Docetaxel or not?

[icanwintwice]

After 4 years of Active Surveillance my Gleason went to 7. I had a 6 month Lupron shot and Proton radiation 7 years ago. 39 treatments. After 6 years of nothing my PSA started to climb up to 1.98. Did an Axumin scan and found two mets in my lower left pelvic Lymph Node. Took a Lupron shot and got on Zytiga May 2022 and my PSA went to .02. Got off Zytiga because of my liver and have since gone to Erleada. Decided on IMRT, did 28 treatments at MD Anderson. Took a second Lupron shot December 2022. My PSA is less than .02 and my testosterone is 0.

My father and my brother have both had prostate cancer as well.

I think the radiation was successful. I am steady at PSA of .02 and testosterone at 0. I have my third Lupron shot coming up in May.

HERE IS MY QUESTION?

Should I do the docetaxal treatments. One oncologist in LA says DO IT because I have a less than 50 chance of non recurrence if I don't do chemo.

Another oncologist in Houston says DONT DO IT because, according to him, if I do 24 months of Lupron, the radiation, and Erleada then I have a 70% chance of non recurrence. According to the STAMPEDE study.......

I am in good shape at 64, but I have heard so many conflicting posts about chemo Im not sure what to do.....

I appreciate this venue and read every day about others experiences.....its made a huge difference to me in dealing with my issues......

all input appreciated!!!!!!!!!

[mrscruffy]

Curious with family members also having it have you had genetic testing?

[icanwintwice in reply to mrscruffy]

I have NOT had genetic testing. I know what to look for in women because a couple of women had the breast cancer gene BRCA.

[mrscruffy in reply to icanwintwice]

My family including myself have BRCA2, my brother has no cancer

[Tall_Allen]

Docetaxel only kills cancer that is actively growing. Yours is not actively growing. You should definitely not take it. Who is the ridiculous oncologist in LA?

You should have 2 years of ADT+apalutamide. Hopefully, that will cure you.

[icanwintwice]

thanks for your reply, I respect your opinion TA.

I shouldn't refer to him as an oncologist. He is a Urologist that specializes in Prostate Cancer. He has at least four youtube videos including one specifically regarding Oligometastatic cancer where he says docetaxel can increase you percentages for a 'cure' during or after the Lupron, Erleada, and the radiation. His name is Mark Sholtz. He has written a book about Prostate Cancer, "Invasion of the Prostate Snatchers". Catchy title.

You say my cancer isn't actively growing? is that due to the Lupron and the Erleada? because there could be microscopic cells that the radiation missed either in my Lymph Nodes or in other organs in my body, correct?

[Stevecavill in reply to icanwintwice]

I disagree with TA. Your disease probably IS metastatic, because you had a rising PSA 6 years after the proton treatment. The axumin scan found two mets, but that doesn’t mean that’s all there is, there can be more the scan can’t see, You could try to get a more sensitive PSMA PET.

The reason your psa is steady is because you are on ADT, not because you have no disease. if you stop ADT it will likely start to rise again. Docetaxel kills active cancer. But that’s true of all the treatments , they only kill cells that are dividing.

I had oligometastatic disease from day 1. My initial treatment was EBRT to prostate and SBRT to bone mets. Plus ADT. Stopped ADT after 2 years. PSA came rushing back. More SBRT. Not very effective, Stated ADT AND did 6 cycles of docetaxel. PSA stayed below 0.1 for 4 years. It rose again last year to 0.5 so did more SBRT. PSA still below 0.5. I’ve been off ADT over 5 years.

The point is you might (I think probably do) still have micro metastases. So docetaxel would kill those. What’s the harm in trying the docetaxel anyway? If it’s to hard to tolerate, you can stop it again. It certainly worked for me

[icanwintwice in reply to Stevecavill]

thank you for your response Stevecavill.

my reply first entry wasn't clear. this might make a difference. 6 years ago my PSA went from 6 to 7, and I moved forward with Proton Therapy at that point. Not when it came back. It was when my PSA rose to 1.98 that I had the Axumin scan that found the two mets. I followed that with a PSMA PET and it found the same. No other mets. The mets were so small and difficult to biopsy that they identified them as malignant and of the same general disease. No Gleason.

I appreciate your opinion. You obviously have a volume of knowledge regarding what I am dealing with....

[Gl448 in reply to icanwintwice]

I’m assuming you mean Mark Scholz in Marina Del Ray.

Scholz is definitely a board certified medical oncologist, not a urologist, unless urology is a secondary specialty he pursued.

He also has hundreds of YouTube videos, not just four.

[icanwintwice in reply to Gl448]

Yes GI448. I should have double checked before writing that. I think his pedigree is beyond significant in the prostate cancer field.

[tango65]

If there is not radiological evidence of progression oncologists don't do anything.

Docetaxel has shown to prolong life mainly in patients with multiple metastases. It does not improve survival in oligo metastatic patients.

If your nodes where in the pelvis, internal iliac artery, then your cancer is not metastatic.

