My father (71) has been recently diagnosed with PC that has metasized in his bones (multiple places including ribs and spine).The doctors are insisting on orchiectomy or a high dose of Degarelix before the biopsy results are available) followed by monthly shots of Lupron.
The mets in his spine has the doctors concerned about potential damage to some nerves that it would pinch against and so they are recommending radiation once the biopsy results are back just to target those problem areas. He will be started on Abiraterone as soon as radiation begins.
Chemo will follow radiation.
I have been drinking out of a fire hose in the last few days since I found out about my dad's condition. Does the plan seem to be the standard care procedure for his age and condition?
I'm also looking for suggestions on what factors led to choosing orchiectomy or continuous adt through injections.
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I would be pleased with how proactive the doctors are with plans of putting the cancer to sleep immediately while they wait for the pathology and plan out the radiation. Have they mentioned germline and somatic testing on the biopsied tissue to check for a mutation that would have good response to a certain treatment? One question I would ask (and I think this is an important one) is if they can do chemo upfront with the hormone therapy and then follow with radiation?) I am no expert, but I think chemo does not work as well after the ADT puts the cancer to sleep. It may be bc the metastatic burden is too small. Tall_Allen is who I would trust with this question. Good luck to you, and please keep us all up to date on how you are doing.
Thank you for your reply. I'm unsure about germline and somatic testing but I'll make sure to ask the doctor if that's being done.This plan here is from the second doctor we consulted and the one we are leaning towards. The first doctor who diagnosed did want to do chemo right away instead of radiation first, but the new doctor is concerned about a few mets in his spine that he wants addressed. I'll be sure to discuss if chemo would also achieve the same results while also addressing the other mets.
I'm grateful to have found this forum. I've spend countless hours reading through so many informative posts.
Please ask him to read the Stampede Trial. I know that Triplet therapy (hormonal, second AR homonal and chemo is often used first to kill as much of the systemic cells and put the remainders to sleep. He is systemic. My thought is maybe they want to save the chemo if his metastatic burden is low. That is what they said about my husband’s case. Still, I would be pushing to see if Triplet would help, then radiation later for the clean up. It’s a great forum, and I am glad you found it.
Triplet therapy (ADT/orchiectomy + abiraterone/durolutamide + docetaxel) is the standard-of-care in his situation. He has to start the docetaxel at about the same time as the abiraterone/durolutamide
I don't really see the value of a prostate biopsy after it is known that there are metastases, but what's done is done.
Ask for a neurological consult on the spinal metastases.
He will always need castration, either chemical or physical. A month of degarelix will immediately stop progression and prevent the testosterone surge from the Lupron.
Thank you. I'll get a neuro consult as soon as possible. I'll have to ask the doctor about the downsides of starting adt a few weeks before abiratone+docetaxel as 103532 pointed out potential of lower effectiveness.
Few weeks are still ok with degarelix ADT injections. The most important is that you are fully castrated before the docetaxel chemotherapy. With firmagon adt injections you could start with chemotherapy in a week time after the first big (240mg) degarelix ADT injection.
He has been scheduled for two 120mg shots of degarelix. Chemotherapy should start two weeks from now by when the hormone blocker should be in full effect.For those that had bone mets, was there significant decrease in pain following degarelix?
I had a sciatica bone pain and I was begging professor Richard Epstein to give me something for that I he said it is expensive but because I had Mets in my spine he prescribed degarelix an a pain miraculously disappeared in one week.
In one week my pain gone. I couldn't believe.
I started having every two weeks psma pet scans in total 4 of them. After 45 days I started docetaxel chemotherapy six circles. After the chemotherapy I had a nuclear medicine bone scan. My PSA was 0.3 but it is normal that the PSA goes up a bit after stopping the chemotherapy. My medical oncologist declared remission of my cancer during the chemotherapy when my PSA dropped under 2.
My new MO wanted me to get a full body CT scan also not just a nuclear medicine bone scan but I refused it and a Canadian registra of my MO said that she also wouldn't do the full body CT scan.
After the post chemotherapy nuclear medicine bone scan I didn't do any scans for 4 full years. I only had a psma pet CT scan with contrast when my PSA went up to 1.25. I didn't have any visible metastasis on the PSMA pet CT scan with contrast only in 95% of my prostate with psma SUV max value of 14.
I also requested from a nice registra of my MO and FDG scan plus the nuclear medicine bone scan plus I also had a bone density scan (with the words I don't want to fry myself if I have visible metastasis) before finally deciding to get the SBRT radiation of my prostate.
Hearing how your pain subsided in a week fills me up with hope. He has had very bad back and hip ache from his mets. While there is a two week gap between the degarelix and chemotherapy, it'll be good to get some pain relief. His doctor also plans for a PSMA Pet scan once post his chemotherapy is done and then only doing PSA tests for the near future.As for continuing the hormone therapy, his options are open between going on Lupron or Orchiectomy.
