Hi everyone. We were informed last week that Dad now has liver involvement as our oncologist suspected there would be as he didn't make a decision quickly enough on his next treatment when she informed him he was resistant.
He has now started on Docetaxel and had his first infusion last week.
The question I have is what can be done to offset any likely symptoms of his chemo and what will be his treatment options once he is through with this. I can't help suspecting his oncologist is withholding his full entitlement with regards to treatments so don't want to be caught out really. For example, when I asked what would be his options should he decide to decline chemo she said palliative care but when I asked if radium is not an option, she backtracked and said yes so it doesn't fill me with confidence to be honest.
Would abiraterone be useful after chemo? He is currently on Enzalutamide and zoladex and is now resistant to these. Thanks again in advance
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Hillwalker87
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He can't get Ra223 with liver involvement. Possibly add carboplatin to docetaxel. He can and should try abiraterone after chemo. By then Lu-177-PSMA-617 may be approved.
It's only because Ra223 was tested only among symptomatic mCRPC men with no visceral metastases. I suspect it might help men with visceral metastases and bone metastases, but because it was never tested in that patient group, NHS will not approve it for him.
Even better, there is a test of Th-227-PSMA antibody at Royal Marsden. It gives the best of both worlds - it kills PSMA-avid tumors directly. It then decays into Ra223 which kills bone metastases. He may qualify after he completes chemo.
But, but, but... My understanding is that the metal-containing agent binds the metal ion so tightly that it remains affixed to the PCa cell membrane and cant escape into the rest of the body. Radium needs to circulate through the body to get to the bone. So how does that work?
Good question! Actually, the metal (Thorium-227 in this case, an alpha-emitter) is very loosely bound to the PSMA ligand (in this case, a PSMA antibody) in a chemical process called chelation via an intermediate "coordination complex." The Ra-223 atom is too large and won't fit in the coordination complex. So when Th-227 decays into Ra-223, the radium detaches itself itself from the ligand and goes into systemic circulation and is attracted to rapidly growing bony metastases, where it replaces calcium. You get two therapies in one!
"Dad now has liver involvement as our oncologist suspected there would be as he didn't make a decision quickly enough on his next treatment" You cannot foresee when liver mets will appear, therefore I do not think this is caused by not acting quickly. I would have expected more bone mets instead.
Liver mets can be treated with SBRT radiation. They are not a good target for Lu-177 therapy. However, you can treat all the other mets he has with Lu-177.
He wouldn't be able to get Radium with visceral mets as TA said. It would only work on the bone mets anyway.
I would consider getting a biopsy of the liver mets. Visceral metastases often have neuroendocrine differentiation and in that case might respond well to adding Carboplatin to his chemotherapy.
If he hasn't done it yet, he could also get genetic sequencing to see if he has any actionable mutations like BRCA or ATM. If he did, he might be able to go on a PARP inhibitor.
It's not unusual to have mets in the liver, but it's less likely than bones and lymph nodes. So I'd say less usual. I think it's generally a later-stage development in most cases.
And I agree with GP24, you need a test for somatic mutations from a tissue sample.
The color test is a germline test, you also need a somatic test. I would think it is difficult to biopsy liver mets. You can use the biopsy material your pathologist has archived from his initial diagnostic biopsy instead.
It is not unusual for PCa to metastasize to the liver, but it is a sign of an aggressive, advanced cancer. PCa usually first metastasizes into lymph nodes and bone and then to the liver and other organs.
We are all non-experts here. We can give advice from experience, however, everyone has dissimilar journeys. I would strongly suggest you get advice from another oncologist, and consider changing. We all must have absolute faith in whomever we have looking after us. Our lives are at stake, after all.
Ice on my feet and hands helped with keeping neuropathy down. Hard candies and biotin helped with dry mouth. Also walking helped me with my fatigue. Staying busy is important. I found that after first week I felt good actually. The chemo helped with the pain and the rest of the side effects went away.
I was also DX with a liver met about 2 months ago. Had a liver biopsy that showed it was ordinary PCa. I was worried that it might have morphed into NEPC after 24 years Hardest part of the biopsy was lying pretty still for 6 hours after biopsy. If you had to go they only gave you a urinal or bedpan. My MO started me on Docetaxel a couple of weeks ago, next dose this Friday. Let me know if you want more info.
Hillwalker, if interested I can send you my docetaxel info..... at present completed 26 rounds and still going strong. the stuff has held my psa and progression for the past 15 months and the chemo crash can be managed. you will need to keep your dad drinking lots of water and even when his body say not take a walk. for me its my existing maint. plan and it has been working. discuss with you gu medonc the use of dex (4mg) on day 3 and 4 to hold down the chemo crash and for sure get him to eat whatever he likes - limit sugar but most everything else. I the one thing is keep moving.....
