Chemo as first treatment

[Sipj]

Is there a reason as to why some patients go on ADT (Lupron, Firmagon, etc) and Chemo instead of a different path at the beginning of PC diagnosis?

Background- my husband was first dx with stage 4 with PSA 350 and bone mets throughout (ribs, spine, pelvis, shoulders, skull). He started on Docetaxal immediately (4th round tomorrow) and Firmagon, now moved on to Lupron. He has tolerated as best as possible the last two chemo infusions but is pretty miserable. He is wanting to stop chemo and go to next step. I feel chemo is the hardest most effective "treatment", but I don't know why I think that...trying to read through everyone's discussions and not able to figure out the chemo missing link.

Still pretty new and naïve to all of this...but I am his researcher/personal medical adviser/cheerleader so I want to give him the correct information.

[Magnus1964]

It depends on the cancer staging. Your husband has distant mets so SOC will be different than someone with localized Pca.

[Tall_Allen]

The latest learning from the PEACE1 trial is that for men first diagnosed with multiple metastases, the combination of abiraterone and docetaxel gave the best results. Email this to his oncologist:

prostatecancer.news/2021/05...

[Sipj in reply to Tall_Allen]

Thank you, that article was very well written. I will definitely be talking to his MO tomorrow about this.

[Schwah in reply to Sipj]

TA is 100% right. It’s been proven. Don’t accept no for an answer from your Dr. it’s proven Science now. I did allThree. It’s not horrible. Make him exercise even If he feels like crap. He will feel

Better I promise plus proven to extend life.

Schwah

[Jac_J in reply to Tall_Allen]

Thanks TA. I read your article months ago and informed my oncologist of its content 2 months ago. He said it was still unproven. I had a consultation yesterday and NOW he says It’s proven. This is after my 4th Docetaxel infusion!

Thank you Tall Allen and all the knowledgeable and experienced contributors to this site. You empower me, and many others, to have intelligent conversations with medical professionals. As equals.

Best regards, and much respect.

[Tall_Allen in reply to Jac_J]

They didn't have the proof that the combination increases survival at first, only the 2 ½ year increase in progression-free survival. In September, they released the proof that there was an overall survival increase too.

[tango65]

The Stampede RCTs did not show an overall survival difference between abiraterone and docetaxel. if he does not tolerate chemo he could be treated with abiraterone.

The Peace 1 study showed a radiographic progression free survival advantage when abiraterone and docetaxel were used. I am not sure if this advantage translates into a survival advantage.

[Schwah in reply to tango65]

Are you serious? A 2 1/2 year increase in progression free survival from two years to 4 1/2 years? And a 1.7 year increase in time to castrate resistance? Those are insane improvements. Doing all three is a no-brainer.

Schwah

[Schwah]

I must respectfully disagree. This picture illustrates my point. All the extra brown dead guys on the left might also disagree. As might the extra extra yellow guys on the left who’s disease came back by not adding Zytega to ADT early on. Note the extra progression free survival corresponds quite nicely with actual survival. This chart will likely be very similar (albeit more years) for those dong all 3 vs two drugs. Sometimes if it looks like a duck and it quacks like a duck….it’s a duck.

Schwah

Visual of people alive vs dead by adding Zytega to ADT

[Schwah]

I understood that. My point was how the chart on Zytega/ADT tracked closely between the deaths and progression free survival and that one would expect the same with all three once that trial plays out. Do you really believe that it isn’t extremely likely that an increase in progression free survival of 125% (3 years bs 5.5 years) and a 1.7 year delay in castrate resistance won’t translate to substantial increases in survival?

Schwah

[Tall_Allen in reply to Schwah]

It did, at least for men with lots of metastases. It will be some time before we get the data for men with few metastases.

[Canoehead]

I have no medical expertise to add to this discussion, but my personal experience may be helpful. Dx 4 yrs ago with bone and lymph node Mets in pelvic area, I started on Firmagon and Docetaxel with the goal to hit it hard early. Chemo kills cancer cells, while ADT is arguably just palliative. Switched quickly to Lupron and pressed the doc to add Zytiga. He refused, but I switched oncologists and started Zytiga as soon as Docetaxel was finished. I will add that for me the side effects of Docetaxel got more manageable for the last three infusions.

I’m a believer, because 4 years down the road my PSA remains undetectable. I believe that early Chemo, combined with ADT, made that possible.

[Tall_Allen]

That is just false. It certainly HAS been proven in men with multiple metastases (see my article for update). It will take some time to prove that in men with few metastases because they live longer.

[Sipj]

Just to add to this, I did speak with his MO. She stated that adding Abiraterone will add more side effects and be much harder of a treatment. At this point he struggles a lot with the chemo/docetaxal already and adding another treatment on top of it would be too hard…

[Cmdrdata]

My personal experience: High dose SBRT in early 2007 with PSA at 20. Never nadir’ed to undetectable. 2010 PSA rise to near 20 and scan detected met at L3. New research Oncologist prescribe chemo cocktail of docetaxel, doxorubicin, ketoconazole, and adriamycin for five 8-week cycles. PSA went undetectable, and met disappeared after the first 8-week cycle. This Onc strongly believed aggressive approach at the first met is the correct way to treat PCa. Three years later PSA started to creep up. I am still undetectable and met free after he prescribe Zytiga, now on my 42nd month. DNA test did not show any PCa related mutations. I am now 75 y.o. And still physically active. SEs are high systolic, hot flashes, gynecomastia, and some muscle weakness. Bottom line, at your age, you should seek a new Onc that usactive in OC research and not go by SOP (standard operating procedure). May the Lord bless you.

[MateoBeach]

Additionally, I recall that in the PEACE-1 results the addition of abiraterone/p to ADT plus docetaxel chemo did not worsen the side effects profile. I would go for the triple therapy since he is de-novo metastatic with high volume of mets. Probably minimizes cancer adaptations to less intense therapies. Anyway, it works well as the study shows. 👍