At what point - stereotactic treatment versus chemo

[Arthur479]

Just has a PSMA scan. The results were non-awesome. 4 pelvic regions with high activity, 7 pelvic spots of low activity (and these according to the doc, would not have been detected on a regular PET scan. No organ involvement.

He is uncertain where to go straight to docetaxel or zapping the 4 most active spots (and maybe more). He will be getting a consult to help him decide.

My question - what is the typical cut off for making this choice?

I am inclined to zap the most active ones and try some other less intense treatments for now.

[DarkEnergy]

Hi, I've been through this all, my "opinion", also consider I'm treated by one of the world's premier cancer centers, Dana-Farber at Boston MA, got PSMA targeted radiation to kill the cancer spots. I did get Chemo therapy for sweeping the circulating tumor cells in the blood stream.

Of course, lowering testosterone is the front line of Prostate Cancer treatment, this means first line treatment of reducing levels of androgens (ADT) to slow the growth of prostate cancer.

Noticed, said to "slow", once cancer, it's for life, we can suppress it and live fully...

[Tall_Allen]

When you say "pelvic spots," I assume you are talking about metastases on the pelvic bones, and not pelvic lymph nodes, right? The cut-off is usually 3, but I have seen up to 5. If those spots are not causing pain, there is no known benefit to zapping them. Chemo will shrink them all - including the ones you can't yet see on a PSMA scan.

[Arthur479 in reply to Tall_Allen]

Thanks Tall_Allen. I have them to bone and lymph. The more active spots are to the bone, but there is no pain from any of them.

My thought on the radiation was to prevent pain and slow things down and buy time while preserving quality of life.

But on the other hand it is sort of appealing to throw everything (reasonable) at the problem. But I do worry about the impact of chemo

Yeah, I am indecisive on this.

[Tall_Allen in reply to Arthur479]

Docetaxel increases QOL (not while you're taking it, but afterwards compared to if you didn't take it). I'm not sure that metastasis-directed- radiation actually "slows things down.") There is no proof that it does yet. In fact, in this retrospective study, it didn't:

prostatecancer.news/2020/12...

[Schwah in reply to Tall_Allen]

If there’s no evidence MDT works, why do you suppose insurance companies do not fight paying for it even if one is not doing it for pain control?

Schwah

[Tall_Allen in reply to Schwah]

Many MOs are savvy about insurance companies and probably write it up as palliative. But why insurance companies pay for some unproven things and not others is a great mystery. There are several clinical trials that will prove or disprove a benefit, but it's still a few years until they mature.

[Schwah in reply to Tall_Allen]

I actually thought the same thing when I had my MDT with Dr. Kishan at Ucla. I asked f we needed to say it was to address pain to get it approved. He said we did not and that it wasn’t a problem to get it approved. He (and apparently the insurance companies) obviously believe it’s potentially life extending although as you say, the hard evidence is still lacking.

Schwah

[Tall_Allen in reply to Schwah]

I know Dr. Kishan well, and his attitude is exactly the same as mine. I even confirmed that with him after you told me that. I think you may have heard what you wanted to hear. As I said, insurance company approval is not any gauge of what is effective.

[Shooter1]

Been there and docetaxel and xtandi nailed mine for 3-4 years. Now fighting BCR, but 5 years in is a lot better than a lot of others have lasted... Good luck with chemo.

[Arthur479]

Really appreciate your insights guys. Somewhat less reluctant to face chemo from reading your posts. I can see benefit from doing both together actually.

Nonetheless, while not complete, one of the studies TA may have been referencing is the Oriole Study. It makes the point about generating other immune benefits in ways that are unclear.

urotoday.com/video-lectures...

Here is an excerpt from the link

“So it is, it's very preliminary. I think the result is clear that SABR causes a systemic immune response. We don't know if it's technically an antitumor immune response, but it is certainly a systemic immune response. And again, it's early, there's not much more we can say at this point about that, other than that, you know, SABR causes a systemic immune response.”

[Arthur479]

Well good news and bad news. No radiation as you guys thought, but the tumor burden is so low (nothing over 10mm, that a round of docetaxel should really help. I am an excellent candidate for LU-177, so the team at my clinic says.