Father’s MO now recommending adding Zytiga

[mooman80]

Hi all, my dad is nearly three years from diagnosis of Gleason 9 with evidence of spread to local lymph nodes (see profile). Has had IMRT concurrent with 3 years of lupron. Latest PSA 0.03, <0.02 6 months prior.

Original plan from MO was to do Lupron for 3 years which would end 2/23. His recent appointment earlier this month though MO wants him to start Zytiga and continue on Lupron with prednisone for another two years. He said the recommendations have changed given recent studies showing Zytiga with ADT is beneficial for men with high grade localized cancer.

Has the SOC change recently? Anyone know which study he is referring to? Overall dad has tolerated ADT well but worry about adding Zytiga on top of it after already doing 3 years. Is it worth adding Zytiga at this point?

Thanks!

[Jancapper]

I believe your MO is referring to the “High Risk” arm of the STAMPEDE investigation. Here, high risk patients did significantly better when on the combination therapy of ADT + Zytiga + Prednisone. There are many reviews of the STAMPEDE trial. Here is one focusing on the high risk arm.

thelancet.com/article/S0140...

[mooman80 in reply to Jancapper]

Thanks for sharing, I had seen this article during my search and wondered if it might be driving the change. I’ll have him ask the Dr for more details when he goes in next.

[tango65]

To my knowledge there is not evidence that after radiation and 3 years of ADT adding 2 years more of ADT and Zytiga makes any difference.

Perhaps his doctor is referring to the Stampede trial where they found that radiation plus 2 years of ADT and Zytiga made a difference when there were local lymph nodes and there were not distant mets..

I believe he should get a second opinion with an oncologist and a RO and see what they have to say.

[mooman80 in reply to tango65]

This is the study I believe is being referred to, and agree his current treatment plan does not match the study. He was surprised by the change when he went in.

[Tall_Allen]

The new evidence from the STAMPEDE trial is that 2 years total of ADT+Zytiga is better than 2 years total of ADT alone. It does not say there is any benefit now that he's already had 3 years of ADT.

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

[mooman80 in reply to Tall_Allen]

That was my understanding as well based on this specific study. Seems to warrant getting a second opinion before going down the path. I thought the standard was typically 2-3 years ADT after radiation, and then restarting should PSA start increasing again. Zytiga only after ADT starts to fail. I worry about him starting Zytiga now and potentially using up that arrow too early.

[Tall_Allen in reply to mooman80]

If he is cured, he doesn't need any more drugs. I don't know of anyone who thinks that pushing concurrent/adjuvant hormone therapy beyond 3 years is useful.

[Boywonder56]

.02 to .03.....doesnot represent a trend...imho....would need atleast another one

[mooman80 in reply to Boywonder56]

I think the rationale for the change is due to the above mentioned studies and not any trend in PSA.

[reichel]

My diagnosis was in 8/20 and I have been on ADT and Zytiga for over a year. One node involved. The side effects come from the ADT mainly so the addition of Zytiga should not cause more imho.

[fzpinc1]

I really don't know much about the study in question and therefore, will not comment on it. . As to the Lupron shots, though, I was surprised to see here that some doctors, apparently, cease treatment after 3 years. I am in my 5th year of treatments post-surgery. I did 38 days of radiation and then began Lupro treatments - quarterly. I had stopped the Lupron once before; for about 9 months, and re-started the treatments when my PSA hit 2.0. I stopped again; almost 1 year ago now, when my PSA's went to "undetectable" levels (<0.006). I have since moved to the south of France and am due for my next test by the end of January. My urologist here said that he would again commence the Lupron shots if my PSA was above 1.0. I will be investigating what other treatments they offer her in France/the EU and will report if there is anything of significance. Once again I will provide that the makers of Lupron advocate rigorous strength training to alleviate side effects. I can tell you that it does work. I work out twice a week with a trainer (2, 1 hour sessions + warmup on bike) and bike on the other weekdays for 1 hr./day. Good luck everyone; don't despair - ever!

[HaakonR]

I was diagnosed with advance stage prostate cancer in early 2020. Gleason 5+5 10. The oncologist that discovered this would only do a radical prostatectomy. After doing research I elected to be treated out of state and that oncologist did 3 months of radiation in combination with Lupron and Zytiga. I did take prednisone for a year and discontinued. At my 2 year mark of Lupron and Zytiga I asked if I could come off those meds and the answer was yes. He had mentioned I would be on Lupron and Zytiga for 2 to 3 years at the beginning. Fortunately they were able to stop my cancer from exiting my lymph nodes during radiation. He and I both felt that since I was doing so well after 2 years of treatment that I could stop altogether and be tested every 3 months. So far my tests have all come back undetectable PSA. Lupron and Zytiga remain in your system after treatment for some time. Hope this helps.

[Adendino in reply to HaakonR]

Hi there, thanks for sharing your treatment. Did you have other high risk factors such as seminal vesicle invasion or extracapsular extension? What was your PSA? My hubs is also 61, Gleason 9 with SVI and ECE but no lymph nodes or bone spread (according to PSMA pet scan). PSA=12. He is currently doing 2 yrs of Lupron + Zytiga/pred and will start his 8 weeks of radiation later this month.

[garyjp9 in reply to HaakonR]

Did you replace the prednisone with dexamethasone or anything else? If not, did you suffer any side effects from the Abi as a result of no prednisone? My docs (and the manufacturer) keep telling me it is necessary to balance the Abi.

[SallyJones]

My husband has not been treated with that drug, so I am afraid I have nothing helpful to give you. I will keep you in my prayers and good luck.

[MateoBeach]

After completing the IMRTa d 3 years of ADT (congratulations!) he does not know if he is actually cured and does not need further treatment. The proposed abiraterone with further ADT does not appear appropriate without further knowledge.

I would want to stop the ADT and see what PSA does in coming months, especially as testosterone recovers. If PSA goes up (above 0.2-0.5) then a PSMA PET scan could show where any remaining cancer may be located. Also, the standard bone and CT scans would be appropriate even though not as sensitive. The man deserves a break and allow his body to recover!

[AlmostnoHope]

I definitely would not add Zytiga now if the Lupron is holding. It just doesn't make any sense.

[JimLin]

I have been on Zytiga 6 weeks now and have had no side effects worth noting. My PSA is .05 and testosterone is 15mg with Eligard. I tolerate Eligard much better than Lupron. The study showed that 37% of men on the combined regimen showed complete remission of tumor. In my opinion, worth the chance! My Gleason is 4+5=9.

Hope this helps