I read the posts in my email every day and I am amazed at the breadth of knowledge and debate. I have learnt more about my prostate cancer here than from my urologist!!
I need your opinions and advice on my current situation.
DX 1/2016, PSA 20, Gleason 4+5, 2 bone mets. On ADT only for over four years and PSA nadir 0.1 and stayed around that for 3 years. In early 2019 it started to rise although CT and bone scans were clear ( 2 bone mets had disappeared) and testosterone remained at 0.1. Bone scan 2/2020 showed 1 met had reappeared.
Started Zytiga + Pred 10 mg on 13/04/2020. Evolution of PSA since then:
13/04/2020 24.6
07/05/2020 17.6
24/07/2020 14.2
23/10/2020 16.6.
In latest analysis Sodium, Potassium, Calcium, ALP, ALT, AST all in normal range Testosterone 0.1
Otherwise my general health is good and I have no pain. I had a CT scan on Friday, results Thursday this week when I see my urologist again.
Do the PSA figures indicate a failure of Zytiga or can there be another explanation? If so, any suggestions for future treatment will be welcome. I would like to have options to discuss with my urologist on Thursday.
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Macscot
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Magnus is an exception. The published studies report a cross-resistance between Abiraterone and Enzalutamide. However, because Abiraterone did not work well for you I would give Enzalutamide a try. If there is a cross-resistance Enzalutmide will work for about three months only.
The general recommendation is to not change treatments based on PSA alone. If your scans are looking good and you don't have any new symptoms, I'd continue.
You might ask about switching the steroid from Prednisone to Dexamethasone (see SWITCH trial). That has given a good downward PSA response to around 40% of those who tried it. It worked for me although that's just anecdotal.
It seems that your cancer is somewhat resistant to the Zytiga + prednisone. Sometimes, switching from prednisone to dexamethasone can help. Email the following to your oncologist:
For 6 months my PSA rose from 22 to 39 then in the last 15 months it has come down slowly to 13...it took a while for zytiga to kick in....we are all different...scans reveal what is happening!...so far my scans are ok
You are so right - we are all different but it could be that I am going to share your experience. I am hoping my scan results this week show no progression. Many thanks for sharing.
Definitely do...my original oncologist was going to change treatment but when I seen the new MO ...he said lets give it some more time...and finally started to work for me!!!
While on Zytiga/Prednisone, and PSA rising, I had genetic testing that showed BRCA2+. Switched to Olaparib and PSA became undetectable for over a year.
Dad had bounces of PSA up and down with Zytiga and the drug was working well (one month up and the month after down), the trend was slowly going towards down though, and that's what you have to look at, alongside your scans.
Recent bone scan also accompanied by CT? Genetic testing would be valuable, especially if the met is accessible to image guided needle biopsy by an experienced interventional RO. Suggest the switch to dexamethasone with the AA. If it finally fails consider docetaxel chemo as an option before enzalutamide. T_A has an excellent review on optimal treatment sequencing.
I am used to Pca prevention and treatments failing. Regular Psa tests didn't detect Pca early enough. I was diagnosed age 62, late 2009, Gleason 9, Psa 6, and attempt at RP in early 2010 failed because docs found too much Pca outside capsule but no spread.
ADT lasted form 2010 to 2016.
From the numbers for Psa you have given, on ADT alone, Psa stayed low at 0.1 until early 2019, then went up to 24 by 2 / 20 and you begin with Zytiga. Since then the Psa has gone down to 14, and is about 16 now, so it seems Zytiga is not working as it does for so many other men to reduce Psa from a high level to a much lower level.
I had Psa rise to about 6 after ADT + Cosadex failed after 6 months, then had Zytiga which my onco said should reduce Psa to about 2 before it rises again in maybe a year.
He said one patient had 2 years of Psa suppression.
So I begin Zytiga, and in a month Psa is 2, and it stays around that level for a few more months then begins to rise to 6 again and fast, so I has 8 months of Psa suppression. There was not much evidence there was any reduction of mets in scans.
All these hormone manipulating drugs just seemed to slow down my Pca progression, but not kill it.
I went to chemo when Psa went to 12 after Zytiga failed. The onco said he thought chemo would fail, but that he'd refer me to docs giving Lu177 when it failed. So I begin chemo and Psa just goes up fast from 12 to 46 after 4 doses, and stays there, and is declared a failure because scans show little difference in met size and number. Lu177 is booked. I have one one more chemo dose while waiting for Lu177, and Psa goes to 50.
I wait one more month before beginning Lu177 in November 2018, and Psa dropped to 25 in that month, and nobody knows why, so its always plausible to say chemo was judged too early, and had I persisted with it there may have been some success.
But 4 doses of Lu177 did much more for me in 6 months with less side effects than the chemo did, and I still have side effects of neuropathy from chemo 2 years ago.
I just had 2 more doses of Lu177 because after first 4 doses Psa went down from 25 to 0.32 after 1 year, but bounced back to 30 last July. Scans show no soft tissue mets and only bone mets.
5th Lu177 was on 24July, Psa went from 30 to 8.7 before 6th dose last 2 October, and I may get latest Psa today when I see local doc about bone density scan result and other blood test numbers.
I guess I may need the maximum possible number of Lu177 does to get bone mets low and eliminate most if not all. After that, its very likely Psa will rise again and scans will show Pca is again on the march, and about all can have then is maybe Ra223, or more chemo, maybe Cabazitaxel instead of Docetaxel.
I'd be having to endure becoming a bit of a wreck after so much treatment and yet my Pca may eventually win. Its why 30% of men who are diagnosed with Pca still die from Pca. This 30% all fight, but they end up losing. Things could change fast, if docs find mets are spreading from survivor mets, which makes the total number of mets an overwhelming number.
But right now I am OK and can cycle 200km a week at good speed, and I feel well at age 73.
Many thanks for your comprehensive reply. I have only had ADT and now Zytiga compared to your multitude of treatments It is likely I will have the pleasures of chemo in due course, but I don't think Lu177 is available here in Southern Spain where I live.
My main exercise is walking my dog 1 hour morning and 1 hour evening in hilly countryside, approx. 4 kilometres each. I would need to up my game a lot to catch up with you, I am 75 and in good health , apart from the obvious. Being in Spain and coming from Scotland has many advantages - at least I don't have walk my dog in cold and rain all the time!!
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