It seems that there is paucity of data related to the effectiveness of treatments after Lu/Pluvicto.
I'm beginning to suspect that pubished survival benefits for Radium 223/Pluvicto and chemotherapy cannot be assumed to be anticipated if the patient has had Pluvicto.
My husband has completed 6 sessions of Pluvicto (pre-chemo) and is now progressing. His team (including Dr. Saad from Montreal) have directed chemo. I"m wondering if now is the time to try BAT (Bipolar Androgen Therapy) as he is without pain. Also, I understand that Xofigo yields better benefits at this stage (low volume) but they are advising against. I'm also wondering about Actinium as his tumors are PSMA avid.
Thanks for anyone with experience to share!
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If I was in your situation, and I soon might be, I think I would lean toward Actinium. It is often used in cancer clinics in Germany. Because it emits alpha particles, it is about four thousand times more potent than Lutetium/Pluvicto. It also has a shorter delivery range than lutetium, delivering more energy to kill cancer cells with less harm to surrounding healthy tissue. Good luck and let us know what you decide to do.
Thanks for your response Ryder. We see the RO on Monday and we're hoping he'll agree to RT to 5 spinal mets. The last time he had RT to a skull met, 1.5 years ago, his PSA dropped for 4 months. Presently, his PSA Is doubling every 2 weeks. That's such an outlier on doubling time that I think he must have a mutation because he has a very healthy diet and lifestyle. No germline mutations and Foundation 1 CTC would be out of pocket. Actinium would be $$ so we need to be smart.
Did you have pluvicto yet? Or do you plan to go right to Actinium?
I am currently on the SPLASH Clinical Trial investigating the use of Lutetium pre-chemotherapy. I was not initially placed on the Lutetium arm but rather on the contrast arm (Zoladex plus Zytiga plus Prednisone). The trial does allow, however, for a crossover should my PSA start going up, which it is. I have often thought about what would I do if the Lutetium doesn’t work. Your post asked the very question that many men with metastatic prostate cancer wonder about. Keep in touch and good luck!
if you check my posts I have published something interesting about Actinium and lutetium used in tandem, there is a clinical study involved and is for people not responding to lutetium alone
Thanks 😊 for your reply. In Germany, many nuclear medicine clinics have been offering Actinium as a backup to, or in tandem with, Lutetium for years. Glad to see some studies underway in North America.
I know one fellow who was approved for a second round of six Pluvicto treatments after his PSA started to rise again…here’s his post from another site: “My good news continues: after treatment #4 (or #10 for those keeping score of my entire LU-177/Pluvicto trek), my PSA continues to drop --from 34.3 to 21.7. That's down from around 297 on 5/15/23 after 4 treatments. More labs next week. As for the SE's, treatment #4 was basically the same as all the others this round. Some added fatigue, but not much more than my Lupron provides me all the time. My blood counts are also good (red, white, platelets in range) so I'm preparing for #5 on November 8. Thanks as always for all the support of the brothers and sisters here.”
Thanks so much for your response! My husband felt only fatigue from Pluvicto but did have a bout of radiation cystitis that wasn't pleasant (requiring catheter).
I’m sorry you’ve not had success with pluvicto. All the same, it’s an option we might soon be pursuing. Can you tell us the hospital/clinic you used in Montreal? How did you access them? What were the costs? We’re in Ontario, so our options are Vancouver or Montreal with the latter preferred due to transportation and family in the area.
I wouldn’t say that we didn’t have success. It’s just that we hoped for a longer remission. My husband did a clinical trial, docetaxel vs Lutetium. I believe this trial will soon be open in Ontario. No costs other than travel and lodging
Thanks. The trial was supposed to open months ago. We couldn’t wait. Since then, docetaxel only worked for two rounds. Started cabazitaxel which didn’t work after first round. Will get second round bloodwork this week and are awaiting PSMA results so if he’s avid, we’ll search for a driveable place in the US for an fdg pet ($) then will have to pay for pluvicto treatment ($$$$$).
Insurance will cover pluvicto if you had chemo in the past. The bad thing about chemo is it can make psa worse then help in some people. I’m not talking about the normal psa increase when cancer is dying from the chemo. Then you might be going into pluvicto with higher numbers. But your Dr can always stop chemo if it’s not helping and your WBC and symptoms are getting worse. It only takes one chemo dose showing its not tolerated, to make you eligible for Lu177 through health insurance.
