Update to Can't treat what we can't see

[SF22]

Update on previous post. I tried to keep that post short and in doing so I did not include current and previous treatment. Sorry, I now realize it is hard to get accurate feedback without providing full information.

11/2016 DX T3aNOMD 5+4=9

02/2017 RARP

10/2017 Lupron + Casodex

5/2018 Lupron + Zytiga + Prednesone

9/2018 completed XRT to prostate bed, left hip and L3

1/2020 - current PSA doubling every 3 months PSA 37.7

My update with Dr. Kwon at Mayo Clinic and the decision I have to make due to the results, Following is a part of my After Visit Summary:

Patient has failed 2nd generation androgen deprivation therapy, Zytiga and is no longer taking. He does continue on leuprolide. Patient should continue on leuprolide throughout duration of chemotherapy. Dr. Kwon like to see the patient back 1 to 2 weeks after his 3rd cycle for repeat evaluation. If PSA is not down trending or there is further advancement of metastatic disease on imaging, Dr. Kwon may recommend changing chemotherapy regimen. There is concern the patient may be developing neuroendocrine differentiation of his prostate carcinoma due to his Zytiga resistance.

Went to U of M to meet with my Oncologist for approval of Taxotere. He was adamant on not approving chemo at this time. Following is from the After Visit Summary:

We discussed a recommendation for enzalutamide at this point - while it may have a lower response rate compared to docetaxel, especially after progression on abiraterone therapy, the toxicity of docetaxel is significantly greater, especially in the context of the ongoing COVID pandemic. The benefits at this juncture from docetaxel are less clear as he is feeling well (we would certainly make him feel worse w/ docetaxel) and lacks radiographic evidence of any disease (thus, would likely not prolong his longevity currently if utilizing TAX 327 data which all had radiographic metastases). We did discuss it is very likely the risk/benefit ratio will change in the future and we would recommend docetaxel at some point - but not currently.

My two day visit to Mayo turned into five days and I had four different scans. All showing no new evidence of increasing disease, I only have PSA progression. Now I need to decide between Xtandi or chemo. HELP! (sorry for long post)

[Tall_Allen]

"the toxicity of docetaxel is significantly greater..."That is not correct. Why do you think that? In fact, the improvement in QOL is excellent with docetaxel. Much better off alternating chemos and hormonals.

prostatecancer.news/2019/12...

In fact, the longer you put off docetxel, the higher the side effects (many of the side effects are because of taking it when the body is already run down by the cancer), and the less benefit it will provide.

[SF22 in reply to Tall_Allen]

Tall_Allen

As always, good information. Not looking for opinions, just facts.

Thanks

[SF22 in reply to SF22]

I meant you always give good information.

[tango65]

Your cancer was castration sensitive metastatic and then after failure of ADT plus Zytiga (abiraterone) would be considered metastatic castration resistant with a PSADT of less than 6 months (higher risk).

When one of the new anti androgens (or ARTA, androgen receptor target agent) fails, it seems that is more effective to follow with chemo , docetaxel if not previous chemo or cabazitaxel if previous docetaxel than continuing therapy with a different ARTA.

nejm.org/doi/pdf/10.1056/NE...

pubmed.ncbi.nlm.nih.gov/302...

With a PSA of 37 and a PSADT of 3 months the chances are that a PET/CT (Axumin or Ga 68 PSMA or 18F DCPYL) will show where the cancer is located. You should request one of these studies if they were not already done. There are clinical trials for the PSMA PET/CTs

clinicaltrials.gov/ct2/resu...

clinicaltrials.gov/ct2/resu...

[SF22 in reply to tango65]

Tango65

Thanks for the information. I had a 68ga PSMA PET CT in August 2018 and found two oligometastasis. Had them radiated. Had another 68ga PSMA PET SCAN in May. No abnormal PSMA expression to suggest presence of prostate cancer.

Had a C-11 choline scan in August and showed uptake in R iliac lymph node and T6 vertebra. Had a second C-11 choline in November and it actually showed a shrinkage of the two uptakes.

[tango65 in reply to SF22]

The PSMA PET/CTs have the highest detection rate and your last one was done 6 months ago. If your PSADT is 3 months, in that time your PSA should have quadruple. Difficult to understand why the Mayo Clinic continue to do 11 C Choline PET/CTs.

I would push for chemo given you PSA values and your PSADT after failing abiraterone.

They are thinking about neuroendocrine transformation, but the PSADT is 3 months. One of the characteristics of neuroendocrine PC is a low PSA expression.

Request a liquid biopsy, having bone metastases and a PSA greater than 10 increase the chances that they could get enough cell free DNA and RNA and/or circulating tumor cells to do a genetic study of the cancer. These studies could show mutations which could be treated with PARP inhibitors (olaparib, rucaparib) and/or checkpoint inhibitors such as Keytruda

[SF22 in reply to tango65]

Asked for liquid biopsy from both Mayo and the U. Did not get a positive answer from either.

[tango65 in reply to SF22]

Foundation One has a FDA approved liquid biopsy test. You could call them and find out about cost and how to get i done without a doctor ordering the test. There is some info in this link:

assets.ctfassets.net/w98cd4...

888.988.3639

Email

[e-mail]

[SF22]

Nalakrats

Thanks for the response. At my last appointment at U of M, a blood draw was taken for a genetic test.

[Nous]

hi SF22 ... i encourage you to check-out envita.com ... especially the section on prostate cancer treatment ... best wishes