Abiraterone stopped working new Psma pet scan shows cancer progression

[Nirman]

My father age 71 have been on abiraterone and triptorelin injections every three months last 3 years and few months since diagnosed last few months psa was rising slowly 0.03 to 3 in few months doctor suggested for the Psma pet scan and 5-6 bone mets including new meta developed on 8th and 10th Ribs we changed the the steroid from 5 mg prednisone to 0.5 mg dexamethesone I wonder what would are better options how should I sequence them enzalautamide, provenge, docetaxal, cabizatexal, xofigo or radium 233, lu177psma how to sequence and how much these treatments generally give what amount of survival benefit and even though his scan shows progression of disease and new mets his alkaline phosphate is still 80 and within range....which next treatment would be better any suggestions so I can discuss with his MO next appointment

[GP24]

The switch to dexamethasone may extend the efficacy of Abiraterone for about six months. Usually your MO will then try if Enzalutamide will work for several months and after that recommend a chemo with docetaxel. Instead of the chemo you could get a Lu 177 PSMA therapy. If you choose docetaxel and the PSA value rises after that you can get a chemo with cabazitaxel. You can also get a gene test and see if the drug olaparib will work based on this test.

[Nirman in reply to GP24]

Thanks the. Gene test msi brca1 brca2 negative so no olaparib option available for him now. can he have provenge while he's on xtandi.?anyone have good experience with provenge I've learnd that it doesn't decrease psa but it lowers load of cancer and increase progression free survival.

[GP24 in reply to Nirman]

Yes, you can have provenge with Xtandi or Abiraterone:

urotoday.com/conference-hig...

[Tall_Allen]

When you say that the scan showed progression, I assume that there was another PSMA scan that you're comparing it to; otherwise, it may just be showing increased detection of what may have always been there.

Here's some info on the optimal sequencing of chemo and hormonal therapies:

prostatecancer.news/2019/12...

Xofigo may be a good option if there's bone pain and no visceral metastases. It seems to combine well with chemo or Provenge, but not with second-line hormonal therapies.

ejcancer.com/article/S0959-...

ascopubs.org/doi/abs/10.120...

[Nirman in reply to Tall_Allen]

Yes after comparing with previous scan and he is not feeling any bone pain abiraterone have stopped working so I guess so either xofigo with provenge or xtandi with provenge or docetaxal and Cabizaxtal and then lu177psma would it be the right sequence? Iam sorry Allen I didn’t understood your reply properly

[Tall_Allen in reply to Nirman]

So he's had two PSMA scans? He can't get Xofigo without symptoms. I think alternating Chemo and hormonal is better, so docetaxel with Provenge would be a good next step, or the Lu-177-PSMA trial for pre-docetaxel, starting in May.

[Nirman in reply to Tall_Allen]

Yes two scans in recent scan new meta appeared on rib okay so we can take provenge with docetaxal okay

[6357axbz in reply to Tall_Allen]

Is that the LU-177 trial that excludes long term ADT users?

[Tall_Allen in reply to 6357axbz]

Pre-docetaxel. but failed either Zytiga or Xtandi

prostatecancer.news/2020/08...

[6357axbz in reply to Tall_Allen]

Thanks. That may come into play for me in the future.

[Hidden]

Docetaxal followed by Provenge, followed by scans, followed by what's appropriate after the scan results.

[immunity1]

Your sequence may depend on your financial resources and logistical ability to access treatment. That aside and given your PC genotype and and your PSMA PET status: My recommendation is, FIrst Lu177 PSMA treatments (4 likely) privately, dont wait for a trial, whilst your mCRPC is 'early'.. Secondly, docetaxel, Thirdly, enzalutamide.....Cant advise on Provenge.

[Nirman in reply to immunity1]

Financial resources not a problem as long as treatment is available in India so I guess it’s advisable to go for Lu177psma before docetaxal or xtandi?

[immunity1]

I believe the Lu177 treatment is available in India, check out previous discussion on this site. I got my 6 treatments in Australia and New Zealand. But travel to these countries in impossible now because of Covid 19. This treatment is most successful in early soft tissue cases.......with very minor side effects Docetaxel would be my next (or alternative) option followed by a second generation lutamide

[MateoBeach]

As others note, Lu-PSMA is better early rather than held for later. If he qualify for the new trial great. Otherwise India seems less cost prohibitive than Europe. Provenge certainly, whether with Lu-PSMA or chemotherapy, which would be next in optimal sequencing before enzalutamide. Good luck. Time to go after it strongly in my view.

[Nirman in reply to MateoBeach]

Thank you very much

[youngigor]

There have been other posts on Lu177 treatment in India, some of which go in the hoops through which one must jump to get the medical treatment visa to enter India from US.

As some on this thread asked about the availability of this treatment in India, can confirm that a google search of:

LU TREATMENT INDIA FORTIS

will yield much useful information. Believe that this center was the one referenced in earlier posts.

The cost of treatment (just under 7K USD) just includes one night stay. Other posters stayed a week or so, which seems the better approach. So figure say $1K for a week + air to DEL (sub $700 for a non-stop economy week visit in a random week in August from IAD).

Haven't been there, haven't had this treatment, get no $$$, but wanted to ensure folks knew this option existed should they wish to review or pursue it.

[Nirman in reply to youngigor]

Thank you this would be useful

[Djangler]

I just fid my first PSMA PET scan yesterday. I'll find out if I'm eligible for Lu177 tomorrow. The imaging technologist told me that they're making it in a plant in NJ. Don't know if this has alleviated the US shortage.

Pay-for-play Lu177PSMA is available in India (cheapest), Germany, and Vancouver, Canada. I didn't know about the Australia option. Canada and Germany costs are comparable - about 2x India.

Good luck to your father. Since he's symptom free, you may want to talk to his MO about doing BAT before trying enzalutamide. There's a study that shows this sequence significantly increases response to enza.

[anonymousdady in reply to Djangler]

If your cancer is found to be expressing the psma receptors, then certainly you are a candidate for the psma therapy...

However in USA there is significant shortage of the Pluvicto and it's not available outside the clinical trials. But in India the department of nuclear medicine therapy center at fortis memorial research institute treating their patients with Lutetium177 on regular basis. nuclearmedicinetherapy.in/

[Djangler in reply to anonymousdady]

Thanks anonymousdady I recently had a positive PSMA scan, and have prior taxane and ARSI treatment so I qualify. Since the NJ factory got FDA approval, Dana Farber has been starting new Pluvicto patients. I'll stay on my current treatment regimen until progression. After that Lu177 is an option. Hopefully supply chain will be all worked out by then.