Dutasteride and Apalutamide

[Squirrel71]

Hi to all

I remain PSA undetectable since mid 2020 with Lupron injections every 4 months and daily Apalutamide and like everyone on this site, I would like to continue to be castrate sensitive or cancer free. I continue to be impressed by the information available from all of you on this site and I regret that I am unable to wrap my head around much of what is said here and more so to contribute in some meaningful way. Although these questions may have been previously answered, I hope that some of you will be kind enough to offer answers in straight forward layman’s terms.

Is there any support for taking Avodart with Apalutamide to extend castrate sensitivity? I have been on Lupron/Apalutamide for >2 years now.

Are there any studies that suggest Lu177 is effective in a castrate sensitive patient?

Is there any data available on what percentage of patients become castrate resistant after long term Lupron + Apalutamide/Aberaterone//Enzalutamide/Darolutamide?

Can triplet therapy be started after long term Lupron and Apalutamide + radiation to prostate?

Thanks

[Tall_Allen]

"Is there any support for taking Avodart with Apalutamide to extend castrate sensitivity? I have been on Lupron/Apalutamide for >2 years now." Avodart is like a drop in the ocean when you are already taking Lupron and Erleada. It won't extend castrate sensitivity.

"Are there any studies that suggest Lu177 is effective in a castrate sensitive patient?" Not yet- there are clinical trials.

"Is there any data available on what percentage of patients become castrate resistant after long term Lupron + Apalutamide/Aberaterone//Enzalutamide/Darolutamide?" They all do, unless they die of something else first.

"Can triplet therapy be started after long term Lupron and Apalutamide + radiation to prostate?" No.

[Squirrel71 in reply to Tall_Allen]

Thank you for your prompt and frank replies. Your input is valued.

[KocoPr in reply to Tall_Allen]

TA, the question that squirrel71 asked Is there any data available on what percentage of patients become castrate resistant after long term Lupron + Apalutamide/Aberaterone//Enzalutamide/Darolutamide?"

Your answer:They all do, unless they die of something else first.

Do you know what the median time frame to castrate resistance?

[dhccpa in reply to KocoPr]

We all hate to deal with that question.

[Tall_Allen in reply to dhccpa]

In STAMPEDE, mean time to failure of abiraterone was 55 months.

[john4803 in reply to Tall_Allen]

In the Titan Study, after 52.2 months, median overall survival in the apalutamide (+ADT) group had not yet been reached.

urotoday.com/conference-hig...

[dhccpa in reply to KocoPr]

See TA's answer below.

[tango65]

If Lu 177 PSMA treatment is effective in castration sensitive cancer, you mean if it will prolong survival when used to treat castration sensitive cancer, there are not data yet.

If you mean if it will kill PSMA positive castration sensitive cancer cells, the answer is yes.

When my cancer was castration sensitive I had Lu 177 PSMA treatment for multiple metastases in retroperitoneal and pelvic lymph nodes, and all the mets became PSMA negative and remain (six years later) PSMA negative after one treatment with Lu 177 PSMA. Other people had similar experiences.

[Seasid in reply to tango65]

Did you receive only ADT and Lutetium PSMA therapy at that point of time, or something else also (like Enzalutamide?) How many infusions of Lutetium did you receive? Did you receive other therapies also like SBRT? Did you receive and when SBRT just before or after Lutetium infusions? Did you receive chemotherapy and how many cycles after Lutetium? Did you receive some other non Lutetium radioactive infusions? Thanks for your contribution. István

[tango65 in reply to Seasid]

Only ADT.

[Seasid in reply to tango65]

Only one infusion of Lutetium is what you received in your lifetime?

[tango65 in reply to Seasid]

yes

[Schwah]

Was that the only treatment then and in the ensuing 6 years? Where did you get the treatment? How much was it? I know Insurance and many doctors won’t do it for castrate sensitive. My MO says it will likely work but if you have a relatively good prognosis (5-10 years plus survival) he thinks the large amount of radiation involved may eventually create other issues. I’m torn.

Schwah

[jazj]

I thought someone here from Australia managed to wrangle approval for trying Lu177 before being castration resistant AND being metastatic (outside of a trial.) Maybe it was another board? Any ideas who it was?

Apparently the less tumor volume you have the more that is absorbed into good tissue increasing the risks. It's so new though, is there enough data yet to even know statistical chances of significant long-term adverse effects when it's not used as a "last straw?"

