Pluvicto / Lu-177 - Do it now or later?

[GDeG]

I am a metastatic castration resistant prostate cancer patient having undergone most SOC (RP, SR, docetaxel, ADT, Xtandi, Zytiga, Oliparib) steps. Now, like others, faced with very limited remaining SOC options: another round of the dreaded chemo like docetaxel or Lu-177 / Pluvicto.

My mets, based on recent last scans, are in bones not soft tissue. It's been suggested to me that Lu-177 should be taken as a last step, for example when soft tissue becomes involved rather than when it is bone only.

Is this consistent with advice provided by other MO's?

Happy holidays everyone!

Gary

[RyderLake1]

Hi Gary,

My advice (for what it is worth) is take it now. As a result of the VISION trial Pluvicto (Lutetium) was approved this year in North America (Canada and the US) for use after chemotherapy. There are several current trials underway looking at it pre-chemo. One is the SPLASH trial. Keep in mind that Lutetium has been in wide use all over the world. Australia, South Africa, India, Britain just to name a few. The Germans have been using it pre-chemotherapy for at least six years. Good luck!

[Tall_Allen]

Pluvicto is a good choice now - why wait?

[cesces]

Pluvicto is a serious treatment.

They limit the number of treatments for a good reason.

It kills Salivary and renal cells along with cancer. Loss of salivary function is serious, maybe as bad as the cancer.

If you have weak renal function, or family members who died on dialysis, maybe you should get a few second opinions before pulling the trigger.

And investigate BAT treatment prior to pluvicto.

[tango65]

Lu 177 PSMA treatment is a good systemic therapy shown to prolong life and treat the cancer anywhere in the body.

There is not reason to do again chemo if Lu 177 PSMA treatment is available to you.

The TheraP trial done by the australians, suggest, some may say it proves, that Lu 177 PSMA treatment is even more effective than cabazitaxel.

I would do the Lu 177 PSMA, less side effects than chemo and probable good results unless there is diffuse infiltration of the bone marrow by the cancer.

[noahware]

In addition to the PSMA-PET that makes sure your mets are PSMA-avid, consider also doing an FDG-PET:

healthunlocked.com/advanced...

"I believe, along with researchers at Peter Mac in Australia, that it is prudent to also obtain an FDG PET scan before Pluvicto. FDG is important (not Axumin, C-11Choline or NaF(18)) because discordance is most likely to occur as metastases mature. It is a way to reduce unnecessary toxicity and avoid futile treatment."

[EdBar]

Have you asked about Xofigo - Radium 223? It targets cancer in bones. Keep in mind that Pluvicto is not a silver bullet, during a recent conversation with my MO Dr. Sartor, who headed one of the trial arms that lead to the approval of Pluvicto by the FDA - “you can separate it’s effectiveness into thirds, 1/3 of men get an excellent response, 1/3 get some response and 1/3 get no response”. Choose your next treatment carefully and review all options before making a decision.

Ed

[Fightinghard in reply to EdBar]

exactly right Ed. I was on the splash trial for prechemo. Took 3 of 4 rounds. Then pulled off because of cancer progression.

[Sweepandscull in reply to EdBar]

I was on the splash trial as well. I’d put myself in Sartor’s second category - some benefit. I had almost no side effects - no damage to salivary glands or tear ducts… and I benefited most from soft tissue/lymph shrinkage - but had bone met progression (with CT correlate) by month 6.

[EdBar in reply to Sweepandscull]

Yes he said they’ve made great strides in preventing salivary and tear duct damage compared to when the treatment was first introduced.

Ed

[foamhand]

I am Stage 4 advanced McrPC, battling Gleason 9 PC since 2015 (age 55). Not a surgical candidate as PC had spread outside the prostate upon diagnosis. I have done all the hormone therapies and they have failed. I have done Docetaxel chemo off and on for 11/2 years. I had to stop several times due to surgeries for other things. I had a PET / locametz equivalent scan last month prepping for Pluvicto, which showed a couple of new involved lymph nodes and all existing cancerous lymph nodes have enlarged somewhat, along with bone mets in my right hip advancing and new invasion of my L5 vertebrae. So far, no major organ involvement. However, in November, I lost my job and company insurance. I applied for disability and was granted full disability, but I get so much disability it may disqualify me from the additional Medicaid insurance. Considering all this, my oncologist has decided we will start by treating the lymph nodes and L5 spine with radiation which starts today for 2 weeks. Hip mets have already been radiated and cannot take more at this time but they have been surgically reinforced with hip rod and screws. Then we will start again with Chemo using Jevtana (Cabazitaxel) until it fails. Hopefully by then, my insurance and Novartis financial aid will be arranged and I can get Pluvicto. Not many regional hospitals have Pluvicto here yet. I'm hoping more options will be available when round 2 of chemo fails. One thing I have read, if you are planning to try radium-223 Xofigo for bone mets, use it before Pluvicto. Dr.s here in the USA hesitate to use Xofigo AFTER Pluvicto. Also, I was told to be sure to be on Bisphosphonates like Zometa to reduce the risk of bone fractures. I have few bone mets. The lymph nodes are our primary worry right now. Chemo stinks for the first 6-8 days, but I bounce back and feel good until the next session. Getting it once every 3 weeks.

[MateoBeach]

Pluvicto is good therapy and no benefit from waiting on it. However, Ra223 Xofigo may be better in your case with bone only metastasis. Also pursue either with Provenge in parallel.