Decision time – looking for opinions/advice please

[Benkaymel]

My Bio gives full details, but in a nutshell, I was diagnosed with APCa with extensive bone mets last year, have been on ADT for 7 months and Xtandi for 4 months. I had a CT scan in December which showed little change from the previous one in August except for some progression in a pelvic lymph node met from 14mm to 21mm. My PSA is still dropping, currently at 0.21.

My MO ordered a PSMA PET/CT scan last month to see how much active cancer there currently is hoping that it would only be active in the pelvic area indicating that radiation to the prostate and active tumours there would be the next appropriate treatment. He said the scan, however, shows there are still active tumours in other bony places such as ribs and spine. I questioned what he meant by “active” given they are not growing and it appears to be the fact that they are expressing PSMA.

So he offered three options:

1. Just continue the ADT + Xtandi for now and reassess in a few months' time

2. Continue as above but add RT to the prostate (which has a large tumour), the increasing pelvic lymph node and a large met on my pelvic bone (which is giving me some discomfort)

3. Start Chemo (Docetaxel)

There is a fourth option that I would need to self-fund which is to start a course of Lu-177.

His advice is to go with option 2.

My questions are:

- Given that my PSA is dropping and the bone mets/tumours are stable (i.e. not growing) but do express PSMA, does that make them “active” in the sense that they would likely respond to Chemo now after 7 months of ADT + Xtandi?

- Forgetting about the cost, would it likely be better to start Lu-177 rather than Chemo now or should I go with the MO’s advice and have RT to the pelvic areas listed above for now?

Thanks for any inputs!

[GP24]

The cost is very high. Otherwise I would prefer Lu-177 over chemo. Lower side effects.

[Benkaymel in reply to GP24]

Thanks, yes, apparently it's £15K to £20K for a course of Lu-177 in the UK but it may become available on the NHS later this year.

[GP24 in reply to Benkaymel]

I meant to get Lu-177 while on ADT+Xtandi. When Pluvicto is approved in the UK you may need to have a chemo before to be eligible.

[Benkaymel in reply to GP24]

Yes, I would continue ADT+Xtandi if I had Pluvicto. I assume that if I self-funded it I wouldn't need to have chemo first.

[GP24 in reply to Benkaymel]

I think so too. In some countries you can get Lu-177 without chemo first if you refuse chemo therapy or your doctor states that you cannot get a chemo due to comorbidities.

[Hidden in reply to Benkaymel]

I would prefer a low dose tandem lu177 + ac225, approx 6500 Euros in New Dehli and Baku, Azerbajdan.

[Tall_Allen]

I don't see why you'd stop Xtandi while it is still working. When it stops working, you can extend it by adding docetaxel:

prostatecancer.news/2022/10...

Treatment of the prostate (debulking) has no benefit and it does have toxicity after "extensive bone metastases."

prostatecancer.news/2018/09...

Early Pluvicto (before chemo) is probably a good option too.

[Benkaymel in reply to Tall_Allen]

Thanks Allen, so are you saying that option 1 would be the best in your opinion at this point? Then when Xtandi stops working do either Pluvicto or docetaxel.

[Tall_Allen in reply to Benkaymel]

Yes

[Janhpr]

RT has not been an easy treatment for my husband, had RT 2019 has proctitis symptoms frequency and occasional blood and some urine leak, wears Tena pants, do only if you have to

[Benkaymel in reply to Janhpr]

Thanks, very helpful info.

[Hidden]

I am biased as my first line of treatment for metastatic prostate cancer in 2004 was six months of chemotherapy with ADT (Lupron or Eligard). I continued with ADT until February 2010. I wish you the best in fighting this bastard disease.

Gourd Dancer

[Benkaymel in reply to Hidden]

Thanks

[Benkaymel]

Thanks