Diagnosed 12/21, PSA 7, negative PSMA PET. Radical prostatectomy with extended lymph node dissection in Mar 2022. Gleason 4+5, +cribriform, +intraductal, + bilat SVI, +ECE. Margins negative (barely) and 1/34 lymph nodes positive with very small focus of cancer. PSA was undetectable until Jun 2023, then 0.05, 0.06, 0.07 over 2 months. Started Lupron this week (plan is for 6 months) and plan to start salvage RT to prostate bed and pelvic lymph nodes in September. Under care of MO and RO at Fred Hutch Cancer Center in Seattle.
Second opinion MO at UCLA recommends adding Erleada to ADT based on unpublished data from EMBARK and FORMULA 509. Primary MO discussed my case with 3 colleagues at other centers and says there is insufficient evidence for adding Erleada.
Thoughts?
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Brokedown_Palace
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UCLA is a center of excellence, can't comment on the other MO's. The data from EMBARK and FORMULA 509 is recently released. Are your other MO's up to speed?
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Embark shows that ADT + ARPI (specifically Enzalutamide) outperforms ADT for patients in your condition. Read more here:
Things you might want to double back and check on include:
1. Did the UCLA MO mean Enzalutamide as per the Embark protocol.
2. Apalutamide does no harm as per the Formula 509. If ADT + Enzalutamide works does that imply that ADT + Apalutamide also work? And if so why switch: it was recently shown that Apalutamide may work faster and deeper then Enzalutamide in the mHSPCa population, see my post from a couple of hours ago:
3. Your UCLA MO is aware Apalutamide might generate a faster and deeper response in the short time frame ( 6 mos) and recommends swapping Apa for Enza.
Like I said above, double back and check with your MO and the UCLA MO.
In fact, you may want to join the INNOVATE clinical trial. It randomizes high-risk, node positive recurrent patients like yourself to 2 years of ADT with or without Erleada:
I had persistent PSA of 0.6 following prostatectomy. The PSMA scan identified two hot pelvic nodes. As a result I had full pelvic RT with extra doses to the identified nodes. I am also on three years ADT with Erleada on top. I was told that the addition of Erleada was per the results of the TITAN trial. The Erleada is four tablets that I take every day. I finished my radiotherapy about 6 weeks ago and am still very fatigued but I hope that wears off. My PSA is now undetectable and had new baseline CT and bone scans last week that were clear. Good luck with your treatment and hope that is helpful.
You have a complex pathology for sure and it looks like you will need to have additional treatment, as I did. I would only give you these items to look at and consider before you proceed.
1. Genomic testing; I dont see any and I am a believer in getting both a GS (Gleason) and Genomic test (like Decipher) before proceeding with a decision on treatment. See these links for any ideas;
PSS this last podcast has three great case histories; see if you can plow thru them. Its a 'Masters Course,' in different pathologies, treatment strategies and potential outcomes that can provide a glimpse into future pathways for your treatment.
2. PSA Recurrence; I dont think you are at BCF (biochemical failure) yet, given your PSA levels, but your pathology is challenged for sure...wont be too long till you reach this level and will need treatment. But look at this podcast to determine what PSA Total vs PSADT (doubling time) mean for your decision as to when to proceed.
3. ADT; pick your flavor, but this treatment has great benefits and potential consequences. Use ADT if it will benefit you; the Decipher matrix report can help determine how effective this treatment can be for your specific genetic conditions. See MIN 16:03 in the podcast at item #1 above (AE-genomic-classifier-in-prostate-cancer).
4. Sexual Health n Recovery; I know...right now this is the last thing your are worried about; it was for me. When I was diagnosed my #1, #2 and #3 concern was treatment; full stop. But it may just turn out that you will live with this disease as a chronic condition and recover...at that time you will want to return to a standard of life more normal than what you are experiencing now...make good decisions going forward; you cant back up once you proceed...but you must proceed after you make the call! Treatment comes first, but with knowledge of what your are doing...
5. Percent Pattern 5; see this podcast and see how it can help you determine your risk for severe outcomes, given your GS 4+5. I hope there is good news there for you...if not its better to know...
6. Incontinence; get dry before and if you, proceed to sRT (salvage radiation)...what you have for leakage the day you start radiation is most likely what you will have when you finish...delay only if you think your risk is not increased, but if you can get dry before you proceed the better you will be in gaining continence.
7. Last thoughts; I put down in one post what I did 'wrong' or poorly during my treatment...none of it could apply to you...if there only one that does then I am happy to share it with you...this is my story and my list of things I 'coulda-woulda-shoulda' done.
nrgoncology.org/PREDICT-RT is a trial that adds Erleada (apalutamide) to ADT which in my case is Leuprolide Acetate (ELIGARD SC). I am just getting started with treatments and will have Brachytherapy followed by EBRT. No spread but they are still adding Erleada. I am at a NCI CCC third largest cancer hospital in the country.Been on ADT for three months and Erleada for a month with no side effects. I am no doctor but I think you would want to add the Erleada. Best, Doug
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