was a genitourinary researcher, suggested early Chemo after scan shows an L3 met. His approach was that with Gleason greater than 7 it is almost certain that the cancer has metastasized elsewhere (systemic), or maybe even detectable (like mine) or not (using existing technology), but person with good health body wise will benefit more from early chemo. I have since been under control with ADT and lately with Zytiga. PSA still undetectable. I am relatively healthy and active.
Tall Allen has given you a lot of good information. I totally agree that a strong ADT is best and radiation for pain relief of bone mets. It will kill the cancer there but if there are too many, it isn't feasible to radiate all of them without overdosing on radiation. As I have mentioned previously, I had one bone lesion and it was treated with SBRT radiation and I am also taking Abiraterone (a.k.a. Zytiga) and Eligard (similar to Lupron). I have not had a bone scan recently to see whether or how far any bone mets have progressed but we also need to limit radiation exposure, so it is a balancing act.
To recap, if his scans show your dad has extensive bone mets, radiation is not an effective treatment. A couple of mets may be worth treating with radiation. In my experience, ADT is always the way to go once BCR, unless it is ineffective. This can be in addition to radiation. I did chemo and ADT right after my RP and PSA was low and then went up. It was the ADT that did the job, NOT the chemo. I am only a fan of chemo as a last resort, as it has a low efficacy against PCa.
You may want to look at this option. radiology.co.nz/services/ra.... I dropped from a PSA of 980 to 0.41 in three treatments. All mets gone and I'm in remission.
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