Insurance will not cover Pluvicto in Canada because our insurance coverages are only set up to cover the usual small amounts of charges that are not covered by government health insurance. In Ontario, Pluvicto is approved for use but is not covered by our government plan, basically because it's not proven to be effective enough to merit the expense. We can go to BC or Quebec to private clinics and pay the $28,000 CDN per infusion out of pocket. There are apparently some assistance programs. Moot for us now, though, as we've since discovered he is not a candidate (kidney issues, low hgb, and poor uptake). My post above was from three months ago. He is now on palliative chemo (mitoxantrone) and, although declining, feeling pretty good with pain controlled and still able to walk with a walker and cane.
Wow, thanks for update. It’s crazy how insurances work in all our different countries. I’m happy that he is getting good pain control at this time. Hopefully something new to try will come out for our love ones. Thank you again for your response.
Tough decision. His 2 week PSADT is alarming. Does it correlate with progression on scans? He might need some interim chemo to slow it down while you consider these other options. The SBRT to the bone mets is fine if the RO agrees. BAT is a possibility since no bone pain, but only is strongly effective in only 1/3 with highly pre-treated mCRPC. I would try it but only if PSA is at least somewhat stabilized so it can be monitored to see if it is working for him or against him. Combined Lu177 and Ac225 would be my choice, either in Germany or Australia (less expensive overall). He can do a virtual consult to discuss and plan. They will need to see a PSMA PET and blood tests, etc. I did Lu-J591 in Australia along with BAT which I continue, but my cancer is more indolent thus not comparable. Paul
if you check my posts I have published something interesting about Actinium and lutetium used in tandem, there is a clinical study involved and is for people not responding to lutetium alone
If it were me I would make sure to talk to Sam Denmeade before making a decision. His STEP-UP trial is in progress and I hear he has some amazing results.
Denmesa@jhmi.edu
If he is too far from you, Rana McKay in San Diego works with him.
If they determine that your husband is a candidate for BAT there are a few tweaks that might be useful.
Thanks so much for your response. Really and truly appreciate it. Meeting with RO today gave me the feeling that the team has basically given up on him. We are near Toronto so I'll see if I can arrange a phone consult with one of these physicians. The efficacy of docetaxel for heavily treated mCRPC is not stellar. One wonders if it's worth enduring the side effects.
I too wonder about the side effects of treatments. If something extends my life by a few months but destroys the quality of the life I have, is it really worth it to me?
Please give Sam Denmeade a call. He's an MO who heads up many of the BAT trials. I call him the BATfather. Most of the MOs you might talk to know hardly anything about BAT. Not a knock on their knowledge. People specialize in different subjects.
Denmeade gives you the straight scoop. Risks and all.
I share your concern about the side effects of treatments. From what I have seen from published reports (if I have read them correctly) is that a median increase in life of just about 4 months (overall survival of 15.3 months from LU177-PSMA-617 + SOC versus SOC of 11.3 overall survival). For progression-free survival 8.7 to 3.4 months. Per article published June 29,2021 in Cancer.gov - NIH - National Cancer Institute. I'm not sure how reliable any numbers I read any more.
TRANSFORMER commentary: TRANSFORMER: A Randomized Phase II Study Comparing Bipolar Androgen Therapy Versus Enzalutamide in Asymptomatic Men With Castration-Resistant Metastatic Prostate Cancer - PMC
Usually true but Denmeade is very good at addressing this for a specific person.
And if you talk to Sartor he might disclose a method to test it out for yourself without long term pain. There is another way that takes his 1-2 day T inflammation pain down to half a day.
can you tell me the reason the Drs gave you to not to try xofigo? Also can you tell us if there was a decrease in psa during pluvicto, and during which infusion the decrease was and which infusion the increase began again? Dad’s Drs were honest with us and stated that pluvicto only works while in treatment, then after the 6 months when treatment is done the cancer will start to progress again. They also told us xofigo only works for three months. 3-6 more months of life to give a chance in hopes of a new treatment voming out is good to our family, mostly when dealing with prostate cancer with mets that has no cure. I think the problem is commercials make it seem like these are miracle cures, but if you read the full study it only keeps psa down for a small amount of time. They never give psa study numbers in commercials, they only say survival rate. The survival rate is just how long the people they continued to monitor in their study lived for even while their treatment stopped working. Not actually how long their treatment worked for. It’s kind of deceiving info they provide by legally using certain words to give a certain illusion of outvome.
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