My husband was recently diagnosed with PCa with 6-7 mets to the bones as seen on the PSMA Pet scan (see profile for details),
The first MO we met at an NCCN center recommended triplet therapy. He has started Firmagon + Darulotomide with Docetaxel planned in the coming weeks.
We also got a second opinion from an MO at another NCCN. He reviewed the PSMA Pet scan with the chief radiologist there and they think that maybe just 3 of the mets would have shown up with conventional imaging.
This MO is convinced that my husband's case is closer to low volume disease and is at worst borderline high volume. He recommends starting with ADT with Zytiga. He doesn't think that Docetaxel is warranted right now unless the genomic test on the biopsy tissue shows high risk markers. He also recommends radiating the prostate plus SBRT to the pelvis mets and to keep chemo as an option for later if needed.
We are now confused as to what is the best way forward.
Written by
Cali3
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My advice would be to search for a medical oncologist specializing in prostate cancer. Some of them offer online consultations. I think this will be well worth your while.
I've managed to survive for nearly 15 years with ADT and SBRT. I’ve been really happy that I’ve avoided chemotherapy. Worth asking what the radiologist thinks. I’m 78.
Bishop, it would be helpful to provide information on your biography. It’s great you have been on ADT and SBRT and survived for 15 years but we don’t know your history.
Chemotherapy isn't as bad as we remember growing up. I was like you, borderline. Low volume on bone scan. High volume on PSMA PET. I did triplet therapy based on higher volume in the PET. I'm grateful my MO was open to it.
You can look in my profile for my husband's details. He was diagnosed prior to triplet therapy being a thing- but a couple of studies had just been completed (stampede and chaarted) showing benefits of adding chemo or zytiga to ADT at the start. My husband started his treatment with ADT and chemo. We were definitely scared of chemo- but it wasn't as bad as we'd envisioned and I truly feel it is a reason my husband is still here and doing well. Side effects from ADT have also lessened over the years- which I know doesn't happen for all but has for my husband. If he were diagnosed today we'd definitely do triplet therapy. It is what has been shown to work best. I would not save anything for later and hit it hard at the beginning.
Large studies have shown triplet therapy to be superior to the piecemeal approach. If the MO isn't on-board, it shouldn't be too long until you find one that is. Hit it with everything you've got.
I like the advice from Fred Saad. "if you're going to need it sooner or later, sooner is better". Logically, there's no benefit in delaying. Each treatment uses a different mechanism of action, so you are hitting the target with multiple weapons at once.
That does sound confusing . To start with, I would recommend that you educate yourself on these treatments, their uses, efficacy and their side effects. You should be able to see a pattern of what experts use these treatments for (i.e. condition and progression) . A fast doubling time, high gleason score, etc. may give you direction. Be as informed as possible to be able to ask questions about the benefits for your husband's specific situation (including studies that show it offers the best life extension), efficacy, and the side effects.
It may also be possible to get these doctors to talk to each other and discuss your husband's case. They may agree on a treatment protocol for your husband. It's possible there are some incorrect assumptions being made by the oncologist who is providing the second opinion. If they are unwilling to discuss your husband's case, your could consider a third opinion to break the stalemate.
It is important that you and your husband have confidence in the treatment plan (that it makes sense to you). You should have peace of mind about the plan, as much as you can for any treatment plan. I think you will continue to doubt their approach until there is a single treatment plan that everyone is comfortable with.
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looking for advice. 
PSMA PET scan 
False Hope?
Can't treat what we can't see
