45 yr young. Next steps?

[dochelem]

Gday All, thanks for support and response to previous post as there was Some really good info, contacts, recommendations shared with me that I did follow up on. One v interesting point of view, shared with me via zoom call recently from a renown respected Professor in my home country of Australia.

He suggested that doing ADT first, before chemo, is a bit backwards. Basically in a nutshell, Because the chemo is most effective on active and dividing cancerous cells, and the ADT puts those cells to sleep, which makes an argument that it renders chemo a less effective. This seems to make logical sense to me.

Is there an argument for going off ADT, watching the PSA and as soon as it’s rising and cells are waking up and leaving the bunker, hit the little buggers with chemo?

I’ve done my first monthly Degaralix injections, and about to start on Abiraterone and Presnidone.

He also thought with my Gleason 9, Lu177 might not be as effective, suggested if it were him he would do chemo first. I’m worried though, that the longer I wait for Lu177, my PSMA might not be as prominent down the track, rendering the Lu177 less effective.

Still deciding between randomized PSMAtrial in NY (hectic travel commitment for lengthy period of time) for the Lu177, going to Germany ot Australia to pay out of pocket for it, or chemo. I’m Leaning towards chemo here locally in Vermont after most recent conversation with said Professor.

Need to make the Decision early next week.

Thanks for input!!

[MJCA]

I was diagnosed age 45 as well. Still here at age 63. All I can say is don’t put all your eggs in one basket. I would seek out other opinions so you can make the most informed decision you can.

[dochelem in reply to MJCA]

yea that’s exactly what I’m doing! Thanks!!

[Tall_Allen]

I mostly agree that chemo is best at the earliest possible time. But hormone therapy weakens the cancer cells, making them easier for the chemo to kill. In the trials, they waited 2 months but most of the men were using a GnRH agonist (like Lupron) which can take a couple of months to fully kick in. But you are using Firmagon (a GnRH antagonist), which starts working immediately. So,IMO it's a good idea for you to start chemo and Nubeqa or Zytiga now.

As for Pluvicto, there is the PSMAddition trial where you can use it as a first therapy:

clinicaltrials.gov/ct2/show...

It is a randomized trial - randomized to either Pluvicto or standard of care (SOC) with a second-line hormonal (+ADT) They do not allow docetaxel in the SOC arm. (Although there is an international Pluvicto shortage now, it doesn't affect Pluvicto used in trials). You will have to decide if that is a risk you are willing to take.

I think that before you go much further, you should have a biopsy of one of your bone metastases with a full workup (histology, IHC, and genomics). A recent study found that genomic categories can predict the type of treatment that are more likely to succeed (your oncologist would have to contact Veracyte):

acsjournals.onlinelibrary.w...

[dochelem in reply to Tall_Allen]

thanks TA. Appreciate that input!

[dochelem in reply to Tall_Allen]

what is the IHC you refer to?

[Tall_Allen in reply to dochelem]

IHC=Immunohistochemistry. They stain the tissue for various proteins. My wish list (most pathology labs will have only a few of them) would include these:

AR (androgen receptor), PSA, PSMA, MSH2, MSH6, STEAP1, PD-L1, PTEN, chromogranin A (CGA), neuron-specific enolase (NSE), synaptophysin (SYP),  DLL-3, CD56, Somatostatin (SST)

Discuss with your oncologist.

[tango65]

When I was diagnosed with mets in 2016, I started ADT, just lupron and I went to Munich and I had Lu 177 PSMA I&T treatment. I had several lymph nodes from the pelvis to close to the renal arteries.

Only one treatment was enough to control all the mets (they became PSMA negative).

If I were in your situation I would consider to get Lu 177 PSMA treatment in the clinical trial, or in Europe (It cost 12K euros in Munich at the present time) and see what happens.

[Hidden]

Everbody is different in terms of scope of disease, body strength, and any existing comorbities. Listen to your medical oncologist. I can only tell you what I did in 2004 with Mets to T3 and C2 of my spine that was caught very early.

