Order of Pluvicto (Lu-177) vs. cabazitaxel/carboplatin chemo?

[tallguy2]

If there weren’t a supply chain shortage of Pluvicto my question is: Is there any scientific evidence for which order the treatments should be done? Did the Vision trial suggest anything?

Thanks everyone.

[Tall_Allen]

The TheraP trial in Australia found that Pluvicto gave a better response than cabazitaxel.

urotoday.com/conference-hig...

Pluvicto first is now the SOC:

ascopubs.org/doi/10.1200/JC...

But the trial did not include carboplatin. Strong uptake of PSMA on a PET scan predicts a better response to Pluvicto.

[tallguy2 in reply to Tall_Allen]

thank you.

Two comments: OS was similar, and poorer results were observed with patients who had non-PSMA expressing tumors. And as you noted before there was a high withdrawal rate among those in the cabazitaxel arm, potentially skewing the results.

Just food for me to consider as I have a choice to make in the next few weeks.

[Tall_Allen in reply to tallguy2]

It was a Phase 2 trial, which was not powered (didn't have enough sample size) to find an OS difference. It was only powered to find a progression difference. They've only published the "intention-to-treat" analysis. More men in the cabazitaxel arm withdrew to get Pluvicto, which artificially increased the OS in that arm. If they publish the survival of patients based on the therapy they actually received, I expect the OS difference will be larger. As you can see, the survival curves were diverging by about 18 months, but later crossed as patients switched therapy.

[Djangler]

Funny how one's perception of time changes. When I was diagnosed a bit less than two years ago, "five years, maybe a decade" seemed very very short. Now 18 months sounds like an unimaginably vast pool of time to swim around in.

Sorry, feeling morose. Looks like I'm progressing on olaparib. Lu177 is unobtanium in Boston, likely until after I'm dead. Next best is cabazitaxel plus carboplatin. Do I want to go through 18 to 30 weeks of chemo degraded QoL just to buy 3-4 months of pfs? I'm not sure.

None of the options seem good at this point. Curl up in a ball and whimper (plus Ativan) is my plan of record for the next few days. Then pull up my big boy pants and move on.

[tallguy2 in reply to Djangler]

I started cabazitaxel and carboplatin yesterday. I am told the side effects aren’t as bad as taxotere (and all I had with that was extreme fatigue). We shall see but if QOL not degraded too much I will stick it out and then if there’s anything left in me maybe Pluvicto.

Best wishes to you!