Advice and Opinions would be great.

[taylor123]

Hey guys, 



Would love to get your input into potential options for my Dad.

We’re at the point we need try something new now.


So we have done triple hormone therapy Bicalutamide (which we stopped a few years back) 

Degarelix and Zytiga are also not suppressing a PSA rise now which is currently 61. It has been as high as 433 about 9 years ago. We got several years out of the above.

He is still asymptomatic.

Options I see moving forward.

* Enzalutamide (Xtandi)



* Ketoconazole

* High dose Testosterone to shock the PCa cells. (I understand this would have to be under close supervision / monitoring)

* Low Dose Chemo with Cabergoline

* Lu-177 or AC-225 (My Dad’s PSMA scan was PSMA positive)

Thoughts on the above and potential sequencing etc, and the prospect of certain agents re-sensitising older agents we have used such as Zytiga.

We shall of course be conversing with my Dad’s prostate oncologist but it would be nice to get some input from you guys

Thoughts on the above and potential sequencing etc would be great.

Thanks in advance.

[Magnus1964]

It is apparent that the -lutimides, casodex, zytiga, etc are not effective for your father. Xtandi would be a good next step.

[taylor123]

I've seen a few cases which propose that hormone resistant PCa is actually prolactin dependent prostate cancer.

I shown a couple of the studies to Ed Friedman and he actually said after he thought on it that he believed targeting prolactin in this way could be curative in castrate resistant men.

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

[taylor123 in reply to taylor123]

europepmc.org/article/PMC/6...

[taylor123]

I’ll private message you when home

[Tall_Allen]

You didn't list the best medicine with known efficacy - docetaxel at 75mg/mm2 every 3 weeks. Try the stuff we know works before you try pie-in-the-sky or dangerous stuff like antiprolactins and BAT. Alternating chemos and hormonals may work best. Kenoconazole is a waste of time after Zytiga. Estrogen is antiprolactin and has known efficacy for prostate cancer.

You didn't say what his metastatic situation is, but if he has predominantly bone metastases, this trial at Royal Marsden is worth looking into. However, it requires treatment with docetaxel first.

prostatecancer.news/2018/10...

[taylor123 in reply to Tall_Allen]

Thanks for the input Allen, much appreciated as always.

We agreed 25 mg/m(2) on days 1 and 8 every 3 weeks with my Dad's oncologist whenever Docetaxel would be started.

They trial looks very interesting. I haven't actually even heard of Thorium-227.

You don't give any credence to the prolactin link?

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

Ed Friedman thought there was very much something to it and I fully trust his expertise.

[Tall_Allen in reply to taylor123]

Docetaxel was originally tested as 30 mg/m2 administered weekly vs 75 mg/m2 every 3 weeks. The weekly dosing was found to be inferior:

ascopubs.org/doi/10.1200/JC...

I don't see why you are trying to reinvent the wheel with your father's life at stake. Sorry if that sounds harsh, but I've seen too many patients hoodwinked tragically to be complacent about such things.

I discussed prolactin with a few oncologists I respect- they were skeptical, although they hypothesized that the anti-cancer effects of estrogen may be due, in part, to its action as an antiprolactin; but it is well known that estrogen mostly fights prostate cancer through other effects. Leslie Costello, the author of that article, is the only one touting it. Also, that article is a single patient - certainly not something any sane person would choose a therapy based upon.

Who is Ed Friedman? I've never heard of him. In the UK, my top choice would be Johann de Bono at Royal Marsden. He is on the leading edge of many promising new therapies.

[taylor123 in reply to Tall_Allen]

I'm not trying to reinvent the wheel Allen and I am very mindful of what is at stake obviously.

Despite being asymptomatic from the PCa, my Father is 80, has heart failure, a separate lung cancer which is stable disease thankfully, COPD and mild anaemia.

His prostate oncologist Nick Plowman, who you may know as he is well known, agreed low dose would be best when we asked about it. Maybe that is because he is taking into account my Father's age and potential side effects from the standard higher dose.

I've seen studies on lower more frequent chemos being efficacious with less side effects.

Yes De Bono at The Royal Marsden is great. Unfortunately we couldn't get to see him or Professor Khoo there.

Professor Edward Friedman wrote this book here

amazon.co.uk/dp/B01K3J0PQQ/...

[Tall_Allen in reply to taylor123]

Thanks for explaining about his frailty. I hope he is able to tolerate the treatment well. I hope you are able to get Neulasta for him - especially important during the pandemic.

Yes, I've seen Nick Plowman's name come up on a few papers. I only know oncologists in the UK who have published significantly in peer-reviewed journals.

[taylor123]

Should PSMA-targeted treatments precede chemotherapies ?

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

[Tall_Allen in reply to taylor123]

That link doesn't really address your question. Almost anything done earlier is more effective than the same therapy done later. That's true whether or not chemo has already been used. However, in men who have already had docetaxel, Lu-177-PSMA may be a better next choice than Jevtana:

prostatecancer.news/2020/05...

[Nous]

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