I've said this before, but can never be thankful enough.. I'm glad to have found this forum and hearing all of your experiences gives me the confidence as a caretaker to guide my dad.
Prostate cancer is easy peasy until it is in a hormone sensitive phase. I will be in my 7 th year in April this year since I am diagnosed and my PSA is stable and probably don't have any visible Mets.
I was lucky enough that my first RO recommend early upfront docetaxel chemotherapy. Probably that is why I am without visible bone Mets, only cancer in my prostate as a result of different DHT environment in my prostate favorable to PC.
Yes - my husband was dx'd with numerous bone mets and was experiencing pain. He had triplet therapy. His pain subsided very quickly after starting his hormone meds.
Now in cases like your father's the triplet is used more and more often. Years ago, we usually started with the less "powerful" therapies and with fewer side effects, then when the cancer became resistant we moved on to the others. But it has been discovered that it is better to hit it hard from the beginning, probably because doing so gives the cancer less chance of immediately replicating clones of cells resistant to the treatments.
the recommendation is what I had done in 2021. My PSA was 542 with extensive bone Mets. I also had radiation to a spinal met as the chemo can cause nerve damage otherwise if the met is close to the spinal column. It knocked my PSA back to 0.07 by March 2023. Has crept up recently and had some more radiation to new spots. Hitting it hard up front does work. All the best
Your father’s proposed treatment plan aligns with **current standards of care** for stage 4 metastatic prostate cancer (mPC) with bone metastases, though there are nuances to consider. Below is a detailed breakdown of why this plan is appropriate, the rationale behind specific choices, and factors to weigh for decision-making:
---
### **1. Treatment Plan Overview: Key Components**
ADT is the cornerstone of treatment for metastatic prostate cancer. It rapidly suppresses testosterone, which fuels prostate cancer growth. Starting ADT immediately (before biopsy results) is standard in high-risk cases (e.g., high PSA, bone metastases) to urgently control disease progression.
- **Orchiectomy vs. Degarelix/Lupron:**
- **Orchiectomy (surgical castration):** Permanent, one-time procedure. Avoids lifelong injections but is irreversible.
- **Degarelix (initial injection) → Lupron (monthly):** Degarelix provides rapid testosterone suppression (within 3 days) and is often used in urgent cases. Lupron (leuprolide) is a long-acting ADT injection.
**Factors influencing this choice:**
- **Speed of action:** Degarelix suppresses testosterone faster than orchiectomy or Lupron.
- **Patient preference:** Some prefer avoiding surgery (orchiectomy) but must commit to lifelong injections.
- **Cost/logistics:** Orchiectomy is a one-time cost; injections require ongoing access and insurance coverage.
---
#### **b) Radiation for Spine Metastases**
- **Why radiation?**
Bone metastases in the spine pose a risk of **spinal cord compression** (a medical emergency) or nerve damage. Radiation (e.g., stereotactic body radiation therapy/SBRT) is prioritized to:
- Reduce tumor size and relieve pressure on nerves.
- Prevent fractures or paralysis.
- Address pain.
Starting radiation *after biopsy* ensures treatment planning accounts for tumor biology (e.g., if rare aggressive variants are found).
---
#### **c) Abiraterone + Prednisone**
- **Why abiraterone early?**
Combining ADT with **abiraterone** (a potent androgen synthesis inhibitor) is now standard for metastatic prostate cancer. Studies (e.g., LATITUDE trial) show this combination:
- Extends survival.
- Delays progression.
- Works synergistically with ADT to suppress testosterone more completely.
Starting abiraterone during/after radiation is reasonable to avoid overlapping side effects (e.g., fatigue).
---
#### **d) Chemotherapy (Docetaxel)**
- **Why chemo after ADT/abiraterone?**
Docetaxel is typically used in **high-volume metastatic disease** (multiple bone lesions, visceral metastases). It improves survival when given early (with ADT) or later (after hormonal therapy fails).
- **Timing:** Some oncologists prefer chemo after hormonal therapy to maximize quality of life (chemo has more side effects).
---
### **2. Is This Plan Standard for His Age/Condition?**
**Yes.** This approach follows **NCCN/EAU guidelines** for high-volume metastatic prostate cancer:
- **ADT + abiraterone** is a Category 1 recommendation (strongest evidence).
- **Radiation for symptomatic/high-risk bone lesions** is standard to prevent complications.
- **Chemotherapy** (docetaxel) is recommended either upfront (with ADT) or sequentially, depending on patient fitness.
At age 71, your father’s functional status (e.g., ability to tolerate chemo) and comorbidities (e.g., heart disease) will influence timing, but the overall plan is appropriate if he is otherwise healthy.
