So my Father is currently in the same position as the men who were recently in Professor Samuel Denmeade Transformer Trial at John Hopkins, given that his PSA is rising on Abiraterone.
Men given BAT before starting Enzalutamide had a far far superior time to progression then those who did Enza and then BAT. My Father is asymptomatic as per the men in the trial also and we have access to genuine pharma Cypionate.
His last three PSA's are
Oct: 61
Nov: 86
Dec: 79
The questions I am pondering are;
1) As chemotherapy can also resensitise PCa to Abiraterone are we potentially missing a sequencing opportunity by not doing the same as the Transformer first.
Would optimal sequencing be BAT -> Enza -> Chemo -> Abi / Enza
2) If we did chemo first and then Abi, is there any reason we couldn't do BAT after Abi at this point and then onto Enza.
While the men in that trial were able to get longer use out of enza, there was no increase in survival from doing BAT. We know there is an increase in survival from doing chemo. In about a third of the men in the trial, T resulted in increased cancer progression, even as early as the first use. This is NOT something to do outside of a closely monitored clinical trial.
We just had this conversation with MO this week. BAT, if you can get a non-SOC doctor to prescribe it, works very well for about 30% of men. 10% do poorly, and the other 60% have rising psa but then they are given abi or enza to get psa back under control before moving on to something else. If you are in the "sweet spot" of progression having failed most treatments yet are asymptomatic, it can be worth trying if the alternative is chemo that buys you 3-5 months but makes you feel like $%^&&@ during treatment.
My husband has failed enza so can't comment on the sequencing although I also read the study that enza after BAT is the preferred sequence.
A third of the men in the trial did have an early and significant increase in PSA in the induction period (first one to three BAT cycles). They simply stopped it and were removed from the trial. The first human BAT trial had a similar proportion with PSA acceleration. But they stopped the program. For most the PSA came promptly back down and no progression on scans was found. So from my view (opinion) it seems that by trying BAT and carefully monitoring PSA is the only and reasonable way to find out if you are a favorable responder or not. And the possible benefits of being a favorable responder outweigh the risk of being a poor responder and promptly switching to another treatment such as enzalutamide or chemo.
Well this was my line of thought as well. I’m sure I read the T will cause a PSA flare initially but it doesn’t necessary correlate to cancer progression.
And precisely, if then you start Enzalutamide then you likely given yourself a prolonged a period of using it as opposed to no BAT before using it which results in very poor efficacy.
Yes you are correct that an initial PSA flare is expected and that does not exclude a positive response. But a larger and progressive rise in PSA means unfavorable response and the BAT should be stopped. Question is where do you draw the line? 50% increase, doubling or 3 consecutive rises? Unclear.
I think that is a reasonable view and personally I would try it. For me it is a question of when. As I am still HS PC and my PSA is currently stable off treatment. But probably when it starts to rise again I will want to try BAT in some form to try to prevent progression to CR.
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Switching from Abi to Enza?
BAT therapy - NIH article
Apalutamide instead of triple therapy for mHSPC 
