What is Your Opinion on Docetaxel Added to Doublet Therapy for Early Oligorecurrent Metaststic M1a Prostate Cancer?

[103532]

Hello, I have touched on this subject before, but it is something that is nagging at me and giving me some sleepless nights. My husband’s bio is updated for reference. At one year post prostatectomy with Stage 3b, he rose from 0.06 to 0.273 in three mos. At psa of 0.16 , a PSMA scan showed three sub centimeter retro caval nodes lit up for metastasis. His dzx was early metastatic disease. He went on doublet with Lupron/Abi/Pred and we made the personal decision to pursue extended pelvic IMRT with boost to avid nodes. Although cancer is not visible on scans anywhere else, my understanding is that the doublet only puts the cancer to sleep for a few to several years before it mutates into MCRPC. I need to understand why we cannot add Docetaxel to this combo when he recovers from the radiation. Wouldn’t it likely “kill” the sleeping cancer before it wakes up and mutates? Or does the cancer need to be physiologically active ? Are there any studies we can present to our oncologist at Yale, as they will only consider evidence based criteria. My husband’s mother was cured of stage 4 breast cancer by chemo alone, and he does not have any germline mutations. Wouldn’t this also enhance his ability to come off the ADT in a couple of years as a vacation, which he desperately wants. I apologize for the redundancy in my previous posts…..this has been weighing heavily on my mind lately. Thank you all for any input you may have. I may be off base in my worries. Thanks!

Stephanie

[Tall_Allen]

As you surmised, the cancer has to be physiologically active for docetaxel to have any benefit at all.

prostatecancer.news/2019/02...

Docetaxel is a microtubule stabilizer that prevents actively growing cancer cells from dividing, but has no effect if the cancer is in a dormant cell cycle.

Pluvicto might be useful, but he would have to get it on a clinical trial or go abroad to get it.

[103532 in reply to Tall_Allen]

Thank you for that quick response. I will keep an eagle eye for fast action at any early signs of resistance. Praying that is not for years to come.

[Cali3 in reply to Tall_Allen]

If that is indeed the case why not just do docetaxel first and then add ADT/ARSI vs doing triplet. Doesn’t doing it all together diminishing the effectiveness of chemo?

[Tall_Allen in reply to Cali3]

Doing them sequentially is what diminishes the effectiveness of the other. That's why triplet starts both the ARSi and docetaxel together.

[103532]

I believe it would. We weee told at the early rise that his cancer was too low burden and studies show to immediately stop the spread with ADT. Our oncologist even suggested that many juvenile cells may die off. We were told to save chemo for higher burden, but, as you can see, I question everything. Thanks for the reply!

[MomOfMaisy in reply to 103532]

That sounds like my husband’s MO’s reasoning. Even with the mets he has, the MO feels it’s a lower volume and to have chemo available if it DOES become higher burden. So far, the Zytiga and Eligard along with IMRT radiation he had are doing their job. PSA is undetectable right now. But like you, I’m always questioning.

[MomOfMaisy]

I’ve asked my husband’s medical oncologist this a few times. He’s currently on abiraterone, prednisone and Eligard every 3 months. Finished 28 treatments of IMRT radiation with a couple boosts. His PSA is undetectable right now. Anyway, his MO said because he’s got low volume mets (two ribs, scapula, lymph nodes and seminal vesicles) and NOT to any organs, he prefers not to start triplet therapy by adding docetaxel. He mentioned quality of life on chemo, as well. Like you, it had been nagging me. But now that he’s doing so well on his hormone therapy I’m not as fanatic as I was at first. He’s stage 4b, advanced metastatic and Gleason 9. Diagnosed in November. The MO said if he becomes castration resistant then chemo is always an option. Or spread to organs.

Like you, I keep thinking he should add docetaxel now while he’s strong and can handle it better. I was always reading the various new studies out there until I driving myself crazy. Lately I’ve been doing less research probably because it doesn’t feel as dire. I know that eventually he’ll become castration resistant. I hope this isn’t the calm before the storm. As for chemo, I also wonder how much more QUALITY of life it would give him if he started now. I’d hate for him to suffer through side effects to gain a small amount of time. Aaack. It’s a hard one!

[103532]

It sounds like you and I think alike. Once I learned that chemo is ineffective on sleeping cancer, I realize there is not much one can do. My husband is on the same doublet combination as your husband, and he is nearly finished with salvage IMRT to the extended pelvis and SBRT to the moderately avid small retrocaval lymph nodes. As soon as my husband completes radiation, I plan to ensure he stays very active and positive. I research everything, so my husband doesn't have to worry about that, but I am very interested in the combination of Xtandi and Apalutamide at the very earliest signs of recurrence. I know that Docetaxel does not always control the PCA for long, but I have also heard it can resensitize the cancer to ADT in some cases. There is also the injectable radiation therapies that are targeted to the psma scans. There is a lot coming down the pipeline, which gives me hope. Please keep me updated on how your husband is doing, and I will do the same.