Rapidly rising PSA and new bone met(s).

[meowlicious99]

Complete case history in the profile.

07/24/22 PSA - 0.97

08/24/22 PSA - 1.31

09/15/22 - PSA - 1.69 - Total Testosterone 23.38 ng/dl ( edit: mistyped as free earlier)

Currently on 3 month lupron (since 08/22 ) and abirateron ( since 10/21 ) + radiation.

New PSMA has shown a (first) bone lesion.

Have an mo appointment later this week.

My questions,

1. Testosterone seems high ( albeit only by a little) . why could that be despite adt and second gen.

2. Looks like castrate resistance has set in ?

3. Where do we go from here?

Some additional options i have on my mind at this point ,

* change from prednisone to dexamethasone ( low hanging fruit )

* spot raditation to zap the new met ( prbly useless with no survival benefits ?)

* change from abi to enzalutamide ( only other 2nd gen available in india) . some encouraging results on this forum @Manus , but a long shot perhaps.

* taxane chemotherapy

* lutetium 77 ( available in india) , i belive disease is psma responsive at the moment.

* genomic analysis . This was never done , not sure how to get a biopsy at this point, no liquid biopsy in india. Olaprib and co available in india. try regardless of mutations ?

[Tall_Allen]

Sounds like a good plan with early Pluvicto!

[meowlicious99 in reply to Tall_Allen]

Thank you, Sir.

Does somewhat high testosterone give us an another avenue to suppress it .

Wondering how lu-77 compares to getting chemo then lu. Chemo is readily available in our city, i need call the lu clinics here in india to see what their availability is like.

Worried about runaway PSA if there is a delay in getting lu.

[Tall_Allen in reply to meowlicious99]

T is low, not high. Pluvicto is best next step.

[tango65]

I agree, you should try Lu 177 PSMA treatment if you could get it abroad or if you qualify with the following clinical trial:

clinicaltrials.gov/ct2/show...

[meowlicious99 in reply to tango65]

thank you!

[Yorkielover2]

Lu177 for sure Lucky you can get it now.

[MateoBeach]

if that testosterone of 23 is truly your free T and not total, then that is way too high. Please recheck that! If total T is 23 then that is adequate as a castrate level, meaning the Lupron and abiraterone are doing their job.

Therefore, if PSA is rising, you may be becoming castrate resistant.

The switch to dexamethasone is worth a try.

You have low volume oligometastatic disease, so SBRT to the metastasis could be beneficial. But if it is PSMA avid you may want to jump directly to Lu-PSMA treatments there. Sometimes enzalutamide is found to increase PSMA expression which can make the Lu treatments more effective. So that is worth discussion and consideration. Paul

[meowlicious99 in reply to MateoBeach]

Oh ! Thank you so much, that was my bad. It total not free. Good catch, i updated the post.

> Sometimes enzalutamide is found to increase PSMA expression which can make the Lu treatments more effective.

ooh nice insight here. Do you have any literature corresponding to this by any chance. I can probably discuss it with MO about this.

I am researching LU providers in India at the moment. Wasn't expecting to get to resistance in a matter of few months after ADT :/ .

Thanks again for your response!

[MateoBeach in reply to meowlicious99]

Here is a good link on this:

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

Dr. Ishita Sen in Dehli is very experienced in Lu-PSMA treatments for PC there. She has been a contributor on this forum.

healthunlocked.com/advanced...

I wanted to share a video we made with Dr. Ishita Sen explaining the PSMA scan results after having one injection of LU-177. I'm using this therapy for my first and primary treatment of metastatic prostate cancer. I went to New Delhi in March for my first treatment and then returned to New Delhi for my second treatment in May. This is when we recorded (with my doctor's permission) Dr. Sen giving my treatment results comparing the PSMA scans.As of June, my PSA remains at 2.9. We will be returning to New Delhi in July for a third treatment and will post results after we return.Dr. Ishita Sen is the Director and Head of the Department of Nuclear Medicine & Molecular Imaging at Fortis Memorial Research Institute (FMRI) in Gurgaon.If you would like more information on LU-177 therapy in New Delhi, contact patient advocate Manav Sadhwani at [e-mail]

[meowlicious99 in reply to MateoBeach]

Thank you! I will read through the link.

Thank you for the Dr.Sen recommendation . Who know maybe our paths will cross IRL in future someday 😀.

[Seasid]

This study explained why it is not recommended to use Lutetium PSMA therapy for low volume cancer. (It is toxic to you and not effective.)

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

[CrocodileShoes in reply to Seasid]

Hi SeasidThanks for sharing. I tried to read the report you referred to, but it's very technical. However, if you are suggesting that it's better to wait until the tumor load has risen significantly, that seems to contradict what I've been hearing from some centres of excellence like the Peter Mac in Melbourne where they seem to recommend hitting Mets early.

I wonder if meowlicious99 or MateoBeach has a view on this? I will be in Melbourne in May and was considering a private consultation while there. My PSA is still relatively low, though Xtandi is failing and I suspect Abi +Pred will not fare much better. My oncologist will probably recommend chemo after that, but is there any survival benefit in doing Pluvicto and then chemo - or even both together?

[Seasid in reply to CrocodileShoes]

I know a member here who was rejected by PeterMac on the ground that he had a low volume prostate cancer.

[marnieg46 in reply to CrocodileShoes]

Hi CrocodileShoes,

just wondering if you've watched any of the GU Cast podcasts from Peter Mac on YouTube. There is one in particular with Michael Hoffman (and others) that you might find of interest - Late night PSMA chat at the ProsTIC Preceptorship. Also Six big things in metastatic prostate cancer 2022 is worth the time if you haven't seen it. Not sure who you'll be seeing at PM but would be great if it was Michael or Declan.

The SAN in Sydney at Wahroonga also offers Lutetium if that might be an option.

Hopefully, MateoBeach might also throw in his tuppence-worth...he always has invaluable, wise, well informed advice.

Keep us posted...Marnie.

ps...didn't post the links to the podcasts as unfortunately they come up as the entirety of the first screen...which is good sometimes and not so good othertimes...

[CrocodileShoes in reply to marnieg46]

thank you Marnie, so helpful. I will check out these videos asap!