My dad (72) was diagnosed in 02/24 with multiple bone mets, Gleason 9 an initial PSA of around 4000. He had triplet therapy with Docetaxel, Lupron and Nubeqa. His nadir was 26.1 in September 2024. His PSMA in November 2024 showed moderate to high activity in his prostate and in one area on his spine. Since September his PSA began to rise up to 31 in the end of November and up to 47 on the 8th January. At the same time his ALP and LDH are constantly sinking. ALP is now at 70, was at a 800 at the beginning of his journey. He is fit, loves life, has absolutely no bone pain (without any medication beside Xgeva) and loves to eat. His Testosterone is at 0.29 ng/ml.
His docs will recommend switching to Xtandi or Abirateron. What do you guys think? Thank you very much!
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- I would give Zytiga a shot. There is a very low chance that it will work.
- Also, an appointment with a radiation oncologist. May RO can radiate something immediate that can also help. Many times, a few METS do not respond to chemo.
- also ask for clinical trials that can work and help you better. You can keep other options like Xofigo or Pluvicto for later.
- scan can tell you the reason why PSA is going up. Last year, my PSA was going up, but my scans were so stable that the doctor did not worry about my PSA number at one point.
Why do you think zytiga has only a little chance? I thought the second line meds for mCRPC are also working in case the psa is rising again (castrate resitance). I feel a little big like we are out of options (beside LU-177, Chemo, etc.) while the docs recommended Enzalutamid oder Abirateron.
Many users believe once you fail, Nubeqa means Xtandi or Zytiga has little chance to work. Zytiga has different mechanisms, so giving it a shot is an good idea. You are lucky that your MO suggested using zytiga or Xtandi after Nubeqa. Many MOs will not prescribe once Nubeqa failed
Good idea to copy and paste most of your post (above) into your dear Dad's bio. Add any other pertinent data you feel is important for other members to view. It will help him/you and will help us. Thank you and keep posting. This is a great site for information and camaraderie.
Interesting that your MO recommends Xtandi over Zytega. I have one that is just the opposite, stating that he likes abiraterone over enzalutamide.
A second opinion is always a good idea, especially since you can probably do a video consult so you don't have to travel. Also video consults tend to schedule quicker than in person , in my experience.
I have used cancer.gov to find clinical trials. It's a lot quicker than going through doctor appointments -- I save them to discuss which trials might be best for me. If you have a subscription to chatGPT I believe there is a tool on MaleCare to find them as well.
I am also in the position of my all of my MOs agree that I should get into a clinical trial and have another round of Pluvicto, etc. as a back up for when I get really sick. 3 of the MOs are in major cancer centers, they just don't have a trial that is right for me.
xtandi is slightly more effective than zytiga but if you do xtandi first and then zytiga, zytiga will work little or not at all. While if you do zytiga first and then xtandi, xtandi should work for a decent amount of time. Having said that, it is better to do abi first and then enza, this has been demonstrated by several studies. And in any case, you should never use them in sequence, it is better to alternate them with chemo.
Given your current situation bone metastases in a dormant state, and ongoing treatment with Degarelix (ADT) the choice between Abiraterone plus Prednisolone and Enzalutamide depends on several factors, including your medical history, tolerability, and potential side effects.
Here’s a comparison to help guide your decision:
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1. Abiraterone + Prednisolone
Mechanism:
Abiraterone inhibits androgen synthesis at multiple levels, including in adrenal glands and the tumor itself.
Prednisolone (low-dose) counteracts the side effects of Abiraterone (e.g., mineralocorticoid excess).
Advantages:
Effective in controlling metastatic castration-resistant prostate cancer (mCRPC) and prolonging survival.
Particularly beneficial for patients with visceral metastases or more aggressive disease.
May improve bone metastasis outcomes when combined with ADT.
Potential Side Effects:
Increased risk of hypertension, fluid retention, and low potassium (due to mineralocorticoid effects).
Requires monitoring of liver function and electrolytes.
Daily corticosteroids (Prednisolone) can have long-term side effects (e.g., bone loss, glucose intolerance).
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2. Enzalutamide
Mechanism:
A potent androgen receptor inhibitor that blocks androgen signaling at the receptor level.
Advantages:
Proven to significantly improve outcomes in mCRPC and hormone-sensitive settings.
No need for corticosteroids, which may simplify management for some patients.
More convenient for patients with a history of hypertension or heart issues, as it avoids the fluid retention risks associated with Abiraterone.
Potential Side Effects:
Increased risk of fatigue and cognitive effects (e.g., difficulty concentrating, memory issues).
Rarely, it may lower the seizure threshold (caution in patients with a history of seizures or brain metastases).
Hypertension may occur but is generally less problematic than with Abiraterone.
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Recommendation:
Both options are highly effective, but the best choice depends on your specific health profile:
Choose Abiraterone + Prednisolone if:
You have significant comorbidities such as neurological concerns (e.g., history of seizures or brain metastases).
You can tolerate the addition of corticosteroids and require broader androgen synthesis inhibition.
You have a preference for a treatment with strong data on bone metastasis control.
Choose Enzalutamide if:
You wish to avoid corticosteroids due to concerns about bone loss, diabetes, or infection risk.
Fatigue and cognitive effects are not major concerns.
Your cardiovascular health allows for it, as hypertension is a manageable side effect.
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Next Steps:
1. Baseline Testing:
Assess liver function (for Abiraterone) and cardiovascular status (for both options).
Monitor electrolytes, blood pressure, and glucose levels.
2. Discuss with Your Oncologist:
Review your tolerance for potential side effects.
Consider scheduling regular follow-ups to monitor response and side effects.
Would you like guidance on preparing for your next oncology appointment or further details about managing potential side effects?
I believe that abiraterone is better tolerated and because you already had Nubeqa for me the choice would be simple Abiraterone. Hopefully it will work.
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