Pluvicto/ Lutetium Or Chemo after Hormone Therapy _ The Journey

[mg_22]

Hi. My father (84yr old) had prostate in 2011, Gleason score 4/4, got radiation at that time, was in contro but came back in 2018. Since then, he has gone through hormone therapy (Luperon, degarelyx, , Enzulatamide, Arbiterone) and the cancer is now Castrate/ hormone resistant so we need to move the treatment to the next stage. It is stage 4 as has moved to lymph nodes but is not in the bones. We have the option to start Pluvicto/ Lutetium or Chemo. We are going towards Pluvicto/ lutetium as it seems to be more targeted treatment and has lower side effects. Pretty big decision and does anybody have experience. Questions struggling with (1) Does starting with Pluvicto reduce expected longevity - body becomes immune eventually to every treatment and would chemo then pluvicto increase longevity (2) in people’s experience, can you do chemo after Pluvicto or is bone marrow issues a given side effect. Any thoughts would be much appreciated.

Update Jan 25, 2025

Thanks you all for your thoughful suggestions. We decided to go with Pluvicto/ Lutetium therapy. Our Rationale follows- We did not get a sense that there are any clear answers on longevity/ rectivation of receptors in Chemo Vs Pluvicto. However, we did get a sense that side effects are expected to be lower which made intuitive sense considering this treatment is more targeted. Also, with a push towards Pluvicto also being considered as first line treatment (even before becoming hormone resistant), though not approved, seemed a positive sign. Finally, it seemed there is a way back to come to chemo (check in after two sessions) if required, as our father, though 84, very diabetic and overweight, is asympotomatoic, and is in relatively decent mental and physical state. Hoping for a positive outcome.

Update March 7, 2025

Results positive for now- PSA dropped to 0.56 at the one month mark- some drop in platelets but not alarming for now. Shout out to Dr. Ishita Sen and her team (Jatin) at Fortis in Delhi India for excellent communications. Fingers crossed.

[GP24]

It is not a big decision. You can get chemo after Pluvicto, no problem. Pluvicto works well against lymph node mets and has fewer side effect than chemo.

This is a study testing this sequence: ejcancer.com/article/S0959-...

[mg_22 in reply to GP24]

Hi: Thanks for referring to this study but may not be applicable to our situation. In going through this study, I noticed this polulation had already gone through Chemo with Docataxel (1st line Chemo) and the comparison in the study was between the staging of Lutetium and Carbazitaxel (2nd line Chemo). We were deciding between starting with Docataxel (1st line Chemo) or Lutetium.

[GP24 in reply to mg_22]

The current FDA approval is for Pluvicto after Chemo (Docetaxel). This is currently changing, but not approved by the FDA yet. Based on your question, I assumed your father could get Pluvicto. If this is not the case, he has to get the Chemo. Or wait several months for the new FDA approval.

[mg_22 in reply to GP24]

He is in India so has access to use Pluvict direct

[GP24 in reply to mg_22]

You wrote: "We are going towards Pluvicto/ lutetium as it seems to be more targeted treatment and has lower side effects." If you can get Pluvicto I would prefer that instead of a chemo. Your father may not need six cycles of Pluvicto, you can check with a PSMA PET/CT after two cycles and four cycles how effective it has been. I needed one cycle only but that is an exception. He should combine Pluvicto with Enzalutamide, even if it does not work anymore for him. itnonline.com/content/nucle...

[mg_22 in reply to GP24]

May I ask what parameters were looked at to decide stopping after 1 cycle? I raised the same question to our doc as the PSA dipped significantly and would like to minimize bone marrow suppression ( drop in platelets and wbscs). However, they said they recommend doing a minimum of three cycles.

[GP24 in reply to mg_22]

I convinced the nuclear doc to treat me although I was hormone sensitive still. After the first cycle I asked for another PSMA PET/CT. It showed no more PSMA avid lesions so the second cycle was canceled. Pluvicto is very effective against lymph node mets.

[mg_22 in reply to GP24]

That’s awesome. Did you transition to hormone therapy or some other treatment after that? How long ago was this?

[GP24 in reply to mg_22]

I had this done twice. The first time new mets appeared after a year. The second time I was fed up with this and started ADT after the cycle. This was three years ago. ADT works for a long time if you have no sign of visible disease. I have no side effects from Lu177 as this were two cycles only one year apart.

[Tall_Allen]

Recent evidence is that survival is the same either way. You might favor chemo first because his performance status and bloodwork is better now than it will be after Pluvicto.

[speranza10]

May I know how long zytiga and xtandi worked and in what sequence were they used please?

[Cooolone]

Maybe aside from the obvious benefit from therapy you are seeking, would be to ask which treatment options might ALSO "Re-sensitize" the AR receptors, or remove the Resistance to ADT.

It does happen... And if the choices are even in regard to efficacy towards the PCa, then I would look at other data that might tilt the scales. So to say, that if one had some efficacy for re-sensitizing the PCa to ADT and the other didn't, even if it were a small chance, I would chose that, but that's just me.

Asking for you, so that those with better knowledgeable than me, can chime in

Best Regards

[mg_22 in reply to Cooolone]

Great suggestion. Thanks

[Mgtd]

The guys above offered some really great feedback but as I read your initial input I thought “wonder what his physical health is at 84”.

That might actually drive the choices. Just something to keep in your mind.

[mg_22]

Thanks you all for your thoughful suggestions. We decided to go with Pluvicto/ Lutetium therapy. Our Rationale follows- We did not get a sense that there are any clear answers on longevity/ rectivation of receptors in Chemo Vs Pluvicto. However, we did get a sense that side effects are expected to be lower which made intuitive sense considering this treatment is more targeted. Also, with a push towards Pluvicto also being considered as first line treatment (even before becoming hormone resistant), though not approved, seemed a positive sign. Finally, it seemed there is a way back to come to chemo (check in after two sessions) if required, as our father, though 84, very diabetic and overweight, is asympotomatoic, and is in relatively decent mental and physical state. Hoping for a positive outcome.

[Bspouse]

please keep us updated. I hope your father does really well on Pluvicto.