Nubeqa or Zytiga, which should come first?

[watertender]

Hello! I am confused on which med is best to add to my ADT, Orgovyx which I have been on for a month now. I am Gleason 9, N0 M0 (as far as I know only was able to get a CT, bone scan and MRI), extra capsulation extension. Urologist suggested Zytiga also but RO said he did not think that was necessary. From what I see adding another medication ups delay to mets, although they are probably already present.

Would it be better to add Nubeqa rather than Zytiga? Should one hold off on either of these to use down the road? Can one stop working and then you switch to another and if so is there a better order of progression?

I am having urinary issues, similar to BPH, and RO seems to think the ADT will shrink the tumor that is impacting the urethra. So far no relief on that end so wondering if adding something else may help as suggested by the urologist. Having bracy done after 2-3 mo of ADT then EBRT.

Thanks to all, have gotten alot of info from this site!!

[Tall_Allen]

1. You will not be able to get Nubeqa outside of a clinical trial. It is only approved for non-metastatic castration-resistant PCa.

2. A recent STAMPEDE trial proved that Zytiga may add to survival in high risk men. But you may have to appeal with your insurance because it is new:

ncbi.nlm.nih.gov/pmc/articl...

3. Consider this clinical trial, which may include Erleada if you qualify for intensification and you are randomized to get it:

clinicaltrials.gov/ct2/show...

4. You should get a PSMA PET scan and a Decipher score of your biopsy cores (part of the above trial).

[watertender in reply to Tall_Allen]

Thank you much. As far as Nubeqa I will need to wait until the PCa is castration resistant it sounds like. Is that then the drug that would be taken after ADT ceases to work? A little confused on that part as I do not have a MO and the RO I have does not seem to be as well informed on prostate cancer meds as I would like. I do think I can get the Zytiga with a hefty copay so well have to ask him about it. Is it recommended to get a PSA check after the first 30 days of ADT or wait longer?

Unfortunately, nowhere near any of those locations for the Eleada clinical trial. I attempted to get a PSMA PET before I began ADT and was emphatically told by my RO that PSMA PET would not be approved until I went to failure.

[Fightinghard in reply to watertender]

You need to get a MO on your team asap. If you share where you live, someone on this site might have a good recommendation to help you get started

[Tall_Allen in reply to watertender]

Where are you located?

Because you are attempting to cure your "high risk" prostate cancer, the ADT that you take along with radiation ("adjuvant ADT") will never stop working.

The kind of therapy you have chosen (brachy boost therapy) has the best record of success with high risk PCa. However, if the type of brachytherapy used with it is seeds (low dose rate brachytherapy) there is a risk (in 19% of men) of serious late-term urinary retention. For that reason, researchers are trying to find a therapy that is equally as successful, but with lower rates of side effects. The INNOVATE RCT is an attempt at achieving that.

Although you are not close to an INNOVATE trial location, you can nonetheless duplicate some of its key features by (1) getting a PSMA PET scan and (2) getting a DECIPHER genomic analysis on your biopsy cores. The PSMA PET scans were FDA approved for high risk patients (and not just recurrent patients - your RO is quite wrong about that). You can find locations near you at this site:

pylarify.com/site-locator

Your RO may be right that your insurance may not cover it yet, but Medicare certainly does. Do you have Medicare?

Although you won't be able to get Erleada off-trial, you should be able to get Zytiga.

[watertender in reply to Tall_Allen]

Well, quite discouraging I had argued with him on the PET scan. I am on Medicare but is it of value now that I am on hormone therapy to get a PSMA scan at this point? I see there are locations about 6 hours or so away, I am in SW Colorado.

If I were to add Zytiga would a scan change any treatment decisions? I do plan on going to UCLA (Dr. Chang) for HDR brachy then the local RO will do the EBRT treatments. The local RO I have thought it best not to do brachy if my BPH symptoms did not resolve after a month or so due to the later urethra issues possible, but Dr. Chang did not see it as an issue.

I am not even sure if I have BPH or if it is the tumor location never got the straight answer from my urologist, all I know is I am tired of my nighttime bathroom visits!

I will look into the DECIPHER genomic analysis also.

[Tall_Allen in reply to watertender]

I suggest you send an email to Telix asking if they have a location that provides the Ga68PSMA11 PET scan nearer to you: [e-mail]

Hormone therapy may increase PSMA expression for a month or two before it decreases. So the window isn't closed yet.

HDR brachy is not nearly so sensitive to prostate size as LDR brachy. Let Dr Chang decide if HDR brachy is warranted - he is the expert. I am relieved that you are doing HDR brachy.

[Sheba215 in reply to watertender]

It sounds like you are closer to Denver. Make an appointment with University of Colorado Medical Center in Aurora, Anchuts Prostate Cancer Clinic. When I lived there I saw Dr. Thomas Flaig, MO in that facility. He is fantastic. University Hospitals always have the latest info on trials a drug availability. Not only do you need an MO on your team, you need to let the MO drive the bus.

[watertender in reply to Sheba215]

Thanks for the reference! Have you heard of Michael Glode a MO associated with the U of CO Cancer center but who works out of the Shaw Cancer Center?

[Sheba215 in reply to watertender]

Yes, I've heard of him. Very good reputation and highly respected.

[slpdvmmd in reply to Tall_Allen]

This points out a another real problem in distribution of care and availability of medication. When I was diagnosed with high risk prostate cancer in 2018 I was started on Zytiga with no argument from my insurance during my last cycle of docetaxel. The argument was the data from the Stampede trial was available clearly showed its efficacy. Individual insurers should not be determining the SOC.

[Tall_Allen in reply to slpdvmmd]

Agreed 100%!!

[Concerned-wife]

Abiraterone is the generic version of Zytiga. Much less expensive. You can even choose not to use your insurance and use GoodRx to purchase it.

[Kkash]

Just as a reference as I think the guidance that’s been already shared by Tall Allen is solid . I have oligometastatic PC, ( 2 sites immediately outside of the prostate) and have been using Nubeqa for a month or two now along with Lupron. I was previously on Zytiga/Degarilix combo.

While my PSA responded immediately, My RO took me off the Zytiga after a few months due to negative liver function that started due to the meds . PSA remains around .002

I’m starting a round of targeted radiation this week (IG-IMRT) .

[MateoBeach]

You have a great plan lined up. Get the PSMA PET scan, worth traveling for. And follow through with Chang, HDR brachytherapy and then EBRT including pelvic lymph node fields. The addition of abiraterone can probably wait while going through this phase. TAs advice is spot on.

[j-o-h-n]

A water tender is a type of firefighting apparatus that specializes in the transport of water from a water source to a fire scene. Water tenders are capable of drafting water from a stream, lake or hydrant.

And all the while I was thinking you had a job tasting water to find out where's it's tender....

Would you please be kind enough to tell us your bio. Age? Location? When diagnosed? Treatment(s)? Treatment center(s)? Scores Psa/Gleason? Medications? Doctor's name(s)?

ALL INFO IS VOLUNTARY, but it helps us help you and helps us too. When you respond, you might want to copy and paste it in your home page for your use and for other members’ reference.

THANK YOU AND KEEP POSTING!!!

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 03/31/2022 3:41 PM DST

[watertender in reply to j-o-h-n]

Thanks to all who popped up with suggestions and comments it is much appreciated.Yup j-o-h-n, you are spot on with the watertender comment-worked as a wildland firefighter some and ran a fleet of watertenders on a big fire once hence the name.