Under the premise that it is better to attack this bastard disease, it is better to have chemotherapy and ADT, in my case Lupron, while the body is strong and the tumor burden minimal. BTW, I had a double bypass for an aortic aneurysm in Nov 2002.

My chemotherapy consisted of nine infusions of Taxotere alternated with nine infusions of Adrimyacin over a six month period. Plus orals of Prednisone, Ketoconazol,e and Erusatamine. The objective was to killed metastatic lesions and existing micro- metastasis.

Good luck and kill the little bastards.

Gourd Dancer

[dochelem in reply to Hidden]

thanks for info! How did that work for you and did it return?

[Hidden in reply to dochelem]

simple answer is, no. Stopped Lupron in Feb 2010; added testosterone in 2011. undetectable until Sep 2022. Slight rise through January 2023. Had PSMA Pet, FDG Bone and finally an MRI with prostate protocol. Scans were clear. The bone scan was compared to 2016 and 2004. DX was BHP with a UTI. See MO in two weeks. I do this quarterly and see where I am at both Urologist and Medical Oncologist agreed. She was looking for distance spread and finding none checked the prostate proper. Urologist was look at the prostate and bladder. PSA went from 0.3 to 4.0 and back to 0.2 by February. I am 76 and just an old man.

Good luck.

[Spyder54 in reply to Hidden]

gourd_dancer, Excellent Response, and great detective work by your Team! Wish you the best for continued success.

Mike

[j-o-h-n in reply to Hidden]

76 ain't old, 86 is.................

j-o-h-n <===<<< Senior management is about to spike my spikes....

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 04/21/2023 7:09 PM DST

[SeosamhM]

Dx at 48 (Now 55), Gleason 4+5. Things have changed a lot in my 6 years, 7 months, and 20 days since. You seem to be keenly aware of the flux in standard-of-care (SOC) and the lack of clarity in treatment sequencing. Your logic in this post is sound and not desperate.

My retrospective data wish list for starting out? NaF PET, PSMA PET, and bone tumor biopsy as TA recommends. Some resources if you haven't seen these before:

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

targetedonc.com/view/psma-t...

[dochelem in reply to SeosamhM]

Thankyou!! what is a NaF pet?

[SeosamhM in reply to dochelem]

It's a sodium fluoride PET - the very best definition for bone mets and great trending, especially if the same machine is used. Axumin (18 F-Fluciclovine PET/CT) has sort of become the de facto "standard" PCa scan (especially since NaF was removed from the Medicaid formulary about 5 years ago), but bone uptake is not consistent. Fortunately, there is at least one new study that says that both Axumin and NaF should be used in tandem to track tumor activity.

See:

pubmed.ncbi.nlm.nih.gov/367...

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

cedars-sinai.org/programs/i...

[Shams_Vjean]

I started chemo about 3 months after Dx and beginning ADT. Didn’t get on the Abbi w/P until a month or so after the last of the docetaxal infusions were finished. I’m an ‘ol f… and I think if I’d been on all three at the same time I’d of been near comatose for the entire chemo regime!!! If your age, a different story.

Even though mine wasn’t the exact “on label” Peace-I trial protocol, I got an excellent response. PSA dropped to near undetectable during chemo and has been undetectable since shortly after beginning Abbi+P. Pain from bone metastasis dramatically reduced during chemo and has been mostly nonexistent since sometime after starting on Abbi+P, more than a year now.

It seems to me that, overall, a good response to early chemo is more certain than with Pluvicto at this point; though trials in the HS stage may prove to yield equal or even better responses for some, but probably not all. No guarantee there. Regardless, Chemo now gets you better qualified for Pluvicto down the road, when supply issues should be resolved.

If you can, get both genetic germline and somatic tumor testing done ASAP, and definitely before starting chemo.

Do the best you can to get and stay physically fit, even throughout chemo treatments. More and more the research supports this as among the best predictors of better survival and QOL during treatment.

Best of luck to you!!! Keep us updated on your progress.

[dochelem]

thanks mate. Appreciate that!!