Abiraterone failing...Xtandi next best step?

[Yadifan]

This is my first post. I've been reading and following so many of you since September. The information, suggestions and hope I've read here has been an important part of my morning.

My husband (age 58) was diagnosed July 2019 with APc. PSA score of 3300. Gleason score 8 (4+4) and 8 (4+4). NM bone imaging showed multiple areas of abnormal activity involving LN, L2, T11, T9 ribs, spine, pelvis, femurs, shoulders, left calvarium. No organ involvement per CT scans. Started on lupron/abiraterone/prednisone and Xgeva infusions every 3 months. PSA lowered to 63.6 then 38.9 to 1.2 in December. PSA was 1.6 in January, 2.4 in February and 14.1 in May. Doctor wants to change from abiraterone to Xtandi. Has anyone had success with Xtandi? Is chemo a better step before Xtandi? Are there other options? I'm concerned that with abiraterone failing after less than 9 months that Xtandi will fail also.

He generally feels good and has tolerated his medications. I've read some that mentioned chemo before Xtandi is more effective. Others say to save chemo as a last resort.

We live in Northern Arizona and are currently being treated at Banner MD Anderson in Sun City West.

Any advice would be greatly appreciated. You guys are all rock stars. And give us daily hope.

Marie

[Tall_Allen]

Chemo would be the favored next step according to best research (below). Don't leave the most effective drug for last when it will do little good and have increased side effects.

prostatecancer.news/2019/12...

[marnett1 in reply to Tall_Allen]

Thank you Tall Allen. We’ll talk to our doctor about this.

[Yadifan in reply to Tall_Allen]

Thank you so much Tall Allen! I read your posts and comments often and value your opinion.

I am confused on this article and was hoping for your input. We expect to talk to our doctor today. Under the heading "Taxotere first" it mentions regarding reasons to do Taxotere first that "if one starts with Zytiga, it may be 3 years before Taxotere can be tried".

Would this apply to us? Will we have to wait 3 years?

After much reading (thank you APC community), we are hoping for second line option of Doctaxel - or whatever may be recommended in it's place.

Again...appreciate your opinion - more than I can say.

Thank you!

Marie

[Tall_Allen in reply to Yadifan]

Hi Marie,

No that no longer applies to your husband - that is only for men who have not yet tried Zytiga. For newly diagnosed men, Zytiga can take 3 years until resistance builds to the point that one has to move on to the next therapy. Your husband is already at the point where Zytiga has stopped working and he is ready for the next therapy.

[Yadifan in reply to Tall_Allen]

Thank you so much for getting back to me so quickly! I appreciate you!

[TeleGuy]

Swapping out your prednisone for 0.5mg dexamethasone can give you extra time if your husband is one of the ones it works for. It's a cheap and easy thing to try. I've posted on this before, you can references if you look at my prior posts or look for the SWITCH trial.

[Yadifan in reply to TeleGuy]

Thank you TeleGuy...we will look at this also.

[RyderLake2]

Hello,

As, I am sure, you have heard many, many times everyone is different. My PSA at initial diagnosis was just short of 1700. Gleason 8. I have been on Zoladex (goserelin) for over seven years now and Xtandi (enzalutamide) for slightly less than three. So far, touch wood, they have been keeping my cancer in check. There are lots of drugs in the "lutamide" family like Darolutamide and Apalutamide with similar mechanisms of action. Switching from Zytiga to Xtandi might just work. I agree with Tall Allen and others that Chemotherapy (docetaxel) might also be beneficial. Another option is Lutetium 177 if your husband is PSMA avid. Hope that helps.

[Yadifan in reply to RyderLake2]

Thank you for your reply. So much to consider and research. Hoping you have continued success with your treatment.

[Hidden]

In general, shorter repsonse times on androgen-based treatments favor going to chemotherapy rather than another anti-androgen such as Xtandi.

I've done chemotherapy and it was well tolerated as it is for most patients. He could try another anti-androgen later after chemotherapy and might get some more time out it.

In the meantime, it might be a good idea to get a biospy and do genetic profiling to check for treatable mutations and neuroendrocrine differentiation (small cell).

[Yadifan in reply to Hidden]

Thank you gregg57. I'm glad to hear chemo was tolerable for you. Hoping the same is true for my guy. Genetic profiling sounds like what we need to do also.

[ctarleton]

Most of the "Standard of Care" treatment options for men in his situation have also been summarized in Guide 20, Second line options for M1 CRPC, on page 82 of the NCCN Guidelines for Patients, Prostate Cancer. You can continue to ask and learn about them all, and to discuss them with your doctor(s).

nccn.org/patients/guideline...

[Yadifan in reply to ctarleton]

What a helpful link this was! We're pretty new at this and feel like with as much as I've been reading I haven't even scratched the surface. I'm grateful for your reply.

