Docetaxil first, then Pluvicto or Pluvicto first

[Flyfisherbug]

Zytiga failed and Dr Milowsky, my MO at Lineberger Cancer Ctr recommends I go on chemotherapy first and if or when that fails, go to Pluvicto. Dr Almaguel, a nuclear radiologist, who is doing trials for Pluvicto which I did not qualify for, having crossed over to Xtandi, recommends Pluvicto without the chemo. He has been treating mcrpc patients in Bad Berka , Germany for years and claims those who have not had chemo do much better. PSMA scan yesterday shows cancer in lungs and pelvic bones increasing and new growth in t3-9 and left adrenal gland. Strangely, PSA only .33. Want to make a decision quickly . Appreciate any opinions, directions to articles,etc. that will help me with this decision.

[RyderLake1]

Hello,

In my humble opinion, I would go with the German doctor’s opinion. The Germans have been working with Pluvicto (Lutetium-177) for many, many years and long before the FDA approved it for the US. The Vision trial (which the FDA decision was based on) approved Pluvicto for use after chemo but there are several trials underway looking to have Pluvicto approved before chemotherapy. Good luck!

[RyderLake1]

Hello,

One more thing. Metastatic prostate cancer that does not exhibit a raised PSA level might mean that you have one of the less common forms of PCa (i.e. neuroendocrine or small cell). These can be nasty and much more difficult to treat. Perhaps another reason for you to lead with Pluvicto. I would definitely speak to your doctor about the possibility of having a rare type of PCa.

[Flyfisherbug in reply to RyderLake1]

Thanks!! I have added that question to my list and frankly had not thought of it.

[ElemanJ in reply to RyderLake1]

In my opinion Lutetium-177 or any other radioligand therapy only works when there is a good PSMA expression. Hence a PSMA PET/CT before is inevitable.

[RyderLake2 in reply to ElemanJ]

No argument from me. No sense treating PCa with Pluvicto (Lutetium-177) unless your cancer is PSMA positive. My oncologist explained it this way: for one third of patients treated with Pluvicto, the results are dramatic. For another third, the results are marginal (neither positive nor negative) and for the final third it doesn't work at all. I suppose the biggest factor is how early you use it. The clinical trials Tall Allen and others on this forum referenced might lead to the approval of Lutetium before chemotherapy. That is what the Germans and much of the world outside North America is doing.

[Tall_Allen]

We will have more data on sequencing after we get more info from ongoing clinical trials. All we know so far is that Pluvicto is better then Jevtana (second chemo) after docetaxel, but that doesn't answer your question. Here's a list of PSMA-targeted radiopharmaceutical clinical trials running in the US - several do not require prior chemo:

prostatecancer.news/2020/08...

[EdBacon]

If it were me, I think I'd go for the Pluvicto first, I do think it's a better treatment than Jevtana.

I didn't have the option so I did Jevtana first and it was a disappointment all in all. It gave me some pain relief which was great, but the cancer recovered and pain came back before the next infusion except for the first 2 rounds. At best, Jevtana slowed down the cancer to buy a little more time for Pluvicto. I'm also pretty tired of chemo side effects, especially when there's litttle to show for them. I'll be doing Pluvicto later this month.

[Flyfisherbug in reply to EdBacon]

Thank you for your insight. Good luck with your upcoming treatment.

[GP24]

I would choose Pluvicto. It has fewer side effects than a chemo and in my opinion is more effective than that.

RyderLake1 is correct, the docs at Bad Berka have published this finding: jnm.snmjournals.org/content... or link.springer.com/article/1...

[Fightinghard]

very low PSA might be indicating that Pluvicto would not work well for you.

Have you completed a PSMA PET scan yet? The cancer must be PSMA avid to attract/attach the Pluvicto to the cancer cells.

[Flyfisherbug in reply to Fightinghard]

I have two over last three months showing acceleration of cancer in the spine and pelvis. Low PSA remains unexplained

[wilcoxsaw]

As your PSMA showed uptake, hopefully with a SUV that was significant, you might benefit from pluvicto as Dr Almaguel states.

You have a PSA 0.33 . All the clinical trials that I am aware of, and also Dr Almaguel who I have met with, require a PSA of 2.0 with two successive Rises after you reach 2.0 to meet their eligibility. It will likely be difficult for you to get into any of these trials, several of which do not require prior chemo treatment. It may not be in your best interest to wait until your PSA Rises to a level above 2.0 based on what you have said.

