My trajectory after a "vacation" and a new metastasis

[Istomin]

My backgound briefly (full details in Profile): aggressive form, BRCA2 mutation, RP in 2017, then 39 sessions of radiation, and 3 yrs of Lupron. All at Smilow Cancer Hospital.

As a result, my PSA was undetectable for 2.5 years, and in 9/21 I was put on a "vacation" from treatment.

Then PSA started to rise: 2/28/22 0.03, 4/5/22 0.06, 6/7/22 0.13, 8/8/22 0.26, 10/25/22 0.50, 11/29/22 0.55, 12/24/23 0.72, 3/27/23 0.78.

PET PSMA scan on 1/21/23 showed a "small (0.6 cm)" nodule in upper left lung. It was targeted with 4 doses of radiation in 4/23 and PSA decreased for a while: 5/17/23 0.61, 7/31/23 0.39, then began to rise: 9/28/23 0.55, 11/10/23 1.22.

I had another PET PSMA scan on 12/1/23, which showed that the lung nodule had resolved, but that there was a “new small radiotracer avid mediastinal lymph node, compatible with metastatic disease.” (Report did not indicate size or which mediastinal lymph node.)

The Q now is what to do? I will meet with my oncologist on 12/5/23 and, as I understand it from discussions prior to the last scan, there are, in principle, 3 possible ways to proceed: (1) wait, test for PSA, and watch what happens, hoping for a plateau; (2) radiate the new metastasis(ses); (3) begin doublet or triplet therapy.

My guess now is that (1) is not wise given that metastases keep appearing; and I don’t know if (2) is feasible because of the location near trachea, heart, spine, etc. My inclination is always toward aggressive treatment, but now that there is a scan result, I will find out on 12/5.

I’m 76 and my health otherwise is good—I exercise a lot, eat healthfully, lost a decent amount of excess weight this year, travel, have a wonderfully supportive wife and family, am keeping productively busy. The AUS I got at MSK two years ago continues to work and was/is a life changer.

Thanks for reading, and I welcome any comments.

[Tall_Allen]

I think your analysis is spot on! I agree that doublet therapy is the way to go. There isn't much data for men that are recurrent and metastatic (but not castration-resistant), but given its effectiveness for recurrent, rapidly progressing, and non-metastatic men in the EMBARK Trial it seems a good strategy.

prostatecancer.news/2023/05...

I don't think docetaxel is useful if there are no bone or liver metastases.

[Istomin in reply to Tall_Allen]

Thanks, Tall_Allen.

[MoonRocket]

I concur with the other post...EMBARK....I'm in a similar situation as you.. recurrent in Spring 2022, restarted ADT July 2022. EMBARK came out Spring 2023, Took some time to research and concluded it was the best course of treatment. I started out with 80 mg daily in early Nov 2023 and will increase to 160 mg in January 2024.Depending on my PSA, I will stop if I reach <0.1.

I'm looking into adding a short burst of BAT when I restart treatment to see if I can extend the efficacy if Xtandi for as long as possible.

[Istomin in reply to MoonRocket]

Thanks, MoonRocket.

[Nyon]

dear Istomin im a bit naive what does AUS and MSK mean thank you so much - clive - will respond more once i understand these acronyms

[Istomin]

AUS = Artificial Urinary Sphincter (for incontinence post-radical prostatectomy, mine was severe). MSK= Memorial Sloan Kettering Cancer Center in New York City.

[j-o-h-n]

My only comment which probably does not mean anything to you.... But I will post it anyway.

I had lung metastasis from a previously treated neck melanoma (MSKcc). I was treated with Keytruda and it worked(MSKcc)..... Probably does not apply to your lung issue (ask Doc)..... but who knows?......The Shadow do....

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 12/03/2023 7:10 PM EST

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

Thanks, j-o-h-n.

[RoseDoc]

Sorry to see you have another recurrence. Triplet therapy at your stage would be standard of care. The docetaxel treatments aren't much fun but, if you take care of yourself during that time, the recovery is fairly quick. Docetaxel has been proven to work for lung mets. Counterintuitively, those with lung mets have a better overall prognosis than those with boe or liver mets.

If you are otherwise in good health, go for the triplet therapy. It offers the best prognosis.

[Istomin in reply to RoseDoc]

Thanks, RoseDoc.