Hello all. First post. I’m 54, dx with Gleason 9, PSA 45; RP with ePLND September 2021; Stage IVA, pT3bN1cM0; EPE, positive margin, SVI, 8/27 + LNs with LVI, microscopic bladder neck invasion. Persistent PSA six weeks post RP @ 4.0. ADT+abi started November 2021, with rapid PSA response. Has been <0.01 since January 2022. IMRT x40, to whole pelvis with boosts to bed and anastomosis January through March 2022.
No PSMA imaging. Conventional scans and fluciclovine scans in August 2021, repeated December 2021, didn’t reveal any bone or visceral Mets.
Thanks to this site, I’ve learned of the two recent triplet therapy studies. With my LN+ disease, but with presumptive micromets, would triplet therapy benefit me?
Comments from all are welcome, but particularly from Tall Allen, hopefully.
Thank you,
Henry
Written by
August13
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There is no proven benefit (and a LOT of side effects) to triplet therapy for recurrent men. It has only proved useful in newly diagnosed metastatic men. You seem to be doing fine.
You do not have mets, the cancer is M0. The use of 2 years of ADT plus abiraterone plus enzalutamide did not improve outcome when compared to 2 years of ADT plus abiraterone and caused more adverse treatment related events.
I will do a rare disagreement with the esteemed TA. He’s right. No proof it will help if you don’t have mets. However, Based upon where you are and your history after RP it’s pretty clear to me you have metastatic disease. You just haven't seen it because you haven’t done the PSMA scans. The triplet therapy has been shown to have huge impact on metastatic disease. I would definitely do it. I actually did it three years ago before the triplet was even proven to work so I’m aggressive.
As per Schwah, the triplet therapy trials that showed benefit for de novo metastatic, do not demonstrate that there is no benefit for your situation. Adding docetaxel chemotherapy might be of benefit. Or might not. Future trials will answer this. “The absence of proof of benefit, is not proof of the absence of benefit.” So you must weigh uncertain possible benefit with uncertainty of risk in careful consultation with your MO. Chemo can be hard but is only for a short time and can be discontinued if needed. Good luck.
As you can see, no one actually knows if it will help you or not. However, the time to start triple therapy for you may have been 5 months ago when you started your post RP ADT and abi.
If I were you I wouldn’t bother thinking about that though. I was diagnosed oligometastatic post op and took triple therapy despite undetectable PSA post, plus radiation. TA is correct, the side effects are numerous, it’s definitely not for everyone.
What is your overall health like? You are young, but if it is not distinctly above average, no co morbidities etc I would approach any more aggressive treatment at this point with extreme caution. Especially because what you’re doing is working now!
In my case it’s quite possible any difference the triple therapy made is negligible. The clinical trial administrator presented it as such in 2019 when I started it. Similar odds likely apply to you. Plus you still have those same good options left, just sequentially now. More are on the way too.
I would just cruise on and not bother it til it bothers you. Sensitive scans will be there to assist if you should need it, which of course were not yet FDA approved just a short time ago
If your cardiovascular fitness and strength are good, maintain it. If they aren’t, build it. It will do more to increase your survival -and quality of it-than any of the drugs, and help you survive them.
This is huge, since for most of us the side effects of the drugs are a considerably greater health risk than the disease anyway.
You are young. You have 2 suspect lymph nodes. Get a PSMA scan and if feasible explore more curative radiotherapy treatments, SBRT, PSMA Lutetium 177 etc.
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