Dr Almaguel as I'm sure you are aware said that the treatment in Germany will cost you between 12 and 15,000 per treatment plus travel expenses. Multiplied by four possible treatments if this is an expense you can afford it certainly would be an option to consider. Dr A I believe will accompany his patients when they travel to Germany and help to oversee the treatment and dosing so it is appropriate for each patient.

You are correct that Dr A feels that pluvicto is much more effective when offered early which is the purpose of the trials being held currently in the United States to try to demonstrate, and he has access to data not yet published available from Germany that he says supports that fact.

Hope this helps!

[Flyfisherbug in reply to wilcoxsaw]

it helps. Thank you so much for your response. The cost now has gone up to $20,000 per session. Inflation is worse there

[Hidden in reply to Flyfisherbug]

It seems that a tandem of lu177 + ac225 both lowdose is much better. The cost is 6500 USD pr treatment in Baku.

Dr Almaguel would surely be qualified to evaluate this treatment.

They even claiim that Xerostomia is less a problem than the two monotherapies.

Astonishing:

(No survival difference was found between the patients having and lacking a discordance between FDG-PET and PSMA-PET lesions (p=0.529).)

pubmed.ncbi.nlm.nih.gov/317...

[Flyfisherbug in reply to Hidden]

Thank you for the informative article..lt raises more questions for my call with Dr A.

[Hidden in reply to Flyfisherbug]

If you d’ont mind, can you please inform us about his views to your questions?

[Flyfisherbug in reply to Hidden]

Will do

[Flyfisherbug in reply to Hidden]

when was it $6500 in Baku?

[Hidden in reply to Flyfisherbug]

2 months ago

[wilcoxsaw in reply to Flyfisherbug]

20 K excluding travel expenses? Wow!

[winkoliu]

One of our members said before "when I had my LU-177 treatments I learnt that in Germany they do not do chemo therapy anymore, so let hope it does become the standard of care everywhere".

[Flyfisherbug in reply to winkoliu]

It looks like it should be, so I am hopeful with you. Unfortunately it does not work for everyone.

[MateoBeach]

I would favor the Lu experience of Dr. Almaguel and keep the chemo in reserve. Perhaps he could consider and employ combined treatment with Ac225.

[Flyfisherbug in reply to MateoBeach]

Thanks. I will be asking about that.

[Claud68]

In Homburg (not Hamburg) an der Saar, each treatment with Lu177 costs between 7.000 and 7.500 Euros. They also offer the combo therapy with actinium225 and Lu177. It is a little bit less expensive.

[Hidden in reply to Claud68]

There are contradicting info on HU regarding the prices and offerings in Western Europe, I have now formally contacted the Bad Berka klinik.

[Flyfisherbug in reply to Hidden]

I think many will be interested in the response.

[Claud68 in reply to Hidden]

We payed about 7 200 euros for Lu177 in March 2022, and also before, in October 2021 and December 2021 in UKS in Homburg.

[Flyfisherbug in reply to Claud68]

I will be checking into that as I need the treatment. Did you only have to do 3 treatments? How long did you have to stay confined? That is more than half what I am looking at.

[Flyfisherbug in reply to Flyfisherbug]

Did you have the combo Theropy?

[Hidden in reply to Claud68]

I got the answer today from UKS in Homburg, 45 minutes train trip from the airport in Frankfurt.

«The cost for one cycle Ac+LuPSMA (without treatment by chief physician) is around 12.000 €.»

[Claud68 in reply to Hidden]

Sorry that the prices are much higher now. Last year we asked them why they could offer cheaper treatments than other hospitals and they explained us that their provider for lu177 had better prices than the others. Maybe this provider doesn't exist because Novartis (owner from Pluvicto) bought this concurrent producer ?

[Hidden in reply to Claud68]

It seems there are more companies starting to produce lu and ac, 6 months ago after FDA approved lu177 many German hospitals offered lu177 for more than 20K euros ++, then suddenly all of them withdrew the publicing of prices, now UKS is down to 12K.

[louschu]

Chemo in 2017 was effective in eliminating my soft tissue cancer but not bone. 177 in 2019 controlled but didn't eliminate the bone leisions. Oxgovyx is inhibiting growth. I think Michigan has identified 28 cell lines. Dr Kwon at Mayo says he see low psa in about 10% of his 6000 patients. I would value his opinion on next step.

[Flyfisherbug]

Thank you.