Radiation plus 2 years of ADT and a new anti androgen may cure you or offer a very good control of the cancer.

[Stevecavill in reply to tango65]

docetaxel does work with oligometastatic disease. You need to compare the stampede and chaarted results. Stampede showed clear benefit regardless of metastatic load

[tango65 in reply to Stevecavill]

If the nodes were around the internal iliac artery your cancer was N1 M0, it was not oligometastatic. If the nodes were outside the territory of the internal iliac artery, the cancer could be considered M1 and oligometastatic.

You had a good treatment (whole pelvis radiation) plus ADT and abi, now apa to treat these nodes and the PSA is stable at 0.02.

No scan is going to detect anything. What are you planning to treat with docetaxel?

Consider finishing 2 years of ADT and erleada and then see if there is radiologic progression of the cancer when these drugs are stopped.

[icanwintwice in reply to tango65]

thank you for your input Tango65. I will get to the bottom of where the nodes were in my Lymph Nodes. The question of whether my cancer is metastatic makes a big difference. If it is metastatic it seems like docetaxel should at least be considered.

[tango65 in reply to icanwintwice]

You should also consider that the Randomized Stampede Trial comparing ADT plus docetaxel vs ADT plus abiraterone did not show a difference in overall survival between both treatments.

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

Even if your nodes were mets using docetaxel at this time may not do any difference.

[timotur]

Dr Scholz recommended docetaxel to me for advanced t3bN1M0/GL-7 in conjunction with Brachy/IMRT, but I turned it down. I read many studies and came to the conclusion, for hormone sensitive, non-metastatic, low gleason PCa, there was no or minimal benefit.

jamanetwork.com/journals/ja...

There is no standard of care for patients with hormone-sensitive PC with rising PSA levels after local therapy. Many clinicians initiate androgen-deprivation therapy (ADT), but only once metastatic disease has developed, and, to our knowledge, no formal clinical trials have examined the benefits of ADT in patients with biochemical relapse only.8 However, in patients at high risk with rising PSA levels after radical prostatectomy, the greater risk of developing metastases after PSA recurrence may warrant early ADT administration9-12and even more aggressive treatment than just ADT alone.13,14

The combination of ADT and docetaxel has improved outcomes over administration of ADT alone in each of 3 randomized phase 3 trials in a hormone-sensitive metastatic setting (GETUG-AFU-15,15 CHAARTED,16 STAMPEDE17). A meta-analysis of these trials noted a 9% improvement in overall survival (hazard ratio [HR], 0.77; P < .001) and a 16% reduction in failure rates (HR, 0.64; P < .001) at 4 years.18,19

According to phase 2 trials in patients with no evidence of metastases but with PSA level progression (ie, increasing above a threshold defining the progression) after primary therapy, early docetaxel administration with or without ADT is feasible and active (ie, docetaxel exhibited efficacy).20-23

However, in a nonmetastatic rather than metastatic setting, the benefit of combining docetaxel with ADT did not prove to be as clear-cut in terms of overall survival (2% absolute benefit: HR, 0.87; P = .22) in a meta-analysis of phase 3 trials (GETUG-12,24 RTOG 0521,25 STAMPEDE,17 TAX 350126) even though failure rates were significantly reduced from 30% to 22% at 4 years (HR, 0.70; P < .001). To our knowledge, no predictive factors have been identified to help select patients who might benefit from initial therapy with ADT plus docetaxel vs ADT alone.

[icanwintwice in reply to timotur]

this is news to me. So Im hearing that even though my cancer is not in my prostate and is in my lymph nodes, and I have two mets, it is NOT metastatic? I thought I was stage 3? not that it matters that much on the Stage but it is outside the prostate and I thought that meant metastatic cancer.....

[MateoBeach]

You wisely chose and received the right treatments. Continue on course with the hormonal adjuvant therapy for 18-24 months. Save the docetaxel. You are not metastatic yet, just N+ And hormone sensitive. I don’t think there is sufficient additional benefit to docetaxel for the associated risks at this time.

[August13]

Echoing what others have said — I was Gleason 9, pT3bN1M0 after RP, with 8/27 pelvic nodes; +margins, SVI, EPE, bladder neck invasion, LVI, etc., etc., etc., but no visceral or bone Mets. My radiation and medical oncologists at Dana-Farber recommended adjuvant whole pelvic radiation with boosts to the anastomosis and bed combined with two years of adjuvant ADT+abiraterone. MD Anderson concurred. I’m just over one year into the ADT + abi; ten months out from the 40 RT sessions. PSA remains undetectable. Fingers crossed it will remain so next month when I get labs again. I too wonder whether microscopic disease was already disseminated when my pelvis was radiated and discussed this more than once with my various doctors. They all basically said the same thing — that without M1 disease, there was no benefit to docetaxel.

[icanwintwice in reply to August13]

thanks August13.....were in the same boat. haven't committed on Docetaxel yet so Im doing the ADT and apalutamide post radiation. so far my PSA is below .02. I have time to make my decision. Keep posting on your condition....hope it never returns'!!!