Adding docetaxel for BCR CSPC at 3-mo doubling rate

[PGDuan]

Hi all, Just a brief update as I prepare for the next round of battle. My PSA is low and rising quickly (BCR, PSA 0.77 up from 0.47 a month ago and <0.5 8 months ago). About a 3-month doubling rate but nothing detected on scans so far.

Over the past weeks I've managed to get several opinions from terrific MOs, all recognized experts in advanced PCA. All recommend taking action soon.

One recommendation is either 6-9 months of ADT or a novel trial using a different pathway (HIF-2a) that has been effective in renal cancer and that would not disrupt testosterone.

Second recommendation is 6-9 months of ADT with intensification, probably abiraterone again, but possibly abieraterone + app;utamide. I previously had 18 months of abiraterone with EBRT after unsuccessful RALP and it yielded 18 months of PSA <0.5.

Third recommendation is 9 months of ADT + abiraterone + docetaxel. The addition of docetaxel is given the fast doubling rate and the fact that I am otherwise very healthy without symptoms.

All recommend another set of scans asap given PSA is likely approaching 1.0 and then spot treatment as available in addition to the above (earlier Axumin didn't detect anything at PSA 0.35), including Choline and PSMA PET Pylarify F-18.

I'm leaning toward door #3, adding docetaxel despite the side effects, thinking that in most similar settings (CRPC or mCSPC) earlier, intensive treatment has shown benefits.

Again, all three MOs are exceptionally experienced with PCA and seem very committed.

Time to get the additional scans and finalize the call this month.

[tango65]

I would continue the actual therapy until there is evidence of radiological progression of the cancer. Do you have information that in your situation adding docetaxel to abiraterone and ADT improves overall survival?

The results of the Peace study do not apply to your situation, since it was done in patients with de novo diagnosis of metastatic PC.

There is also the consideration that docetaxel may not help patients with a low cancer load. So far you do not have radiological evidence of mets.

[PGDuan in reply to tango65]

Hi Tango - thanks for the perspective. Alas there isn’t clear evidence yet on OS benefits. The thinking is that docetaxel is effective where fast doubling time / PCa cell division. The thinking is that I have early mets but just haven’t detected them yet.

[Seasid in reply to PGDuan]

You can always stop chemotherapy any time or change to a weekly lower dose chemo if you have side effects. I was fine, only grade 1 neuropathy. You can keep your hands and feet iced during chemo. Here is some information about chemotherapy from Dr Fred Saad. urotoday.com/journal/everyd...

[PGDuan in reply to Seasid]

Hi Seaside, Thanks for the tips and reference article - all very very helpful.

[Seasid in reply to PGDuan]

One more link about chemotherapy: grandroundsinurology.com/dr...

[PGDuan in reply to Seasid]

Thanks a bunch for this extra article - I happen to be talking with her about my situation tomorrow morning.

[Hidden in reply to tango65]

My MO told me no way based on the same info you gave.

[Tall_Allen]

Just some thoughts... #3 sounds like a good choice, given the rapid PSADT. #2 abi+apa may be good too -- there is some evidence that the combo may be more effective. I would love to see a trial of HIF-2a inhibitor combined with either radiatiation or a radiopharmaceutical where hypoxia is known to interfere with therapy.

[PGDuan in reply to Tall_Allen]

Thanks so much for the comments. Super helpful.

[slpdvmmd]

I concur with other thoughts stressing the importance of doubling time. Looks from your profile like you have not previously had taxanes so probably has a role with no definable PSMA positive targets at this point.

[Timmer1967]

Our age and treatment path are similar. Three months ago I made the decision you are currently faced with. I chose your option #3 and will have docetaxel infusion #5 on Tuesday. I would like to share something that made chemo more tolerable for me. Have the steroid you get prior to each chemo infusion administered in the IV versus taking it orally. This change eliminated most of the acid reflux side affect which is common. Best wishes to you.

[Seasid in reply to Timmer1967]

What if you do not have acid reflux? I would rather take it orally. It would be not good for you if they don't put the dexamethasone into the fluid. Maybe I am just paranoid...

[PGDuan in reply to Timmer1967]

Thanks very much for the info and this tip! Hope all continues to go well for you.

[Seasid]

Could you do Provange parallel with chemotherapy? Provange extends life when it is used early with low PSA.

[PGDuan in reply to Seasid]

Good question - I had not been exploring Provenge up until now but will look into it and discuss this with my doctors. Pylarify scan just received today says intense focal uptake at C5 and mild at ribs 5 and 7. PSA still at 0.67 (it dropped a bit since last month).

[Seasid in reply to PGDuan]

Would you radiate C5 if it ha intense focal uptake? (I am not a doctor, but that question came to my mind.) What the MOs think about it? Don't ask first the ROs as we are not interested in their opinion at this stage.