Dad with Advanced PCA :(

[MissMel2024]

Hi everyone, I am new here and appreciate any assistance that could help my father.

My dad is 73 years of age. Over the last few weeks we have gone from a raised PSA level 8.9 (up from 6 in 2022 and 2021, 5.1 in 2020), Negative DRE, to an MRI (PIRADS 5, SAG T2) to a positive biopsy (10 cores taken, 9 positive, overall score G9) to a PSMA PET Scan and now an Advanced metastatic Cancer diagnosis.

We are devastated and doing all we can to help guide him down a path of treatment. We know that we cannot cure this now it has moved outside the prostate but can anyone please assist with interpretation of the PET output below and provide thoughts re best potential treatment.

PET Output

At the apex of the prostate gland in the midline and to the left of the midline there is a linear region of markedly increased tracer uptake. SUV = 26.6 – in this location this focal abnormality extend beyond the gland. Slighlt more superiorly there is similar uptake in the midline and to the right of the midline and SUV =17.7 consistent with the disease in both lobes. In the mid zones bilaterally there is peripheral uptake consistent with disease involvement and there is also abnormal tracer uptake at the base of the gland in both lobes extending into both seminal vesicles. There is a very small 2mm lymph node in the pelvic mesentery anterolateral to the bladder which is markedly tracer avid consistent with nodal involvement and there are multiple separate abnormalitites in lateral pelvic, right internal iliac, right common iliac, posterior pelvic mesenteric nodes and nodes on either side of the aortic bifurication in the lower abdomen consistent with regional nodal disease.

Thank you so much

[Justfor_]

From what I know now, I would immediately started some ARSI (Androgen Receptor Signaling Inhibitor or commonly dubbed Anti-androgen drug) to pause progression and get some decision time. There are many available options and it takes time to weight pros and cons. Rushing to the first/earliest offered or highest recommended seldom proves optimal. You have to take your time to decide but not being under stress.

[Maxone73]

Consider the available options that a good MO will propose , a lot depends also on how fit your father is. But at his stage there are many options. It would be better if it was confined to prostate gland, but the fact that it's not spread to the bone or to internal organs is very very positive. It's basically a regional nodal disease still. Present medical treatments cannot cure it, but can control it for many many years, and good habits (diet and exercise) will extend that period.

[Tall_Allen]

It may be curable. It will take whole pelvic radiation from the aortic bifurcation on down, preferably with a brachytherapy boost to the prostate. It also requires 3 years of ADT AND 2 years of abiraterone. There is a clinical trial that uses 2 years of ADT + apalutamide:

clinicaltrials.gov/study/NC...

There is also a clinical trial using a briefer but more intense duration of radiation, called SBRT.

classic.clinicaltrials.gov/...

He can enter both trials.

[Scout4answers]

He has a lot of life ahead of him. My DX was similar see my profile for details. Resistance exercise is the best medicine he can take outside of the standard of care that MDs will recommend.

[Atdabeach]

Don't despair! Based on what you've posted, his case sounds very treatable, and possibly curable -- in either case he likely has plenty of years left.His case sounds very similar to mine (except my PSA was twice his), and I'm nearing the end of 2 years on ADT, with 44 sessions of proton radiation (full pelvic coverage, with a "prostate boost" for the last 16) after 6 months. My PSA has been undetectable for the last year and a half. Once ADT ends, we will continue to watch my PSA, and if it rises above 2, we'll discuss next steps, which can include a number of options. I'm 71, and making the most of however many years I will have. My wife and I are traveling, working out, and enjoying our retirement.

I hope your Dad has access to a top cancer hospital, with a medical oncologist and a radiation oncologist. He will likely be told, as I was, that surgery would not be indicated, as his disease has spread beyond the prostate. As Tall Allen said above, he will need both radiation and hormone therapy.

You've come to the right place for info and support. Best wishes to you and your Dad, and keep us updated on his progress!

[j-o-h-n]

Greetings to your Dad and to you MM2024,

First of all DO NOT PANIC. Next consider all options before jumping in the pool. Post here for good info and comradery. He will definitely make it to 90 years old or beyond. Get him to a good Ca Hospital with a good R.O. and M.O. Update his bio info for your use as well as our use and tell us where he is located (City/State). Give your Dad our fondest regards and to keep living and laughing.

Good Luck, Good Health and Good Humor.

j-o-h-n

[j-o-h-n]

P.S.

PCa Abbreviation List UPDATED 1/26/2023

Can be found on the right hand side of your main screen (helpful but a bit dated).

Good Luck, Good Health and Good Humor.

j-o-h-n

[MissMel2024]

Thank you to everyone who has responded. Some of your comments definitely made the tightness in my chest a little lighter. The thought of Dad having this diagnosis but able to live another 10-15 years, makes the journey in front of us seem a little easier.

We met with the radio oncologist on Wednesday and he suggested the following

1. Start cosudex tablets now for 28 days and then stop

2. Start Zoladex injection within the next 2 weeks, then once every 3 months for the next 2 years.

3. Referral to Medical Oncologist to discuss adding second generation hormonal therapy.

Radiotherapy will not begin until September/October - 20 treatments EBRT daily for 4 weeks. He has suggested per Tall_Allen that he will hit the prostate and all the nodes up the pelvis and into the lower abdomen with a little beyond that as well.

We will be meeting with him again and the MO shortly.

My questions are:

1. Is this a gold standard treatment? Is there anything else we can ask for? Tall_Allen you suggested 3 years ADT, should we speak to the MO about this, and the second generation drug, would it be better to ask for abiraterone or apalutamide?

2. I will ask the RO about the addition of brachyatherapy to the prostate.

3. I have read a lot about triplet therapy, but unsure whether this is something that would suit in my dad's case. I will ask MO about this when we meet, but if anyone has any advice here it would be appreciated.

I will also update this bio will his details, thank you so much to everyone who has taken the time to respond. It really does mean so much.

Also, we are based in Sydney, Australia and he will be having his treatment at Chris O'brien Lifehouse which is a dedicated cancer facility in Australia.