Hillwalker sorry doing house work this morning and not keeping up with emails or chat... As for chemo as stated it seems to work for me but must admit not everyone can take the stuff. what to watch out for: chemo crash happens a few days after the infusion. along with chemo your medonc will all so include dexamethasone (dex) and some form of anti nausea medication. the dex will be approx 10 mg and will give your dad a boost for a few days but when it wares off then the crash. for the first 3-4 rounds I would just be aware that it happens and make sure to get a lot of rest. after or with your medonc's agreement you can add 4mg of dex a couple days after to help with the chemo crash. in addition for me I find prune juice helps with constipation which for most come with chemo the day after. just one glass the day of the infusion helps me greatly. as for the ice and neuropathy that for most comes with chemo you can purchase mitts and socks which can be frozen to help slow the flow of blood to both his feet and hands. not everyone gets neruopathy but i must say a good number of guys do. keeping active helps with the fatigue... its hard but the more he can do in the form of exercise during chemo the better he will be. take walks, swim, ride a bike all are good. if his doc approves and after you see that the stuff is working extending the cycle period for 3 to 4 has helped me a lot. once again drink lots of water.. not sure it this helps. advise if you think of anything else!Max
Hi, Where in the UK is he being treated? You may find that quite a few of the suggestions you might get on this site regarding certain tests and advanced treatments are not available on the NHS. There are 'rules' about sequencing for example, and consultants usually cant go beyond the NICE/NHS England guidelines in their protocols, unless its a clinical trial of course. In the NHS there are stoppers such as "NHS England's policy stipulates that either enzalutamide or abiraterone (another antiandrogen) is to be offered only once in the treatment of prostate cancer." So looks like no -re-challenging after chemo for example. On the other hand, some treatments were available in the UK (eg. LU-177) privately before approved in the US. In any case, is always good to know the 'theoretical' options - as some relevant treatments may still be available privately if you have the funds. Its important to check out with the oncologist whats available if you pay - assuming thats an option. In my experience some NHS oncologists dont always discuss what they know they cant offer. Probably with the best of intentions, since they dont want to raise hopes for people who just cannot afford these often costly treatments. Good luck with the chemo. There are lots of posts on this site which suggest that the reality is not as bad as the expectation, so take heart! Hope it goes well.
My husband finished 6 cycles of Docetaxel in December. We read all the chemo tips on this site and others before he started treatment and we are sure they helped him avoid some of the worst side effects.He iced his feet and hands to avoid neuropathy. He bought chemo socks via Amazon and held frozen water bottles while wearing lightweight gloves. He’s avoided neuropathy, except for a little bit of numbness on the bottom of his feet. He did have some numbness in his fingers but it’s already gone away. We expect the numbness to go away in his feet eventually too as it’s already much better. He also bought a chemo ice cap to avoid hair loss but 13 days after his first treatment his hair fell out so the ice cap wasn't used for his subsequent treatments.
He also did a modified fast before every chemo treatment too, which is to supposedly aid the effectiveness of the chemo.
He was lucky in that he didn’t experience major side effects except for fatigue. He did experience what we thought was thrush but found out it wasn’t thrush but something called stomatitis. Apparently it was an adverse reaction to the immunotherapy (Opdivo) he was on as part of a Phase 2 clinical trial. The trial is to see if that drug will work on prostate cancer. My husband, Steve, is on this site too under the name Stevana if you want to message him directly with any questions.
Steve always felt good the first few days after chemo but had a chemo crash on the 3rd or 4th day after chemo where he felt especially tired. On those days he didn’t do much but after a day or two of rest he would be well enough to work in the yard, do a light work out, etc. Hopefully your dad will tolerate the chemo fairly well, too. Good luck and I hope this helps keep his cancer at bay. Below are links to more chemo hints from this site.
I should have mentioned that Steve’s scans after chemo were great. All lymph nodes shrank, the bone mets were stable and no new cancer growth. I hope your Dad sees good improvement too. At Stage IV we know it’s not curable but at least this treatment gives us more time together. Good luck and keep us posted. 🙏
"as he didn't make a decision quickly enough on his next treatment when she informed him he was resistant". When I read that, I was thinking that he may think it is his fault for getting liver mets. He shouldn't. Once the cancer spreads it can be anywhere. I may have cancer cells in my liver right now but they are not visible on scans yet so I think they are not there..
Good luck with the chemo. It wasn't fun but it was easier than I imagined. Rounds 5 and 6 were the most difficult so be prepared for a lot of fatigue at that time. Chemo really knocked my cancer back so it was worth it.
not helpful to blame the patient that he "did not make a decision quickly enough". Also not provable. This is speculation on the part of the oncologist and serves no good purpose. Shame!
To be fair, it's probably more how I'm interpreting what she said, not that I'm overly keen on her approach. The point she was making that there was a trial at the time that he would qualify for but only in the event he had extensive metastatic disease which at the time wasn't too much. But as he hadn't decided on taking chemo since February (when informed he was resistant,) she assumed there would likely to be progression thus qualifying for the trial. She called him a couple of weeks ago highlighting the liver met chucked up in the latest CT scan so was asking if he would like to take the trial. So unfortunately she was right in her assumption, not that I agree with her execution but perhaps she felt it was the only way to push him into taking treatment as he does have a habit of dawdling does my dad
You are a good and incisive daughter. Like mine. She won't ME get away with anything, either. My gripe is that some physicians DO blame their patients or make blaming statements.
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