Treatment Question

[Juju0713]

Hi to all, my dad (age 62) was diagnosed with Stage 4 prostate cancer with multiple bone metastases in October 2022. He is also BRCA2 positive. He received 6 doses of docetaxel which he completed on 1/30/2023 and has also been taking apalutamide daily and eligard injections every 3 months. His PSA on 4/10/2023 was 2.9; on 6/12/2023 was 4.3; on 7/10/2023 was 4.7; and on 7/28/2023 was 6.3. His MO ordered a PSMA scan but the only thing that was approved by his insurance was a bone scan and CT scan of chest, abdomen, and pelvis with contrast which he completed early this week. The results from the CT were:

IMPRESSION:

1. Stable osseous metastasis involving the thoracolumbar spine and bony pelvis.

2. Stable enlarged right paratracheal lymph node.

3. Enlarged prostate with circumferential wall thickening of the urinary bladder most likely representing long-standing bladder outlet obstruction.

and the Bone Scan:

IMPRESSION:

1. Slight improvement of metastatic bone disease with no new lesions and resolution of a few previously seen lesions.

Overall it seems like a good report, however I am still concerned about his rising PSA. When I asked his MO about this, she basically said we wait until it reaches about 10 before becoming concerned as it is most likely the residual lesions producing the PSA. She said we will continue his current medications for the time being. My question is should we be making any changes or adding anything at this point such as a PARP inhibitor, etc. or is she correct in saying to wait? She did say she was going to switch him from apalutamide to enzalutamide but that is due to a rash he has had from the apalutamide that is not going away. Thanks for your input.

[Chasbearcat999]

I can't understand why no PSMA, but one thing I found out is that it isn't always WHAT your insurance covers, but WHO is asking. Get a referral to a hospital near you and have them deal with the insurance company. My uro was two weeks into dealing with my insurance company to get one approved. My wife works for a hospital. He referred me there for the PMSA and two days later the hospital called to schedule it. They have no legitimate reason to turn him down for one.

I'm not a doctor, and it seems the PARP inhibitors make sense but she may have a good reason for doing this.

[dhccpa in reply to Chasbearcat999]

Many times a PSMA scan won't change treatments for an already metastatic patient.

How many Mets did you have and did the results of the PSMA scan change your choice of treatments?

[Chasbearcat999 in reply to dhccpa]

Agreed. I didn't see the existing mets part.

[Tall_Allen]

IMO, she should add the PARP inhibitor when she switches him to enzalutamide. That combo is now FDA-approved in men who are BRCA+

prostatecancer.news/2022/06...

I don't know why you think a PSMA PET scan would be useful.

[NotDFL in reply to Tall_Allen]

Agreed; the scans that were used already showed a lot of metastases.

[larry_dammit]

The waiting game is a terrible game. Stage 4 here 8/1/16. Switching his med sounds good to me. I’m on it since 12/16. If I remember right I had a flare up of psa after the chemo but the xtandi brought it back down in short order. Ask those questions and don’t be afraid to get a second opinion

[EdBar]

I’d wait and see what effect the chemo and enzalutamide has first. I’d appeal the denial of a PSMA scan too. They have become the go to scan for prostate cancer. PARP inhibitors have some significant side effects and should not be taken lightly. I’ve been battling stage 4 since 2014, you can look on my profile to see what treatments I’ve undergone.

Ed

[dhccpa in reply to EdBar]

Did having a PSMA scan change your choice of treatments? Or just revealed more detail,?

[EdBar in reply to dhccpa]

PSMA scan only became available recently and revealed a spot on my rib that I had radiated. All other treatments were under the advice of oncologists who specialize in the treatment of prostate cancer.

[ishitasen]

In view of rising serum PSA levels, I would definitely go for a PSMA scan, which will help in characterizing the exact disease status (i.e. distribution and PSMA expression). If a PSMA scan is found to be positive then you can try for the Pluvicto (Lu-177 PSMA) therapy, which is more acceptable with less side-effects compared to the enzalutamide and improved quality of life.