Dad has PC in pelvic nodes ? Is he on correct treatment

[Jbooopin]

Dad is now 73. Lives in Sydney, Australia. Ethnicity is Caucasian.

PC history below:

2020 May: PSMA test and rising PSA at 4 give rise to biopsy. Reveals Gleason 4+3 stage 2b.

2020 June: Ends up getting robotic RPC. In post surgery biopsy PC did just breach Prostate capsule. But margins negative. Restage to 3a. Still 4+3 Gleason but high grade percentage (4+5) is 55%. No cancer in seminsical vessels.

No further treatment recommended.

2020 to 2022: PSA drops off to undetectable and life continues.

2022 May to August: PSA rises and doubles in a 3 month period to 0.14.

2022 August: PSMA test confirms cancer is very lightly in 5x Lymph nodes in the pelvic area

Oncologist treatment is the following:

Start ADT Lupron immediately

Late September start xtandi (takes a while to get into Australia)

Suggest course of meds 1.5years

This month (October) PSA now dropped to 0.1 but the oncologist wants it below 0.1.

Next PSA test in 3 months using PSA as the only detection mechanism unless it goes back up.

In December Radiotherapist to do targeted radiation on affected nodes for 30 sessions.

Oncologist thinks 80% chance of survival for next 5 years

Radiotherapist thinks 95% chance survival for next 5 years

He currently does heaps of walking, is eating healthier and doing strength workouts 2x a week but is a bit overweight.

He is having vitamin d and calcium tablets.

Questions below:

Is this the best course of treatment?

Ive read about the triplet therapy incl. Chemo? Ive read about cycling meds to reduce CRPC dominance? Any thoughts in relation to his cancer profile? Should he be doing this?

Is the radiation therapy correct or should it be targeted over the entire pelvic area or other suggestions?

Is tri monthly PSA detection the standard for monitoring, considering his PC profile?

What do you think the overall survivability is for his PCprofile?

Any other suggestions on treatment are welcome thanks.

He recently decided he is going to see another oncologist just to be sure of his decision

Many thanks. Ive been reading up as much literature as I can and this forum has been invaluable.

My Dad is my best mate.

[GP24]

The pelvic nodes could be radiated too at St. Vincents. You could get a second opinion there:

svhs.org.au/our-services/ou...

[Jbooopin in reply to GP24]

very helpful. I will let him know. Thankyou

[Jbooopin in reply to GP24]

how do you know this guy btw?

[GP24 in reply to Jbooopin]

I have watched presentations by one of his colleages in nuclear medicine. So I looked up who is in charge of radiation oncology at that hospital.

[dublin1717]

Your Dads story is very similar to my husbands, who is aged 55 although he was 3+4. Our course of treatment 2 yrs after RP last June was 33 full pelvic rad sessions and Lupron & cosadex for 6 months. This began just as psa had climbed from 0.03, 0.05, 0.07, 0.09, 0,11 over 6 months to 0.15

My advice is do monthly bloods and get full pelvic rad asap. I’m sure our more knowledged guys here will comment too.

Pm me if I can help at all.

He’s lucky he’s got you.

[Jbooopin in reply to dublin1717]

why do you think whole pelvic vs targeted radiation is better?

great point on the monthly PSA checks.

[Tall_Allen]

"Is the radiation therapy correct or should it be targeted over the entire pelvic area or other suggestions?" Definitely! Just targeting the affected lymph nodes is a recipe for failure. 2 years of abiraterone or enzalutamide with it, or better yet, consider the following clinical trial in Australia that uses darolutamide:

clinicaltrials.gov/ct2/show...

Triplet therapy is only for the newly diagnosed, and it is only for cancer beyond the pelvic lymph nodes. Do not cycle meds - think about reducing the cancer burden by hormone intensification. You do not want to give the cancer a chance to grow.

Drop the calcium unless he has a deficiency. The Vitamin D is useless but probably harmless unless he is taking too much.

[Jbooopin in reply to Tall_Allen]

he is doing 18 months of Lupron and xtandi as well. They wanted to delay the targeted radiation a few months from when he started the medication to enhance the effect of the radiation. Does that change your opinion of his treatment?

Another member here mentioned whole pelvic over targeted radiation, what do you think?

[Tall_Allen in reply to Jbooopin]

2 months of hormone therapy before radiation is standard. See my reply to you above.

[tango65]

The Stampede trial showed a good survival with radiation plus 2 years of ADT and abiraterone. (The 6 years metastases free survival was 82%. Median overall survival was not reached at the time of the publication, it was around 80% at 8 years).

thelancet.com/article/S0140...

thelancet.com/action/showPd...

Abiraterone may be better tolerated than enzalutamide.

accessdata.fda.gov/drugsatf...

accessdata.fda.gov/drugsatf...

[RMontana]

Jbooopin, you Dad is starting our right...the more he exercises the better his body can fight off all types of disease, PCa included...but he of course will need more help...here is a good podcase from UCTV Univ of CA that is only 1 year old. I talks about risk stratification, classifying what type of PCa you are dealing with and introducing methods to project and predict outcomes. It also addresses genomic testing which you dont include in your history and that you may want to consider. ADT and SRT (salvage radiation) is covered as well as all the current data on outcomes for combinations of treatments. I found the nomogram at min 8:40 useful as it uses baseline tests at start of treatment and CAPRA scores in a most interesting way and stratifies the outcomes based on results.

youtu.be/yDT_qWG_3oU(Not working as expected?)

Question for you, in your history of treatment state; " Still 4+3 Gleason but high grade percentage (4+5) is 55%." Can you explain the 55%? After my surgery I was also GS 4+3, with a 4+5 pattern at the margins, but what exactly was the 55% addressing? Is this the percent 4 in the 4+3 rating? TNX

PS it the podcast was useful I have some others as well...TNX

[chefjlu]

Sounds pretty much in line with protocols. My quick: PSA slight rise over time - Biopsy 2018 (summer) - Gleason 7 & 9, roughly 30% of prostate - RP in early 2019 - at same time hernia repaired - 1 lymph node found to have cancer activity, margins involved, Stage 3a - PSA dropped to undetectable, no treatment until PSA rose slightly in Nov 2021 - PET Scan in Jan 2022, one spot found in pelvic area in area of lymph node removed - started on Orgovyx (ineffective in lowered testosterone), switched to 1 month Firmagon shot (worked in 2 days) - after 1 month Lupron (6 month shot) and started Abiraterone - PSA at 1.124 when started Radiation to prostate bed and then pinpointed as progressed over 2 months - at end of Radiation PSA .043 - 2 weeks later PSA .024 - 2 weeks again PSA .017 - 1 week again PSA .012 - 6 weeks after PSA fully undetectable. The charts say 5 year survival 98% - 10 year survival 95% to 98%. My Oncologist basically has thrown out the chart. I exercise regularly (very important) - adjusted diet - keep in touch with my "team" of Drs. and keep track of everything. Keep in mind we all respond uniquely and different medications impact each person in their own way. I have had very little in the way of side effects through anything - hot flashes are about it - my doctors all say that being active/exercising is a key part.

[NecessarilySo]

Seems okay except the pelvic lymph nodes should have been detected with pre-op scans and then radiation therapy could have been used for prostate and lymph nodes, with one pelvic series. Hindsight is better than foresight. Also, PSA 4 was within normal so it seems a bit premature or overanxious to do RP right away. If PSA is less than 0.2 in December, I would think radiation therapy could wait. I'm no doctor but I have opinions based on readings.