Newly diagnosed with N1M1a

[qidao23]

My father (68 yr old) is newly diagnosed with Gleason 8 in March and his PSMA PET result just came back with N1M1a (details in bio page).

Before the PSMA PET, RO's plan is the whole pelvis with IMRT followed by a prostate only boost based on CTScan and clear bone scan and stated that his treatment fields will depend on what PSMA PET says about lymph node.

What expectation should I have on my father's prognosis?

Should his primary doctor be a MO or RO? He is primarily seeing a RO and going to see a MO and another RO for 2nd opinion. My father is given the option to start Casodex for 1.5 weeks before ADT or start ADT directly. Do folks think Casodex is worth to take while waiting to get 2nd opinions?

Thanks a lot!

[Tall_Allen]

Good question about RO vs MO in his case. My thoughts are: his infected lymph nodes extend rather high, but I think it is worth a shot to cover them all with radiation (with a boost to the known hot spots). The RO will manage that.

He will also need 3 years of ADT and 2 years of abiraterone. The MO usually manages that. The Casodex at the start is to prevent a flare of symptoms because Lupron starts with a testosterone surge. But he has no symptoms. Another option is to start with a month or two of Firmagon before switching to Lupron. Discuss with his MO.

[Tall_Allen in reply to Tall_Allen]

Another option:

The PSMAddition trial allows PSMA treatment if at least one M1a lymph node is ≥1.5 cm. The para-aortic LN is 1.5 cm.

clinicaltrials.gov/ct2/show...

You will have to make this decision before he begins hormone therapy, which he will get as part of the trial. The trial also allows radiation therapy to the prostate and pelvic LNs (I think). I'm not sure if the trial allows radiation to the M1a LNs. I think it's worth discussing.

[qidao23 in reply to Tall_Allen]

Thank you very much for the information!

How much time do we have to weigh different options before starting any treatment, and is there safe treatment we can start now while waiting?

This actually leads to another question. Is his disease considered as oligometastatic or more wide spread? The MO mentioned average life expectancy of metastatic cases is 5 years and probably the result also depends on where the spread is.

[Tall_Allen in reply to qidao23]

You don't have very long to make a decision. If you start ADT now, that starts the clock on the PSMAddition trial. They only allow 45 days of ADT before he is signed up for the trial. Contact them today to start discussions about that option.

I think it is idiotic of your MO to discuss life expectancy when everything depends on his response to therapies.

[Hidden in reply to qidao23]

I agree with TA, MO or RO should NEVER discuss life expectancy.

Mine discuss the here and now.

[LongTimeRunning in reply to Tall_Allen]

I just started PSMAddition and am in the treatment arm (next week first dose). I was told by the trial coordinator I couldn't have concurrent radiation treatment in the investigational arm, but that was months ago when the study was still in midst of paperwork before starting. I barely made the 45 day window.

[Tall_Allen in reply to LongTimeRunning]

not concurrent- before or after.

[qidao23]

Thanks everyone for your reply! May I know if PSMAddition has seen very promising result?

If assigned to control group, can one still see his own doctor and make adjustment to the treatment plan freely? Can one choose to quit the trial at anytime if the plan does not seem to work well?

TA, how about the triplet treatment, is it also a good option for this case?

[Tall_Allen in reply to qidao23]

triplet is for.bone metastases.

[LongTimeRunning in reply to qidao23]

In the PSMAddition control you will get the same blood draws, scans as in the treatment arm you just won't get the lutetium treatment. You can still still have your own doctor. I'm seeing a doctor within my MO team that is not involved in the trial as well as my family doctor. The MO team is handling my ADT meds (which you need to take as part of the plan). If you need meds for anything else, it would be prudent to consult with the physcians as part of the trial team. If things get worse in the control arm, you can crossover to the treatment arm.