Triplet Systemic Therapy for low volume mCSPC

[PGDuan]

Hi everyone, first a big thanks to this group for all the input. I’m incredibly grateful for tons of input, the latest PSMA scans, and excellent medical advice.

The very recent ARASENS trial results helped me finalize treatment plan for low volume mCSPC —> ADT + Daralutamide + SBRT + Docetaxel.

This aggressive plan would not have been the case months ago without the scans or trial results. As for me, I’m in the controversial zone where it isn’t fully established that adding chemo results in longer OS. However, I’ve had a 3-6 month doubling rate, but am otherwise fit and healthy without any symptoms.

See below for a recent article and guidance.

[Hidden]

I love your graphical summary!

For what it's worth, my MO is against chemo until it is absolutely needed. Side effects are real.

[PGDuan in reply to Hidden]

Thanks RSH. Totally understand. We are all in our own battles. I’ve been on the fence for quite a while, and am now a little relieved that I’ve made a decision. One of my doctors said it well, “there is no right/perfect answer at this time”. One just has to decide and move forward.

I may regret side effects down the road, but I also fear the regrets of not going big given early indications it may be best (for my specific situation).

[PGDuan]

Thanks Nal. It’s a mystery for sure. I am guessing some escaped before the initial surgery in 2018. I was GS 4+3 and PSA 11, and on pathology 0/15 on nodes and margins, but there was a reference to PNI that I overlooked at the time. There have been a few recent posts that PNI is a pretty negative indicator. The post-surgery PSA of 4.0 was a real sign it didn’t get it all but subsequent scans at the time pointed to local lymph nodes so EBRT and ADT+Zytiga cleared it up right away and I was then <0.05 for 2 years.

Not 100% sure that I’m taking the “best” path, and the MDs note there isn’t a perfect decision. I’m sure future studies will tell us more down the road. Hoping this will buy me the most time for now, and that insight on other options progress in the years ahead.

[SeattleDan]

Can you guys please write out what the acronyms you’re using stand for??

[Grandpa4]

I am in a very similar situation except my PSMA has some equivocal lesions that my doctors are debating the significance of. I am thinking early aggressive treatment makes some sense unless it ruins my quality of life for the next few years. I am already on ADT and Abiraterone and feeling good. About to get radiation therapy. How sick does chem make you and how long are you sick? I will talk this over with MO on Wednesday.

[PGDuan]

best of luck. You are asking good questions about the tradeoffs.

[PGDuan]

Maybe I spoke too soon. I was feeling some relief to finally feel like we’d made the “best” treatment decision for my situation, but many of you have noted concerns that recent trial data and benefits of triplet therapy in this situation have been mainly for de novo (new) case of low volume mCSPC. The results may not be as relevant to me since I already had primary treatments.

The most interesting consideration is that docetaxel only kills actively dividing cancer cells and not dormant ones. Thus if I get SBRT to the 1-3 focal spots the actively dividing cancer will be gone and the docetaxel will be unnecessary / non-beneficial for OS but still introduce toxicity and side effects.

Guess I’ll discuss this again with my care team next week.

Not sure if I’m the only one, but I’ve tried really hard to become educated on PCa and get as many highly-informed opinions as possible. It sure isn’t easy. Talking to multiple doctors is helpful in rounding out the questions and understanding…but not necessarily when it comes to taking “bet your life” decisions.

[Brysonal]

I agree it is not easy at all to feel a definitive right answer. I have been both ends of the spectrum with with 2017/2018/ 2019 all about quality of life. 2020 brought me back to earth with my urologist saying I was a 1/1000 failure of hifu in a low risk Gleason situation and now was advanced with PSMA flashing in T1 and third rib. I continued with a QOL focus hoping for the abscopal effect from SBRT. When this failed I hung my hopes on Lu-177 doing some magic but my increasing PSA, quick doubling time and new mets led to me flipping into a super aggressive approach of Degarelix, Lu 177 x 3, Docetaxel x 3, 20 rounds of radiation to pelvis and prostate, SRRT to Th9 and a brachytherapy boost.

By first for me the worst part is the Degarelix ( had 7th injection this week) . I am holding a presecription for Apalutamide which 1 onco wants me on and 1 is more chilled.

I am still hopefully of a replacement for HT to be discovered very soon but will be back at gym this week

Good luck with your choices . It’s so strange I never thought their would be choices!