Help with choosing treatment pathway

[Ronnie7C]

Would really appreciate feedback from members as to the Pros and Cons of recommended treatment pathways.

I'm 67 years old and have had not health issues until now, Non-smoking, non-drinking tennis coach. Diagnosed March 2020 with Stage 4 high volume metastatic prostate cancer. Gleason score 9 (4+5), PSA 75 and ALP 273. Bone scan showed multiple bone mets in four areas.

Had first LHRH injection on 20th April and blood test on 11th May showed PSA 12 and ALP 534.

Oncologist #1 recommends combination treatment of ADT and AR agent (Enzalutamide) followed by chemo; whilst Oncologist #2 recommends combination of ADT and chemo followed by AR agent (Enzalutamide). Undecided on which recommendation to follow.

Have PSMA PET-CT scheduled for 6th July. Have no medical insurance coverage but have access to public hospital service where ADT + chemo are provided free of charge but Enzalutamide is not freely available.

[GP24]

ADT plus Chemo or ADT plus Abiraterone will work equally well in your case. I would not use Enzalutamide because Abiraterone works just as well and is probably covered by your health system. ncbi.nlm.nih.gov/pmc/articl...

In your case I would recommend ADT plus Chemo because you are so fit, you can handle the side effects well. Ask the oncologist if he can use a schedule with injections every two weeks or each week. This has lower side effects.

[Ronnie7C in reply to GP24]

many thanks for your response and advice.

The injections you mentioned, are they in reference to ADT injections or to chemo injections?

How does adjusting the injection schedule to 2 weeks or 1 week help to lower the side effects?

[GP24 in reply to Ronnie7C]

I meant Chemo infusions. If you are on a schedule for one infusion per week or one infusion every two weeks, the dose per infusion is reduced. Studies found that the side effects are lower then. I mentioned the weekly schedule because I read that this is frequently used in India so your oncologist in Hongkong may be familiar with that schedule.

[Ronnie7C in reply to GP24]

Sounds like a great idea to me. Will do some research on the idea and definitely discuss this with my oncologist. Thanks for the advice.

[Hidden]

I Welcome you .. A healthy life lived .. great job ... I too had good health until dx five years ago . I think if we live long enough we’re bound to get something.? I’m no expert . Others will chime in on treatments. Welcome Ronnie 😎🌵

[Ronnie7C in reply to Hidden]

thanks for the welcome message. Have been reading many of your posts and very encouraging to see you are keeping up the fight

[Tall_Allen]

I think ADT+Chemo is preferable. Here's why: docetaxel is given in 6 infusions, 3 weeks apart. So in 15 weeks, you are able to move on to your next therapy (I think abiraterone is preferable to enzalutamide). Whereas, if you start with an AR agent, it won't incur resistance for about 3 years, at which time you can start on docetaxel. So in the first year, you can start on two different powerful therapies if you start with docetaxel. In general, hitting harder up front gives better results than waiting. And side effects are less with all the drugs if used earlier (in fact, the degree of side effects are similar for early-use docetaxel and abiraterone, although they are different in kind).

[podsart in reply to Tall_Allen]

Wondering why u prefer Zytiga vs Xtandi?

[Tall_Allen in reply to podsart]

Because of these:

thelancet.com/action/showPd...

eu-focus.europeanurology.co...

[podsart in reply to Tall_Allen]

Interesting, Thanks

2nd link won’t load properly

[Tall_Allen in reply to podsart]

Hmm. It works for me, but it is just a comparative cost analysis showing that starting with abiraterone is cheaper than starting with enzalutamide.

[podsart in reply to Tall_Allen]

Thanks again

[Ronnie7C in reply to Tall_Allen]

Many thanks for the advice which I note several other guys also agree with. Your comments make a lot of sense so that is very likely the treatment pathway I will follow. Hoping that the PET-CT doesn't throw up too many unexpected surprises. Thanks again.

[noahware]

Because of the high tumor volume, it makes sense to me to go double-barrel and do ADT and chemo both, now. Perhaps there is also a case for doing them sequentially rather than concurrently, but for myself, I would want a multi-prong approach to reduce the cancer-cell load as much as possible.

[Ronnie7C in reply to noahware]

Thanks for the replay and the advice. Yes, the double-barrel approach is the way I intend to go but wasn't sure if ADT+chemo was the more favoured path as opposed to ADT+AR (Enzalutamide). Have been given an appointment for 15th July to start chemo by which time will have received results of PSMA PET-CT.

[HopingForTheBest1]

Ask your doctor about genetic testing. It could lead you to an effective treatment option. It did for me as I am BRCA2+ and have been effectively on Olaparib PARP, keeping my PSA at undetectable levels for over a year so far.

[Ronnie7C in reply to HopingForTheBest1]

Thanks. Will follow up on this genetic testing issue at my next meeting with oncologist.