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

[Grumpyswife in reply to jazj]

Another member brysonal received his treatments in Finland before castrate resistant and chemo, I believe.

[Schwah in reply to jazj]

Hmmm. That’s a good reason not to use it too early huh?

Schwah.

[dhccpa]

All good questions.

[j-o-h-n]

Just remember this Squirrel...... it's all fooking nuts...............

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 07/12/2022 12:14 PM DST

[MateoBeach]

Studies of Lu treatment experiences in Australia and Europe from patient series results ( not RCT trials) suggest that Lu-PSMA works better in early disease than in more advanced. And works better in lymph-node only metastasis than in bone. And works at least as well in hormone sensitive as CRPC. Overall survival and long term risks in HSPC are not yet fully known and likely will not be fully clear for several more years since HS has longer survival to be evaluated. So one must make their own decision based upon limited information. But waiting also carries risk. For me, I chose to have Lu-PSMA treatments in Australia with favorable initial results. Details in my previous posts. Your situation is unique as is mine. Suggest consulting a doc experienced in this, which will necessarily be outside the USA at this time.

[Seasid in reply to MateoBeach]

Are prostate cancer stem cells (CSCs) PSMA positive?

[MateoBeach in reply to Seasid]

Well Seasid, when I search PC CSC markers list it is a very interesting topic. But I find no specific mention of PSMA as one of the markers. Not sure why.

However, using a simple logic. It is known that all ( or nearly all) PC cells originally highly express PSMA, though some later lose this. Consider that metastasis is started via CSCs. So if one has metastases that are PSMA positive, then they could only have come from a CSC that was likewise PSMA positive.

Of course this is important in that if one is following up with metastasis targeting therapy such as SBRT for PSMA avid mets, then a follow up treatment such as Lu-PSMA can be expected to have some activity against remaining CSCs.

[Seasid in reply to MateoBeach]

Are cancer stem cells sensitive to radiation? Can we kill them and with wich radiation? Can that be determined at least to get an idea how sensitive the cancer stem cells are to radiation? And how could we determine the sensitivity to radiation? If not than we are in trouble. The cancer will grow back despite we radiate ourselves to death. How many Lutetium infusions we need? We don't want more radiation than it is absolutely necessary. I think at this point we still in an experimental stage.

[Schwah]

You may want to update your bio as your results are remarkable. If I understand, you were stage 4 metastatic. Was that after radiation or prostatectomy ? And the only systemic treatment you had was one session of LU177 in Munich 6 years ago. No ADT or other T blockers. What is your PSA history before treatment and the past 6 years? What is the contact info for Munich? What did you didn’t? Sorry to throw all these questions at you but this results make it tantalizing for those of us who are ogliometastatic and hormone sensitive. Do they claim Your results are common?

[Schwah]

Ahhh. Thanks for the details. Sounds like the LU177 did basically the same thing as SBRT directed at individual mets. By the way, which immunotherapy did you do. I actually paid out of pocket last year for Provenge along with SBRT to the one met they found during my first drug vacation and then went back on Zytega and Lupronfor a year. Back to undetectable now and just starting my second drug “vacation”.

Schwah

[Seasid in reply to Schwah]

Maybe more than SBRT. SBRT is local therapy. Lutetium 177 is a systemic therapy. Maybe it also killed the micro mets. The mets not visible on the PET scans. And what's about the prostate CSCs? Are they also PSMA positive? Do we know something about this?

[Schwah in reply to Seasid]

Good point re the micromets. I’m still considering despite being castrate sensitive but my MO (who definitely thinks out of the box), says my life expectancy is still long enough that he’s concerned about the long term affects of the radiation exposure. What are “CSCs” by the way?

Schwah

[Seasid in reply to Schwah]

Cancer stem cells

[CAMPSOUPS]

Immunotherapy 2007. Was that Provenge?Always have appreciated your input on the forum.

[Seasid]

You need urgently a systemic treatment. The best would be for you 6 cycles of Docetaxel chemotherapy plus Provenge parallel. Could you do it? You can always stop chemotherapy anytime if you develop side effects. I had no problem with the chemo. After chemotherapy you may be able to continue Nubequa if you stay oligometastatic. Do not wait. Don't think that because of the PSA drop after the SBRT you are safe. You need a chemo parallel to Provenge now. Don't delay your desission.

From Dr. Fred Saad about chemotherapy:

urotoday.com/journal/everyd...