Chemo or not?

[Runner1957]

Since April my psa has started to rise with monthly results below;

April 0.03

May 0.05

June 0.07

August 0.53

October 5.0

November 36

December 8.0 after 2 weeks of Bicalutamide.

I had the following PET x 3 and MRI x 2 (full body) scans from 0.5 upwards. The first 2 PET scans and first MRI did not show up anything discernible as cancer.

The 3rd PET and 2nd MRI scans proved positive. I live in the UK so have a private consultation for an opinion and to get my scans carried out promptly and then a consultant with the NHS who provide my treatment.

My private consultant feels that doublet therapy is most suitable at present as I have definitive lesions in mu left iliac bane with suspect ribs x 2. This classes me as Oligometastic except the rate of the PSA velocity indicates more may be underlying and not seen on scans. After receiving his advice was prepared to go with his suggestion.

My NHS consultation was after the private one when the consultants opinion was that triplet therapy would be a better option. This totally confused me although looking aa research it seems there is not better outcome for Oligometastic patients who have chemotherapy.

For information is Have shown below the private consultants rational but I would appreciate and advice or experience you can share?

Diagnosis:

Metachronous metastatic prostate cancer diagnosed with a PSMA PET scan of 27 November 2024 and whole body MRI of 26 November 2024. PSA on 28 November 2024 was 36. LFTs shows normal readings with alkaline phosphatase of 47. PSMA PET scan and MRI scan shows an increase in size of the previously seen left iliac bone lesion that measures 19mm versus 6mm with DWI signal characteristics in keeping with hypercellular bone marrow lesions/metastatic deposit. Subtle heterogeneity in the signal characteristics within several ribs is unchanged though on the PET scan the SUV has increased in the left anterior 7th rib and right lateral 8th rib. Whilst the MRI does not suggest these to be bone metastasis the PET scan report says that these might also represent early bone metastasis. No other suspicious PSMA avid lesions elsewhere.

Previous History:

Carcinoma prostate diagnosed in July 2020. Had robotic prostatectomy in October 2020. Final

histology was pT3a N0 Gleason 4+5=9 with negative margins.

PSA prior to surgery was around 10. PSA post-operatively was undetectable at <0.1. 30 July 2021 – 2.8.

PSMA PET scan on 23 September 2021 shows an 8mm right internal iliac/posterior pelvic side wall node which has got SUV of 3.4. This is highly suggestive of a metastatic node.

Completed radical radiotherapy to prostate bed and pelvic

nodes in Worcester. LHRH agonist therapy completed April

2023.

Subsequently he was monitoring his PSA on a two

monthly basis. PSA remained undetectable until March

2024. PSA in April 2024 was 0.03, May 2024 was 0.05 and

in June 2024 was 0.07. Testosterone in May 2024 was

11.2. PSA test done in the USA July 2024: 0.2.

PSA on 7 August 2024: 0.53. PSMA PET scan of 15 August 2024 shows foci of rib uptake as before with mild increase in avidity – these are likely benign. No new or abnormal uptake identified elsewhere. (Indeterminate foci of uptake noted in the anterior left 7th rib and posterolateral right 8th rib) as before with mild increase in avidity (left 7th rib SUVmax 4.3 previously 3.6, right 8th rib SUVmax 5.7, previously 3.7).

PSA in October 2024 was 5.0. Alkaline phosphatase was normal at 52. Whole body MRI of 11 October 2024 – formal report is awaited and verbal communication and discussion with Dr Tunariu was that there is a 10mm area in the left iliac bone which is suspicious though not definite for metastatic disease. There is a sacral insufficiency fracture. There are small retroperitoneal lymph nodes, but they do not meet the criteria radiologically for being malignant.

Discussion Today: He queried regarding the option of triplet therapy or doublet therapy. I have explained to him that whilst triplet therapy may be considered. However, the triplet therapy trial reports are from denovo (synchronous) metastatic disease patient cohort and importantly the low volume metastatic patients did not show a survival benefit with the addition of the triplet therapy in comparison to the doublet therapy of ADT plus Docetaxel. Therefore, in metachronous metastatic patients who are low volume, my preference would be for doublet therapy with ADT plus either Apalutamide or Enzalutamide.

[Tall_Allen]

Sounds like good advice to me. When either of those fail, you can try a triplet, as in the PRESIDE trial:

prostatecancer.news/2022/10...

[petrig]

Triplet therapy if you can.Adt+docetaxel+Nubeqa. Its is best combination to get now available. I was treated with triplet theraoy.

[Hawk56]

From my foxhole, you are not wrong in either choice, doublet or triplet.

The clinical history you describe is one of a pretty aggressive PCa.

The path I chose was to do triplet therapy. I was not high volume but DLL the other clinical data pointed to bring high volume if I didn't take an aggressive approach.

That was me though, nothing wrong in your analysis and if you go with doublet therapy, that is a reasonable decision.

You can always do chemotherapy later.

Kevin

Clinical History.

[God_Loves_Me]

I am NOT doctor, I am NOT medical advisors. I do not have knowledge like Allen. I do listen him carefully and do follow him.

Here is my advice just to think about it. I think go with clinical trial may give you opportunity to buy more time and use doublet or triplet therapy in future. Many clinical trials actual reporting very good numbers even in phase 1 trials. I hope you get some recommendations of clinical trials + Understand its side effect and compare with chemo (doublet or triplet )

I think comparison of treatment may help you to make better decision.