Immediate vs Deferred Treatment of BCR after primary and adjuvant therapies. ADT, now or later?

[PGDuan]

Hi all, A few of us are in the BCR situation so here is a helpful (but hard to read) paper on the situation when BCR and PSA comes back > ncbi.nlm.nih.gov/pmc/articl...

I'm not sure what to make of the paper yet, and as there isn't a standard of care the "big" question for me is when to start ADT after primary/secondary treatment failure. Now or a little later?

We know that generally "early and big" is good (which I did after recurrent PSA following initial RALP), but I've also seen some things that suggest waiting a bit longer.

I have low but notable PSA (<.05, 0.15, 0.29, 0.16, 0.29 over the last few months), all after after RALP and adjuvant RT with 18 months of ADT + Zytiga.

Will learn results from from genomic testing and a PSMA PET MRI last week and then meeting with my MO on Wednesday.

Thanks in advance for any insights or reference to research / specialists that may help.

[Magnus1964]

Your PSA is still low. You could wait for a few more PSA results. If you get three rises in a row, then think about ADT. I waited a several months after primary treatment failed to start ADT. That was a long time ago..

[KSK54 in reply to Magnus1964]

I am also in same situation.

Instead of starting hard core ADT I have started estrogen therapy and my PSA has come to <0.009 from 0.300. No side effects except little boobs.

I intend keep using it as long as my PSA remains low. PSMA Pet CT is all clear.

[KSK54 in reply to KSK54]

Many people are going this way and the STAMPEDE study has found good results in their Patch part.

[Blackpatch]

Hi - what genetic eating are you having done?

[PGDuan in reply to Blackpatch]

Invitae genetic testing of my genes/heredity, and foundation one genomic test of the tumor removed in 2019.

Results from the Invitae genetic testing didn’t find anything notable (no BRCA, etc.). Should know results of the tumor test later this week.

[slpdvmmd]

PSMA PET/CT is changing the definition of BCR, as this form of imaging often defines physical recurrence not appreciated by standard imaging.

[Seasid]

You should not rely on any PSMA pet scan when your PSA is under 0.5.

[Seasid]

You should strongly consider chemo therapy as soon as as possible. Don't wait to long with it. You should have only 6 cycles as you are still hopefully hormone sensitive. Don't delay this.

[Seasid]

I would avoid any local therapy as much as possible. Just don't do it. Lutecium PSMA therapy is strictly speaking only local therapy and a cancer could repopulate very quickly if you are unlucky. Any therapy have side effects. So avoid them. The side effects can accumulate. I had only firmagon injections and an early chemo 6 cycles in 2018. And my last psa was 0.29. My nadir was 0.12 and I still have my mother ship! I had no operation and no radiation therapy of any kind. My psa was 100 when I started firmagon injections and my biopsy GS was 4+3.

[PGDuan in reply to Seasid]

Thanks for the perspective; I've certainly been wondering the same. I still don't have results yet from a PSMA PET scan to see if there is anything 'local' to treat anyway, but my MO suggested intermittent 6 months of ADT.

[Seasid]

He is too young to radiate himself too much. Lutetium psma therapy is recommended if your life expectancy is under 8 years. It has too many negative side effects, plus it is only effective if you do not have PSMA - (negative) cancer. I am really not a doctor, but for myself I would rather live radiation for and of life treatment when you have lots of symptoms and pain and when you don't care about anything just to get better for a very short time. You can have only a limited number of radiation therapy. Better if you save it for later. All of this lutetium PSMA treatments are still in development and in early phase. Better wait until we know more. I am in Sydney but if I were in USA I would want to be treated in Boston in Dana Farber. I don't have any real reason for that, but I have a feeling that people there have a great team and that they communicate great. At least that what I hope. So you don't have to come to me to give you advice. If they overlooked something in my PSMA PAT scan I would definitely move to Dana Farber or maybe to NY. I wouldn't stay in Stanford.