PSA rising

[seeker47]

Hi All, I am new here.

My Dad (65) was diagnosed with cancer of the Prostate in Mar 2019, stage 4, PSA 62, Gleason -8 and mets in his bones. He started on Hormone Therapy (Surgical ADT + Bicalutmide). His PSA started coming down until Nov 2019 (PSA 2.5) and there was a marked difference in his pain levels. In Nov 2019, his PSA started rising again (PSA 6). His first oncologist (let’s call her OC1) asked for PSMA scans and suggested we for radiotherapy. Her plan was to stop Bicalutamide during the radiation therapy and start with Abiraterone soon after. However, for various reasons, we decided to switch to another leading oncologist( let’s call him OC2) in the city. OC2 also suggested radiation therapy but recommended that we continue on Bicalutamide, which we did. By the time radiation could start, the PSA levels had gone up, to 12. One month After the Radiation therapy ended (i.e Mar 2020), the PSA level had increased to 14. However, after another 40 days, (First week of May). The PSA came down to 8. OC2 reviewed the reports and concluded that PSA will go down further. He also suggested we repeat a PSA test only after 3 months and NOT BEFORE THAT. However within a month’s time, my Dad started experiencing more pain in his back (Upper and lower). So we tried pain killers for a week (As suggested by OC2 during his last review) . However, the pain only got worse and his PSA went up to 57 (June 24th). PSMA scans show new skeletal mets and a large nodal mass in the Thorax region (No organs involved). OC2 is suggesting Chemo as his preferred line to treatment now to manage this or we could try Abiraterone for 45-60 days and see how that goes. We went back to OC1 for a second opinion and she suggested we start on Abiraterone right away and do not really think of Chemo for now.

The thing is that my Dad is already feeling weak and has not recovered completely from the side effects of radiation therapy.

We are really confused and cannot decide on what the next step should be. Any guidance and help will be really appreciated.

Sorry for the long post!

Thank you!

[RyderLake2]

Hello,

I believe your Dad should start immediately on a stronger form of Androgen Deprivation Therapy to bring his PSA down. I personally am on Zoladex (goserelin acetate) which is administered by an injection into the belly once every three months. Firmagon (degarelix) works quicker but requires a monthly injection. If neither of those drugs bring your Dad's PSA down, he needs to add either Xtandi (enzalutamide) or Zytiga (abiraterone). Note that I said add to the ADT not replace it. A bone strengthening drug like Prolia (denosumab) would also benefit your Dad and lessen the chance of a skeletal related event (SRE). A maintenance dose is once every six months. Daily Vitamin D and Calcium (with Magnesium) is probably a good idea as well for bone strength. Hope that helps.

[Tall_Allen]

I think Chemo is best because in just 15 weeks, your Dad can have abiraterone too.Provenge combined with chemo may be a synergistic combination. Was the nodal mass larger than 3 cm? If so, that may preclude Xofigo. It may be useful to biopsy a large metastasis.

[seeker47 in reply to Tall_Allen]

Thank you Tall_Allen! Yes the nodal mass is larger than 3 cm (4.5 X 1.5 ). Interesting that you are suggesting for a biopsy of this large metastasis. What will it be needed for?

[Tall_Allen in reply to seeker47]

Several purposes:

1. histology - they can see how differentiated the cells are. Less differentiated cells (anaplastic) or neuroendocrine differentiation require stronger and different measures.

2.IHC - they can stain for and quantify various proteins (e.g., androgen receptor, PSA, PSMA, CgA, NSE, DLL3, SSTR2, PD-L1) that may guide therapy.

3. genomics - there are a few, relatively rare, genetic mutations, like MSI-hi/dMMR, BRCA, , and mutational burden that may guide therapy.

Maybe biopsy a bone met as well in case the lymph node turns out to be different.

[RyderLake2]

Hello,

After looking at your post a second time and seeing that your Dad's PSA has gone from 8 in May to 57 in June, makes me think he he has a very aggressive cancer. It is not just what his PSA score is but how fast it doubles. My personal opinion is that his PSA (and probably his testosterone) should be monitored much more frequently than once every three months. I have a blood test done once a month. Your Dad is going to have to move very quickly on this. Make sure you and/or your Mum goes with him to all oncologist appointments. Take notes and ask questions. Hope that helps.

[seeker47 in reply to RyderLake2]

Thank you RyderLake2! The OC2 also said that it looks very aggressive and hence suggested Chemo. And yes, I will keep your suggestion in mind and get his PSA tested more often. I will also get his testosterone levels tested. Thanks again!

[Pleroma in reply to RyderLake2]

I am withRyderLake2. PSA tests once per month. Move to chemo as soon as possible. Seems like the OC's are letting your Dad slip through the cracks. Save Abiraterone till later.

[Hidden]

Welcome the good child. I have much respect for you and other children here advocating for dad. That is love. You will get the answers that you seek by our knowledgeable leaders of the pack. I know it sucks to see dad suffer so . Love is the best drug for him always . Pamper him and love him much . My dad had this also . I’m waiting to see what is suggested by others. Take care of pops . He must be a good man . If he was not , you wouldn’t have turned out so good yourself. Take care .. 🙏

[Hidden]

On this stage of the disease I am completely ignorant, so not any meaningful medical suggestion from my part. Yet, judging from the performance results, in conjunction with the attentiveness factor (3 months PSA) of OC2 I would hastily run into OC3.

[Hidden]

If it were me, I would agree with OC2 and go with chemotherapy, mainly because the short response to ADT and his PSA nadir of 2.5. Based on his history, I don't think he would get much out of Abiraterone, but he could try it and see.