What's next after Xofigo?

[Oldie68]

A couple of weeks ago I finished six cycles of Xofigo. My PSA went from 1.4 ng/mL to 8.5ng/mL and my AP from 274 U/Lto 71 U/l. So it looks like it worked. I was told that rising PSA with this treatment is normal, although currently nobody knows why. I am wondering what comes next. If you have had Xofigo in the past, what did your oncologist suggest for next treatment? Did you have a monitoring break between the end of Xofigo and the next stage? For how long? If you tolerated it well, were adding more infusions an option?

[Tall_Allen]

It is safe to retreat later, but there is no benefit in doing more than 6 at a time:

onlinelibrary.wiley.com/doi...

It appears to be safe to follow with Pluvicto:

pmc.ncbi.nlm.nih.gov/articl...

jnm.snmjournals.org/content...

[Oldie68 in reply to Tall_Allen]

Thank you Tall_Allen. I am not sure what is better: to start Pluvicto earlier, or to keep it as an option for later, when the cancer metastasizes to organs.

[Tall_Allen in reply to Oldie68]

Most therapies work better if used earlier.

[Oldie68 in reply to Tall_Allen]

I agree. But choosing between first Enzolutamide and then Pluvicto or first Pluvicto and eventually Enzolutamide isn't easy.

[Tall_Allen in reply to Oldie68]

Do both! There seems to be a synergy:

prostatecancer.news/2024/04...

[davebliz]

I started Radium 223 in Feb/24 and did 4 sessions. Scans showed that tumors had started on my lungs so we stopped Radium 223 and started Cabazitaxel. I've done 7 sessions so far and the tumors on my lungs have reduced.

[j-o-h-n in reply to davebliz]

Good News dave............ if your current fight against the lung tumors should fail..... ask the doc(s) regarding Keytruda and bliTz them.

Good Luck, Good Health and Good Humor.

j-o-h-n

[Oldie68 in reply to davebliz]

Thank you for sharing. How do you tolerate Cabazitaxel? Any side effects?

[davebliz in reply to Oldie68]

I'm having a lot of fatigue with Cabazitaxel, especially after my 6th and 7th sessions. I also have edema in the feet so have started on a diuretic.

[jackchen]

It's great to hear that your alkaline phosphatase (AP) levels have dropped significantly, which often indicates a positive response to Xofigo. The rise in PSA during or after Xofigo can indeed be confusing but isn't always indicative of disease progression, as PSA dynamics during treatment with radiopharmaceuticals like Xofigo can be atypical.

### What Might Come Next After Xofigo?

Here are some possibilities your oncologist might discuss with you:

1. **Active Monitoring:**

- Many oncologists opt for a monitoring period after Xofigo to evaluate how the treatment has affected the disease and to observe for side effects. This typically involves regular PSA checks, imaging, and monitoring symptoms to decide on the next course of action.

2. **Continuation of Systemic Therapy:**

- If you were already on androgen deprivation therapy (ADT), this will likely continue. Some oncologists may add or adjust systemic therapies such as:

- **Second-generation androgen receptor inhibitors** like enzalutamide (Xtandi) or abiraterone (Zytiga).

- **Chemotherapy**, such as docetaxel or cabazitaxel, if not already used.

3. **Immunotherapy:**

- **Sipuleucel-T (Provenge)** could be considered if you meet the criteria, particularly if your disease remains asymptomatic or minimally symptomatic.

4. **PARP Inhibitors:**

- If you have specific genetic mutations (e.g., BRCA1/2), drugs like olaparib or rucaparib might be an option.

5. **Additional Radiopharmaceuticals or Radiotherapy:**

- Xofigo is typically limited to six cycles because of potential cumulative bone marrow toxicity. However, further bone-directed therapies like external beam radiation may be an option for localized pain or specific lesions.

6. **Clinical Trials:**

- Enrolling in a clinical trial might provide access to emerging treatments such as new targeted therapies or combination regimens.

7. **Supportive Care and Quality of Life Management:**

- If you've tolerated Xofigo well but still have bone pain or symptoms, treatments like bisphosphonates (e.g., zoledronic acid) or denosumab may be added to help prevent fractures and manage bone health.

### Timing Between Treatments

The gap between Xofigo and the next treatment will depend on:

- How well you tolerated Xofigo.

- Evidence of disease activity (via scans, PSA trends, or symptoms).

- Your overall health and preferences.

Oncologists often schedule follow-up imaging within 4-12 weeks after completing Xofigo to assess its impact before deciding on the next steps.

### Extending Xofigo

Currently, Xofigo is limited to six cycles based on clinical trial data and FDA approval due to the potential for bone marrow suppression with prolonged use. However, in some off-label scenarios or clinical trials, additional infusions might be explored under close monitoring.

### What Others Have Experienced

Experiences vary widely. Some patients move on to systemic therapies like enzalutamide or chemotherapy, while others explore clinical trials or focus on palliative care if the disease is more advanced.

It’s crucial to maintain open communication with your oncology team. Discuss your treatment goals and preferences, as well as any side effects or concerns, to tailor the next steps to your needs. If you haven’t already, a multidisciplinary team (including medical oncologists, radiologists, and palliative care specialists) might provide additional insights.

[Oldie68]

Wow, thank you for the detailed response! You seem to know a lot. I am wondering if you are an oncologist. Your profile doesn't provide any clues. 😀