I’ve just started my journey fighting advanced PCa and am hoping for some advice from you guys who have lots of knowledge and experience.
After a PSA result of 13.0, I had an MRI of the pelvic area and was diagnosed with Stage 4 advanced PCa in May 2022. Gleason 8, LN involvement and a quite large (few inches) tumour on my right inferior pubic ramus. I had my first Prostap (= Lupron) injection two weeks ago and had my first consultation with the MO this week. He is planning to put me on Enzalutamide shortly and IMRT is a likely option further down the line when the ADT has shrunk the cancer. I am waiting for my appointment for a full body CT scan to see what the extent of the mets are.
Right now, I’m pain free and the only symptom I have is frequent toilet trips and slow/intermittant flow rate – especially bad overnight. Otherwise, my QOL is near normal. I’ve dramatically improved my diet (virtuality no alcohol, plant based, green tea, turmeric, D3, etc) and started regular weight training exercise.
My question is regarding whether/when to consider chemo? My initial thought was to let the ADT shrink the cancer, then IMRT to affected areas and think about chemo as an option after that. However, I’ve read that some recommend going in hard and early with chemo as it may give a better prognosis further down the line? Since my QOL is good at the moment, I’m reluctant to whack my body right now with chemo, but would it best in the long run to do so or better to keep as a later weapon?
I know everyone is unique but I would value your opinion on chemo treatment. Thanks
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Benkaymel
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There is no better time to do chemo than now for several reasons.
(1) The ARASENS trial proved that there is improved survival by starting darolutamide (enzalutamide would probably work equally well) and docetaxel at the same time (called "triplet therapy":
(2) You would have to wait quite a while if you only use Prostap + Xtandi now. The cancer cells that are not killed by the hormone therapy are driven into a self-protecting dormant state where they are invulnerable to chemo.
(3) You will never be in better shape to endure the rigors of chemo than you are right now. Cancer has a debilitative effect on the body so side effects are always worse the longer you wait.
(4) The benefit of treating the prostate is independent of the other systemic therapies. If you have an enlarged prostate that is interfering with urination, it would be best to wait until the other therapies have shrunken it before beginning radiation. Radiation causes inflammation in your prostate and if you are already experiencing frequent peeing at night, you risk urinary retention if you don't wait until it has shrunk.
The ARASENS trial uses (ADT+docetaxel) as the baseline to compare adding darolutamide so is slightly different to my situation of starting with (ADT+daro (or enza)) and considering adding chemo. Looking across all the trials, the summary seems to be that either (ADT+chemo) or (ADT+daro/abi/enza) increase time to progression by 1 - 1.5 years over ADT alone and adding both (triplet) gives an additional 1 year or so.
The ENZAMET trial is closer to my situation since it uses enza, but again the baseline is (ADT+doce) and enza is added to see what difference it makes. The graphs towards the end of the article do compare (ADT+enza) with the triplet and indicate very little if any long-term advantage to the triplet (although there is some short-term benefit in synchronous high volume cases). I have my CT scan next week so will find out the volume of my mets.
What none of the trials show is a comparison with the serial options. E.g. when ADT alone fails, traditionally abi or enza would then be administered and would give a certain additional time to the next progression - is that an extra 1.5 years or more or less? When that fails, if chemo is then used, how much time would that add?
Maybe I'm over-analysing but I think I need more data to make a fully informed decision. I'll keep researching.
It doesn't work the way you imagine. If you do them sequentially (in any order), you drive the remaining cancer cells into a senescent state in which they are invulnerable to the next medicine. That is why everyone is so excited about triplet therapy. But there is only a narrow window of opportunity - you have to do the docetaxel at almost the same time as starting the second-line hormonal.
Thanks, yes I saw that in the article where it states;
"Timing is important! When chemo or advanced hormone therapy is used as monotherapy, protective mechanisms (like cellular senescence) kick in soon afterward. It protects the cancer cells from destruction by the other medicine. They have to be used together or wait until the first drug stops working."
The last comment (that I have underlined) seems to suggest that if you wait until the first drug stops working, the next one can then be used. Have I misinterpreted that?
I currently have a PSA (yesterday) of 10.69 doubling at less than 3 months for the last three tests. So I am now considered castrate resistant. I was hoping to qualify for a LU177 trial that does not require chemo before but am I just being silly and does it make more sense to start chemo now and do regular treatment with LU 177?
yes, it is the UCSF recruiting in August that I have hopes for. Not sure if I will qualify and they do not let you know until recruiting begins. Looking at other studies it appears that they are not always on time. the question is whether i should avoid chemo or just do the chemo first and then qualify for standard treatment.
I was diagnosed with stage 4 in august of 16, my oncologist and I decided to hit the cancer hard while I was still strong and healthy. I started chemo 2 weeks after I was diagnosed, along with other stuff. Did 6 rounds of Taxotere and bone shots with adt treatment. Rough start but I’m 6 years into the war as of next week. I didn’t see any reason to wait till I was worn down and weak to do the chemo. Just saying. Follow your heart, and your doctors thoughts. He’s the professional but no one knows your body like you do. Good luck warrior 🙏🙏🙏
So you only did the 6 rounds of chemo - no more since then? What other treatments have/are you taking? By 'bone shots' do you mean radiation?
Diagnosed with Stage 4 in May 2004. Received first injection of Lupron. Six weeks later started a six month Chemotherapy with ADT clinical trial. Deal with micro-metastasis through systemic treatment early when the tumor burden is minimal and your body strong. Best wishes and success on killing the little bastards.
Thanks gd, I've read your remarkable and largely unique story of how you managed to conquer this curse and am very happy for your success. I'm awaiting the chance to go on a clinical trial myself but have to have a certain genetic condition to be eligible - should find out in a few weeks.
I am in a similar situation as you, diagnosed with Gleason 9 in May 2022. My first Eligard injection was at the end of May. After getting second opinions and advice from Allen (everyone said start chemo now), we worked with my MO and changed from abiraterone to darolutamide. I got my first docetaxel infusion on July 11th. 6 cycles are planned but my MO said yesterday he might want to do 7 depending on how I feel.
Now is the good time to start as you’ve been on the ADT a bit but not too long as Allen said.
I have one 1 cm bone met on my right acetabulum. I’m only taking alendronate now proactively because of the ADT. The thought is (since there is only one small lesion), the chemo and the ADT will take care of it.
My RO is in agreement with all this and wants to wait until later in the year when I get IMRT to the prostate after the chemo and ADT has had a chance to work. He also wants to see what it does to the lymph nodes before making decisions about what to do with those.
Thanks Alvin,You're right that everyone is saying start chemo now. I'm slightly surprised though in your case as you have low volume mets and the trials Allen referenced seem to say that triplet treatment is "not statistically" better for this case. I will find out after my CT scan next week how expensive my mets are.
My oncologist professor Joshua said that 6 cycles of early chemotherapy are the norm.
I would not do more than 6 cycles. After more than 4 years I am still only on Degarelix (Firmagon) injections. It may change soon as my PSA started to rise.
I just had my 68GA- PSMA PET/CT scan but I don't know the results yet.
Depending on the results of the scan we will decide what to do next. My last PSA was 1.26.
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