In addition to SBRT for the two mets that make me join the happy recurrent crowd, what would be my best treatment option? I have had no SOC medication for 2.5 years. My T is 4 European scale 110 US scale.
1 Only ADT for seven months. This is what MO recommends, besides SBRT, since stronger/longer medication a) will have highly detrimental CVD effects b) confer resistance c) he will have nothing to measure effects against since there are no RCT:s for low-volume disease. One month Firmagon (synergy with the SBRT) followed by six months Bicalutamide since he says that is as efficient as Firmagon for low-volume metastatic disease with less side effects. SUV max for the two mets is 27 and 35.
After dx 3.5 years ago, MO put me on ADT for just six months + SBRT to a single met. I pushed to make it 10 months ADT.
I ask him now if it isn´t likely that new detectable mets will again return in a couple of years with such short ADT, he replies that it is possible (and then have radiation whack-a-mole). I don´t know if his stance is affected by his cancer clinic making its big money on radiation.
2 ADT + Abiraterone
Since I have undetectable PSA ˂0.1 (1.7 at dx):
3 ADT + Chemotherapy The only study I can find on treatment for low-PSA indicates that adding docetaxel to standard of care for low-PSA patients had very good results, although it was for non-metastatic advanced localized disease : Mortality Risk for Docetaxel-Treated, High-Grade Prostate Cancer With Low PSA Levels: A Meta-Analysis | Oncology | JAMA Network Open | JAMA Network
4 Triplet ADT + Darolutamide + chemotherapy, as per ARASENS (117 recurrent oligometastatic PCa men. Fig 1A in the supplemental version of the latest update, with an HR for adding Daralutamide of 0.695 in line with the large de novo groups, albeit large confidence interval.
Since I have BRCA+
5 BAT
6 BAT + PARP inhibitor Bipolar androgen therapy plus olaparib in men with metastatic castration-resistant prostate cancer - PubMed (nih.gov (Anecdotally one member on this forum is on BAT + pulsed Olaparib only taking this three days a month around the T injection, with no toxicity from the PARPi).
7 Olaparib + Abiraterone. An amazing 39 months radiographic Progression Free Survival for this combo for the BRCA+, vs 14 months for Olaparib alone and 8 months for Abiraterone alone, makes this appealing in my eyes. In castrate-resistant men, with the belief that the improvement may be even bigger in the hormone sensitive.
8 LU-177 / Actinium, with emerging evidence of efficacy for those at hormone sensitive stage before chemotherapy. Or its intriguing version LU177 J591. However, PSMA scan shows “minimal PSMA uptake” and “without clear PSMA uptake” for my two mets. It´s the NaF scan that confirmed the mets. Details in Bio.
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in reverse order. A modified BAT personal trial could be very valuable for you as it has for me I had two injections of Lu177-J591 in Perth one month after treating 2 visible LN Mets on PSMA PET scan. I combine this with long cycle BAT PROGRAM. Three months of high testosterone alternating with one month of ADT Orgovyx plus darolutamide. Two years now with undetectable PSA.
Olaparib and similar very good but only for those with BRAC1/2 mutations
"... I combine this with long cycle BAT PROGRAM. Three months of high testosterone alternating with one month of ADT Orgovyx plus darolutamide..."
I am on ADT Orgovyx. My urologist says I cannot add darolutamide (Nubeqa) unless I also add the chemo docetaxel (Taxotere), per FDA rules. Did you do anything special to get darolutamide?
I have an MO who says I do not need an ARI. I have a Urologist who wants to prescribe apalutamide (Erleada), is reluctant to do enzalutamide (Xtandi) because of SEs, and did agree to apply for enzalutamide (Nubeqa) as an exception. But he says I have no grounds. I prefer Nubeqa because I have undocumented seizures.
Like you, I find no definitive answer, lots of choices!
Attached is my clinical history. On this, my fourth treatment over ten years, my thoughts were SBRT and six months ADT. My radiologist agreed on the SBRT but thought 12 months on ADT. My oncologist thought SBRT and 24 months of ADT with an ARI as potentially "curative."
I looked at my oncologist and said "I have advanced PCa, my clinical history indicates we will not cure it, rather, we may be able to manage it as a chronic disease with intermittent treatments, each designed to provide 2,3,up to 4 years off treatment with active monitoring and decision criteria when to go back on, off."
He looked at me, looked at my chart, said, you're right, let's do 12 months Orgovyx, add an ARI if the Orgovyx does not bring your PSA to undetectable within the first three months.
It did...at our 25 January consult he threw out 18 months since I was "tolerating" the ADT "so well...! I said let's decide at the 12 month point in April, not opposed but not inclined unless we have supporting data for the additional six months - PFS, OS.... As to tolerating, yeah, hot flashes, muscle and joint stiffness, fatigue, genitalia shrinkage...yes, does not interfere with my life, just got back from a skiing trip in Colorado, during these 10+ months been on vacations to Iceland and Oregon with my wife, rode the Garmin Unbound, a 52 mile gravel bike ride in the Flint Hills of Kansas near Emporia, most days I go to the gym, lift weights, swim, do the indoor bike..I think when he and I meet in early April, should the labs indicate undetectable PSA, I will stop and actively monitor, labs and consults every three months and when (not if) it comes back based on my decision criteria, three consecutive increases spaced 2-4 months apart, PSA between .5-1.0, we'll image with Plarify (or whatever is newer and better then) and decide on treatment, again..
In these 10+ years, I will have been on treatment 3, off 7.
So, to answer your question, none of your choices are "wrong." I am not sure anyone in this forum can rank order them in terms of progression free survival, overall survival given the heterogeneity of our cancer...rather, you may need to decide based on balancing quantity, quality of life and other criteria relevant to you, financial toxicity, co-morbidities, life expectancy and the input from your medical team based on their training, education and experience.
Let the forum know your decision and post updates!
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