PSA is increasing with Docetaxel, what should we do now ?

[mgaa]

My father is now 66 years old, back in Dec 2020 he was diagnosed with Advanced PC now his PSA rised to 6.630 ng/mL on Docetaxel, what are our options given that my father is not in USA (in Egypt) ? or how should we proceed if someone has a positive experience after Docetaxel stop working ?

Here's the complete story:

Dec 2020: PSA 75.3 ng/mL with no UTIs, then urologist asked for biopsy.

*pathology report reveals : Gleason score 4+4=8

PATHOLOGY REPORT

Diaqnosis :

Prostate, TRUS guided biopsies,

- RT APEX, PROSTATIC CARCINOMA GLEASON SCORE 4+4 = 8 (GRADE GROUP 4),

INVOLVING 100 % OF THE NEEDLE CORE TISSUE.

- RT MID, PROSTATIC CARCINOMA GLEASON SCORE 4+4 = 8 (GRADE GROUP 4),

INVOLVING 100 % OF THE NEEDLE CORE TISSUE.

- RT BASE, TINY FOCUS OF PROSTATIC CARCINOMA GLEASON SCORE 3+3 = 6

(GRADE GROUP 1), HYPERPLASIA.

- LT APEX, PROSTATIC CARCINOMA GLEASON SCORE 4+4 = 8 (GRADE GROUP 4),

INVOLVING 100 % OF THE NEEDLE CORE TISSUE.

- LT MID, PROSTATIC CARCINOMA GLEASON SCORE 4+4 = 8 (GRADE GROUP 4),

INVOLVING 100 % OF THE NEEDLE CORE TISSUE, CAPSULAR TISSUE.

- LT BASE, TINY FOCUS OF PROSTATIC CARCINOMA GLEASON SCORE 3+4 = 7

(GRADE GROUP 2), HYPERPLASIA, CYSTIC ATROPHY, PROSTATITIS.

*MRI results: Tumor Grade =T3b,N1,M0

*Tc99 MDP Skeletal scintigraphy results:

- Solitary active osseous lesion at this level of LV3 warranted further CT

correlation and follow up.

- Otherwise the rest of the skeleton is unremarkable

and then he started his treatment plan as following:

Zoladex 10.8 (goserelin acetate implant) shot every 12 weeks.

Casodex 50mg (bicalutamide) one tablet every day.

Jan 21: PSA decreased to 10 ng/mL

Feb 21: PSA increased to 17 ng/mL , then 28 ng/mL by end of Feb 21

Mar 21: "Gallium-PSMA"- PET/CT scan that showed Tumor is M1b instead of M0, with solitary pelvic nodal deposit and multiple osseous metastatic deposits.

Updated Diagnosi: Metastatic Castration-Resistant Prostate Cancer (mCRPC).

he stoped Casodex 50mg (bicalutamide) and switched to Zytiga 500mg (Abiraterone acetate), 1000mg daily along with Solupred 5mg (Prednisolone) only 5mg daily.

Mid Apr 21: PSA decreased to 12.5 ng/mL

May 21: PSA decreased to 9.4 ng/mL

Jul 21: PSA decreased to 6.6 ng/mL

22 Aug 21: PSA decreased to 5.3 ng/mL

25 Aug 21: another "Gallium-PSMA"- PET/CT scan to monitor progress , it showed a decrease of prostatic tumor mass and overall increase of the nodal and bony deposits. so the national health authority refused administrating Zytiga and asked him to switch to chemotherapy.

His MO suggested to wait and continue on Zytiga for another couple of months meanwhile he redirected him to AstraZeneca Egypt for HRR testing details as following:

Sample type: Peripheral blood

HRR NGS panel Results: No pathogenic or likely pathogenic variants were detected.

20 Sept 21 : PSA increased to 6.1 ng/mL

Oct -Nov 21: switch from the daily dose of 5mg Prednisolone to Dexamethasone and in a lot of cases that could bring PSA down or make it stable for more months, but that didn't work

10 Nov 21: PSA increased to 6.99 ng/mL

end of Nov 21: Started first cycle of Taxotere 20mg/1mL vial (Docetaxel 20mg/mL), each cycle consists of:

40mg Taxotere per week (along with other medicines for fatigue and stomach pain or allergy that can be caused from chemotherapy) for 3 weeks, then followed by 1 week of rest and then PSA test by end of week 4, and those are the PSA results:

16 Dec 21 (after cycle1): 5.530

13 Jan 22 (after cycle2) : 3.880

12 Feb 22 (after cycle3) : 3.680

13 Mar 22 (after cycle4): 5.150

9 Apr 22 (after cycle5) : 4.990

11 Apr22: another "F-PSMA" - PET/CT

Follow up PSMA PET/CT study revealed:

Regressive course of the prostatic primary neoplastic mass.

Stationary course of the regional nodal deposits.

Variable response of the osseous deposits with newly developed lesions.

15 May22 (after cycle6): 6.630 ng/mL

what are our options given that my father is not in USA (in Egypt) ? or how should we proceed if someone has a positive experience after Docetaxel stop working ? many thanks in advance.

[Tall_Allen]

Can he get Pluvicto there? (it is unavailable anywhere for the next 6 weeks). If not, can he get Xofigo?

[Cynthgob in reply to Tall_Allen]

6 weeks from now? Or six weeks from the shutdown of production?

[Tall_Allen in reply to Cynthgob]

6 weeks from shutdown, which was last week. But that was just Novartis' estimate.

[mgaa in reply to Tall_Allen]

is there a difference between them ? I don't think they're available in Egypt but I will double check with his MO tomorrow. Thank you

[Tall_Allen in reply to mgaa]

Both radiopharmaceuticals but entirely different:Pluvicto= 177 Lutetium-PSMA-617 Xofigo=223 Radium dichloride

[GP24]

He could try Xtandi now. In Israel he can get Pluvicto or Lu177 therapy.

[mgaa in reply to GP24]

Could Xtandi be effective after Docetaxel fail ? Thanks a lot

[GP24 in reply to mgaa]

It will not work for a long time, but it can be effective for several months.

[MechD]

mgaa, My experience is not with Docataxel but with cabazitaxel/carboplatin since I've been diagnosed with BRCA2. I was switched from taxotere to cabazitaxel before starting chemo treatments this January and have responded well. PSA pre-chemo 54, current, 0.8. I didn't notice that BRCA gene mutation was a listed condition for your father so I'm not sure what I can offer from my experience. However, before starting chemo, a secondary consult recommended Xgeva as a treatment for me due to bone metastases if my current regimen fails.

[mgaa in reply to MechD]

Thanks a lot MechD for your reply, he did a "HRR NGS panel" test and sample type was "Peripheral blood" and the result was: "No pathogenic or likely pathogenic variants were detected", I'm not sure if that's roling out BRCA2 or there's something missing here, you can also find the target regions for the test attached as a pic to my reply.

He has already started Zoledronic acid (Zometa) shots last month because his latest F-PSMA PET-CT showed major improvement in the prostate tumor but mixed results for bone metastis. his CO mentioned we might switch to Denosumab (Xgeva) in the future.

HRR_NGS_panel_target_regions