---
### **3. Key Factors in Choosing Orchiectomy vs. ADT Injections**
| **Psychological Impact** | May affect body image/mental health. | Avoids surgery but requires needle tolerance.|
**Practical Tip:** If your father values avoiding surgery and can manage injections, Degarelix/Lupron is often preferred. If he dislikes frequent medical visits, orchiectomy may simplify care.
---
### **4. Additional Considerations**
#### **a) Bone Health**
- Start **zoledronic acid** or **denosumab** to prevent fractures and reduce skeletal-related events.
#### **b) Genetic Testing**
- Request **germline/genetic testing** (e.g., BRCA1/2, HRR mutations). If positive, PARP inhibitors (olaparib, rucaparib) could be future options.
#### **c) PSMA PET/CT**
- If available, this advanced imaging can better define metastasis spread and guide targeted therapies (e.g., PSMA-targeted radioligand therapy).
#### **d) Clinical Trials**
- Trials for novel therapies (e.g., immunotherapy, PSMA-targeted drugs) may offer additional options.
#### **e) Palliative Care**
- Early palliative care improves quality of life and helps manage pain/fatigue.
---
### **5. Monitoring and Next Steps**
- **PSA/Imaging:** Track PSA every 3–6 months. Repeat bone scans/CTs as needed.
- **Side Effects:** Watch for ADT-related issues (bone loss, fatigue, cardiovascular risks) and abiraterone’s side effects (fluid retention, liver enzyme changes).
- **Second Opinion:** If uncertain, consult a prostate cancer specialist at an academic center.
---
### **Final Thoughts**
This plan is **evidence-based and appropriate** for your father’s stage 4 prostate cancer. The urgency of ADT and spine radiation reflects the need to control aggressive disease and prevent catastrophic complications (e.g., paralysis). The choice between orchiectomy and injections is highly personal—focus on your father’s preferences, lifestyle, and values.
You’re doing a great job advocating for him. Stay engaged, ask for clarification when needed, and lean on his care team for support.
Thank you for taking the time to put down such a detailed response. We switched doctors immediately once we found one that was working with us to provide clarity about the treatments instead of just pushing for things to be done 'just because'.The tips about bone health are also relevant and I'll make sure to ask the doctor about his plans for that.
The first shot of Degarelix was given yesterday and Dexamethasone has been prescribed which seems to be a 'steroid'.
My situation was similar as that of your father although I did not have bone metastases. At diagnosis (age 64) my PSA was 248 with Gleason scores of 9-10 on all cores. There was local spread to lymph nodes. I chose the (unusual in US) route of a bilateral orchiectomy and have been quite pleased with the result. It has been almost four years with no follow up medications or procedures other than scans which have all been clear. Side effects have been minimal--just a couple of minor of hot flashes every day or so. My PSA is slowly rising (9 at last check) and I expect to be put on abiraterone if it gets much higher. The mean effective time for that medication is 36 months though it can remain effective for more than 60 months.
With the numerous treatment options available I would definitely follow the same regimen if I had to do it again.
He's open to Orchiectomy, but I am glad he's going with the Degarelix for the time being as he has taken the diagnosis pretty hard and while he mentally recovers, it buys us time to decide on going the surgical route.I hear now arbiraterone is given much earlier for cases like my dad. Would that not apply to your case as well?
Osteoporosis wasn't brought up in the conversation yet, but the doctor talked about (calcium?) supplements for bone strength. Abiraterone vs ARPIs hasn't been discussed either and I'll look into that.
Have they presented Orgovyx to you, as an ADT option ? Sorry if I may have missed this in the thread. It's a 2nd generation ADT option. Pills daily, as opposed to injections.
That’s the path I took 10+ years ago with the same dx. Read my profile to see the treatments I’ve had over the years. I’m still here, life is different but good. I also believe in prayers, lots of prayers, God works miracles.
Hi that's a VERY aggressive plan especially for a man of that age. The ochieotomy should hang any further production of cells since the prostate is excised in this procedure. The Mets in multiple areas is a challenge, and going down the chemo/ radiation road is highly taxing on the body. Chemo in this instance is Veeerrryyy risky, the side affects are horrid, and the failure rate is extremely high. That's a personal decision that he has to come to terms with. Radiation has its pluses also with many side affects that are less than desirable. I suggest do your research on the doctor surgeon, facility, and effectiveness of this procedure and follow up meds, that's a lot any way you look at it. Trek your dad to choose the least path of discomfort and recovery, at this point the prostate is NOT the challenge, and Know that He has to motivate regardless of the results of path he chooses. So, comfort over quality of life or combination of the 2. IDK luv I hope this helps, Godspeed.
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Is this an acceptable radiation treatment?
First post: Father with metastatic PCa, looking for natural treatment experiences after stoping oral chemo/radiation. 
Should I seek radiation treatment to my spine will undergoing ADT. There is pain.
advice needed for treatment after chemo with rising PSA 
Wait time for radiation is 6-8 weeks in BC Canada; will this cause an issue with triplet approach?
