Systemic Therapy for Nonmetastatic Castrate-Resistant Prostate Cancer

[maley2711]

Link to a new video and transcript on this topic.......

practiceupdate.com/C/107658...

Results from studies of 3 drugs look very promising.....delay of metastasis by 2 years? I assume most men here are already up to date on this. Side effect profile of these drugs?

Are there really many men who are nonmetastatic and also castrate resistant? Seems an odd scenario?? I suspect most such men are metastatic but scans have not yet been able to detect.....PSMA PET would reduce number of men in that category?

[LearnAll]

PSMA PET CT scans are going to be revolutionary in finding more treatments and more accurate assessment of extent of prostate cancer in the body.These scans ,once mainstream have potential to drastically change how and whether a certain treatment is needed and for how long.

The research will also be affected in major way...for example.. If a researcher uses a certain natural substance or herb and can show by PSAM PET CT that it has reduced or removed the PCa tumor....This finding can not be disputed as it will be seen clearly on scan ..like daylight.

My guess is that research is going to accelerate due to PSMA PET CT scans.

[cigafred]

Non-metastatic castrate-resistant PC: No evidence of metastatic disease by any imaging modality. Castrate level of testosterone (ie, testosterone < 50 ng/dL) Rising PSA level despite castrate level of testosterone.Of course the PSA comes from somewhere, almost certainly undetectable mets. The question is whether to wait for a rising PSA to start second-line ADT.

[LearnAll in reply to cigafred]

Its a fine balance....If ADT is used too strongly and for long.. we run the risk of converting our Androgen Sensitive Cancer to an aggressive variant like Neuro Endocrine. If we do not use strong ADT and if we have aggressive Pca..we run the risk of inadequate treatment.Therefore, we need to assess the inherent aggressiveness of our PCa and tailor our treatments accordingly. Many times, less can be more.

[Hidden in reply to LearnAll]

As TA has posted numerous times, going big on ADT early leads to much longer OS. That is no longer in dispute. The large RCT have answered this question. As for the concern for NE PCA....you have stated it was 20% and possible 30% of cancers treated with ADT.

For me I'll take the chance I'm in the 70%.

BTW, you should always start your first post in your replies that you are GS7 so that people understand you are not in the GS8, GS9 or GS10 category.

[GP24]

Maley wrote: "Are there really many men who are nonmetastatic and also castrate resistant? Seems an odd scenario?? I suspect most such men are metastatic but scans have not yet been able to detect.....PSMA PET would reduce number of men in that category?"

The trials which let to the FDA approval of these drugs used CT/bone scan to determine any metastases. Therefore you are nonmetastatic and castrate resistant (nmCRPC) if CT/bone scan do not show any mets. However, there have been trials that show that up to 90% of these patients do have mets on a PSMA PET/CT. But just CT/bone scan are relevant to decide on nmCRPC.

There are quite a lot of these patients. If you start with ADT as soon as the PSA value rises, as most patients do now, you will become castration resistant without having any mets on a CT/bone scan.

[maley2711]

Are you suggesting use of these drugs even with negative standard scans and stable post-treatment PSA? Are these drugs considered chemo......anything given after ADT fails??

[maley2711]

One thing to add. My understanding that , with initial radiation treatment, few men will achieve essentially PSA of 0.....Docs look for a nadir/low, and then alarm bell if PSA rises much above the nadir. I would think that some men with negative margin after RP might also have some PSA from remaining prostate non-cancerous prostate tissue at margin, but I don't remeber having seen any discussion of that possibility? Impossible? Or does the margin never contain prostate tissue???