Embark study

[billfenley2]

Hi friends, When the Embark study came out, and the FDA approved Xtandi for its use, my MO was enthusiastic that I add Xtandi to my intermittent ADT treatment. What I'm wondering is, I can certainly understand that adding Xtandi to the intermittent ADT treatment delays average time to metastasis, but in doing so, am I just borrowing from what would otherwise by my standard post-intermittent-ADT treatment, and making that post treatment less potent, so that the net result is the same? Robbing Peter to pay Paul, sort of? Thanks!

[MoonRocket]

I'm doing the mono enzalutimide per the EMBARK trial. I would say not to think that way. In ten years there will be additional treatments some of which will resensitize you to Xtandi.

[billfenley2 in reply to MoonRocket]

Thanks MoonRocket, yeah, I'm not sure how to think of it, but I'd certainly like to think that all things considered, there's an advantage over my old treatment plan. I just took it for granted -- but now I can't figure out what it is! Your variable is a nice one to weigh.

[Tall_Allen]

Here's an article on EMBARK:

prostatecancer.news/2023/05...

" ...am I just borrowing from what would otherwise by my standard post-intermittent-ADT treatment, and making that post treatment less potent, so that the net result is the same?"

Why would the post-iADT-treatment be less potent? Everything we know is that the net oncologic benefit is greater when advanced hormone therapy is used earlier. While the survival data are not yet mature, so far mortality has been reduced by 41% in men using the EMBARK protocol.

[billfenley2 in reply to Tall_Allen]

THANKS TA, THAT's exactly what I want to know. If my post-ADT treatment were an AR inhibitor like Nubeqa, I'd think that using an AR inhibitor like Xtandi early might diminish it later on, but weighing it all out, the tentative evidence is that the net results are NOT the same in terms of mortality.

[dhccpa in reply to billfenley2]

Why would you follow Enzalutamide with Darolutamide? Isn't the latter similar, but primarily for metastatic patients?

[billfenley2 in reply to dhccpa]

Thanks friend, The Nubeqa was part of my original treatment plan, following Lupron, when the Lupron stopped working. We replaced that plan with EMBARK.

[dhccpa in reply to billfenley2]

Yes, but I was unclear on what you were saying about "diminish it" related to Enza and Daro. Sorry; I guess I'm a little foggy this AM. Last question, I promise (and maybe I'm not asking it clearly

If you already used Daro, and then you use Enza, what would be diminished later on?

[billfenley2 in reply to dhccpa]

PLEASE ask me all the questions you like! I'm no TA, but I'd love to try to be helpful. So for me, I've never taken anything but Lupron, until last month. After my radiation & recurrence, without mets, my plan became intermittent Lupron, and whenever in the future that stopped working, the plan called for Nubeqa. After EMBARK was announced, my MO switched me to Lupron+Xtandi. Xtandi and Nubeqa are similar (AR inhibitors), and I was wondering if I was "using up" my AR-inhibitor defense unnecessarily, since the Lupron alone was still working fine for me, and might have continued to work fine alone for years.

[dhccpa in reply to billfenley2]

OK thanks very much. I have it now. Yes, I've been on nothing but Lupron for metastatic PCa, so all developments about the next level (AA, Enza, Daro, etc.) are much more relevant today then a year ago.

[billfenley2 in reply to dhccpa]

As I say, I'm no TA, but I'm surprised you've been on Lupron alone for metastatic PCa. I thought its standard of care has, for years, been to combine Lupron with, say, Zytiga. And lately, have I been reading? that triplet therapy is now the ideal? with a chemo?drug added?

[dhccpa in reply to billfenley2]

Yes, you are correct. Back in 2018, the doubling therapy hadn't reached every corner, although within a year it had. However, being stable on Lupron a couple of years in, my MO left it to me after we discussed, pointing out the research was done on newly diagnosed patients. We discuss it each time (and chemo as well), but we decided (subject to change) to add treatment when PSA rises 2 points above nadir (0.5), or scans show progression. Last Axumin PET on 1/3 shows no progression, though PSA has crossed 1 (it has done that before before falling back, but may be more persistent this time).

I may go with chemo first, but not sure just yet.

We may run PSMA if we can get Medicare to cover it. Of course, we have no earlier PSMA for baseline, but might be good to get my footing the PSMA door.

[billfenley2 in reply to dhccpa]

It sounds like you've been doing well, & I certainly wish you more of the same, brother!

[dhccpa in reply to billfenley2]

Thanks. And back at you.

[MoonRocket in reply to billfenley2]

EMBARK is for recurrent men after initial treatment. Are you recurrent? Or did your MO just swap Darolutamide to Enzalutimide based on the EMBARK trial? I'm not sure if you can extrapolate results but I'm guessing the results would be similar.Have you ever been diagnosed with metastasis beyond the pelvic area?

[billfenley2 in reply to MoonRocket]

Thanks MoonRocket, right, I'm recurrent, no mets. I was never on Nubeqa; that had just been a future part of my plan, for when I became castrate resistant.

[billfenley2 in reply to Tall_Allen]

Well, where mortality has been reduced by 41%, that seems to be a comparison with men on Lupron only. But your statement that "net oncologic benefit is greater when advanced hormone therapy is used earlier" speaks directly to my question.

[dhccpa in reply to Tall_Allen]

Good report. Do you have something similar for patients on ADT (Lupron) only who have become castrate resistant? I'm not there yet but could happen at any time.

[TEBozo]

Good question. I've been on its first cousin, Nubeqa, for four months as mono therapy and my PSA still rose. Will start Orgavyx this week in advance of a spot radiation treatment on a chest node and a surgical removal of a pelvic node . Certainly a small percentage chance of cure, my team is contending that this cutting edge, but certainly inconvenient treatment plan will " re-set the clock" insofar as my PSA/ Metastasis goes.

[billfenley2 in reply to TEBozo]

That's exactly what I'd think, TEB -- pushing the clock out farther and farther. I wish you well.