[GP24]

There is a cross-resistance between Xtandi and Abiraterone. Xtandi will usually just work 2.7 months after Abiraterone failed.

ascopubs.org/doi/abs/10.120...

"... median time to PSA progression on 2nd-line therapy was 2.7 months"

[GP24 in reply to GP24]

I would give Dexamethasone a try instead of Xtandi.

ncbi.nlm.nih.gov/pmc/articl...

[Yadifan in reply to GP24]

Thank you GP24. Will check into Dexamethasone also. I was concerned about Xtandi having the same results as Abiraterone.

[Hidden in reply to Yadifan]

My PSA went up from undetectable to .79 after 15 months on Zytiga. I switched to Dexamethasone about 4 months ago and it's undetectable again. My doctor said he had a patient that had a PSA drop for 6 months after switching.

[Hidden in reply to Hidden]

Great news. How did you here about Dexmethaxone,????

Sounds great

Thanks

[Hidden in reply to Hidden]

I think I read about it here. Dexamethasone is like Prednisone on steroids.

[Hidden in reply to Hidden]

Hi Gregg:

What was your PSA when you started Zytiga? How did you chose between Zytiga and Xtandi?

Thanks,

Tom

[Hidden in reply to Hidden]

My PSA was rising quickly, doubling every 3 weeks. When it hit 26, my doctor called me the same day I saw the results. He said he'd have Zytiga ready for my appointment and also arrange to have the pharmacist there too.

[TeleGuy in reply to GP24]

I am really struck by the statement in the article that the results from switching from prednisone to dexamethasone (median time to progression of 11.7 weeks) are similar to those of going directly from abiraterone to enzalutamide.

For me, the steroid switch quickly brought my PSA back under control and gave me time to go through the logistics of getting on to 177Lu treatment.

[GP24 in reply to TeleGuy]

TeleGuy, I think this sentence is misleading in the article. He probably meant: ".... 11 of 30 patients (39%) had confirmed ≥30% PSA decline after switching to dexamethasone with median time to PSA progression of 11.7 weeks. Compare these results with the response rate (41%) and duration (2.8 months) with enzalutamide after abiraterone in CRPC treatment"

[HopingForTheBest1]

I was on Zytiga/Prednisone for 6 months when my PSA started accelerating. Had genetic testing, and was switched to Olaparib as a result with great results so far.

Get genetic testing for determining possible effective treatment protocol.

[Newyork6264 in reply to HopingForTheBest1]

Was that due to being Brac2 positive?

[Yadifan in reply to HopingForTheBest1]

Genetic testing...will do this. Thank you HopingForTheBest1. Glad to hear you're having good results with Olaparib.

[HopingForTheBest1]

Yes it was.

[Yadifan]

Thank you Nalakrats. I frequently read your posts and value your opinion and knowledge. Will contact Foundation One also.

[619eh]

Don’t expect much from Xtandi. Everybody’s different, but it didn’t work for me at all.

[Yadifan in reply to 619eh]

Sorry to hear it didn't work for you, but appreciate the info. Good luck to you on whatever treatment you're doing now.

[monte1111]

Everybody's different ---- after chemo (extensive bone mets) Xtandi has me at <0.1 for 3 years next month. I don't know anything, but others seem to lean to chemo as your next step. I think chemo as "last resort" is outdated advice. May be time for a second opinion. Best of wishes. Chemo is not that bad for most of us.

[Yadifan in reply to monte1111]

Thanks monte! Your post is encouraging. And glad to hear another say that chemo is not that bad. Continued good luck with Xtandi.

[j-o-h-n]

Greetings Yadifan,

It may be a good idea to copy and paste some of your husbands bio (above) and paste to his home page. This way it will be available for him/you to use and for other members to view.

He is lucky to have you..... (he owes you a dinner)....Post on this site....good info and good looking guys........

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 07/06/2020 8:03 PM DT

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

Thank you John! Appreciate your advice and your great sense of humor! You're one of my favorites on this site. Will keep y'all posted. Stay healthy and please keep us smiling. It's a tough job...but someone needs to do it.

[Olivia007]

My dad was on Zytiga and that started to fail. They meaning all of his doctors didn't think xtandi would help well it did. We don't know for how long but every treatment they have only helps for so long then on to the next. My dads doctors were so skeptical and its been 6 months and it has kept it down. We are happy. The side effects weren't bad but I don't know for sure. My dad only says he was tired and he seems a bit forgetful but he is 82 so who knows. I'm glad they were willing to try xtandi and dads PSA went down very low I just pray it stays there for a while. Hope that helps.

[marnett1 in reply to Olivia007]

Thank you Olivia007. That’s hopeful news!! I hope your dad has continued success.