Age and timing for Triplet therapy?

[vintage42]

I am age 81, active and neither fit nor frail, radiated in 2021 without hormone therapy. Radiated again in 2023 for a pelvic node. In December the PSA rose to 3.78 and a PSMA-PET scan showed cancer growing in prostate, shrinking in pelvic node, and spread to one abdominal node.

I started ADT with Ogovyx 4 weeks ago and feel no side effects so far. The urologist has set up the addition of the ARI Erleada in 3 weeks, though I would now prefer Nubeqa because it does not cross the blood-brain barrier. Nubequa would take another 2 weeks to get (or 7 weeks after start of Orgovyx).

I have read that the addition of chemo Taxotere for Triplet therapy would be beneficial, but can have severe side effects in the elderly, and also must be started with or soon after ADT. Am I likely too old to tolerate the chemo Taxotere, and have I missed the window for starting it?

[vintage42]

I can tell I might have a different experience with chemo. I am a sedentary 81 and you are 50 doing heavy workouts.

[GP24]

The triplet therapy has been tested for newly diagnosed patients. Adding chemo in your situation would be overtreatment without benefit.

[vintage42 in reply to GP24]

Is it possible that "newly diagnosed" means newly started on hormone therapy? The chemo kills actively growing cancer cells, which mine were until I started Orgovyx 4 weeks ago. My cancer cells are still relatively unmolested.

[GP24 in reply to vintage42]

No, these patients had several bone mets at diagnosis. So the cancer was more aggressive than yours. If you just take Erleada or Nubequa these lymph node mets will not kill you. If you still want to do something against them, get them radiated with SBRT.

[vintage42 in reply to GP24]

Yes, I last summer I chose IMRT for the pelvic node because it could lightly (preventively) do the rest of the pelvis at the same time. I have asked the MO about SBRT now for the new abdominal node, and he said why not wait to see what the ADT and ARI meds do to the PSA. The urologist that is treating me is more aggressive and would prescribe the SBRT if I asked.

[GP24 in reply to vintage42]

The ADT and ARI will cause a drastic drop of the PSA value and the mets will start to shrink. ART and ARI will not make the cancer cells resistant against a chemo. However, instead of a chemo I suggest a Pluvicto therapy. This will be available at an earlier disease stage in the coming years.

[vintage42 in reply to GP24]

Looks like Pluvicto would be for when I become castrate-resistant. Hopefully that will not happen until after a couple of years of ADT plus ARI.

[GP24 in reply to vintage42]

I would expect four years on ADT plus ARSI. Maybe more in your case.

[Tall_Allen]

Triplet has no proven effectiveness for lymph node-only metastases.

[vintage42 in reply to Tall_Allen]

Thanks, I had not heard that and it's the last straw. So if I wait to add chemo to make it Triplet until I have bone metastases, I will have had months or years of the Doublet suppressing the cancer cells. Wouldn't that would make the cancer unresponsive to chemo?

Is Triplet therefore best for people who are "newly diagnosed" with cancer that has metastasized to bones and have had no previous hormone therapy?

I didn't want chemo before, and now even less No place for it at my age and history!

[Tall_Allen in reply to vintage42]

"Is Triplet therefore best for people who are "newly diagnosed" with cancer that has metastasized to bones and have had no previous hormone therapy?"

Yes. This article reviews the data so far on docetaxel timing:

prostatecancer.news/2019/02...

[vintage42]

I looked at the three Triplet trials for adding chemo: ARASENS in 2022, and PEACE-1 and STAMPEDE in 2023. I did not see that ARASENS was for just for newly diagnosed. PEACE was for de novo, which I guess is newly diagnosed. STAMPEDE was for cancer already spread to nodes, just starting ADT. I could have missed or misread.

I still wonder if the operative element in "newly diagnosed" is having no previous hormone therapy.

[maley2711]

even if triplet applied to your case, I believe adds no more than 1 yr to life expectancy when compared to "doublet", and maybe even less to someone 80+ ????? You have the studies.....am I correct?

[vintage42 in reply to maley2711]

Maley2711 said that a few days ago in another thread. The STAMPEDE trial in 2023 found that those who had docetaxel alongside hormone therapy lived on average 10 months longer than men who had hormone therapy alone.

[maley2711 in reply to vintage42]

The good news is that so far no visible bone or other distant tumors...though of course they may exxist but too small to be seen. You needn't have any regrets about avoiding ADT when you had initial RT...not at all SOC for 3+4!!!!! Hasn't been shown to provide a benefit sufficient to justify ADT SEs! You did have ADT with your salvage nodal RT?

You seem to have a handle on treatment at this point!! Congrats on making it to 81 and still in decent shape.....with some luck, you might add another 10 years? Hoping for you!!!!!

[vintage42 in reply to maley2711]

"You did have ADT with your salvage nodal RT?"

I think "salvage" only refers to re-treatment of the prostate, and that nodes are not salvaged. So my pelvic node and pelvis in general were given IMRT, without ADT, because the urologist and the RO said if the PSA went down I would not need ADT.

The PSA went down briefly and then up, so I had a second PSMA scan that showed an abdominal node. That is when I insisted on ADT plus an ARI.

[tayninhtom]

why not f/u SBRT to the nodes? Minimal impact on energy. Worked for me.

[vintage42]

The pelvic node has already had IMRT. For the abdominal node, I am considering SBRT now or waiting to see if doublet therapy shrinks its lesion.

[TJGuy]

You should consult a center that has many additional forms of treatment that may be available to your condition. There are many types of thermal ablation that might be able to be used.Such as

Radio frequency ablation

Microwave ablation

Cryoblation

Lasers or ultrasound

In addition to

Surgery

SBRT

IMRT

Pluvecto trial at UCLA with SBRT & Pluvecto with no ADT

[vintage42 in reply to TJGuy]

My condition is -- cancer still in the prostate and spread to nodes. I assume you are referring to salvage treatment for the prostate. At three years out, it cannot have more radiation yet, and removal and ablation all carry severe risk. I did have a HIFU consult and was told that salvage is generally only offered and worthwhile if the cancer is still confined to the prostate.

The best treatment for my condition is the doublet therapy that I am starting, with possible SBRT for mets. Pluvicto would not be used until I am castrate-resistant, which is 3-4 years away.

[TJGuy]

unconventional.rice.edu/des...