After about 18 months on Firmagon combined with ADT (Zytiga, then Casodex, then Xtandi), my primary medical oncologist is recommending chemo/docetaxel to treat my bone mets. My advanced prostate cancer has multiple bone mets, but the recent PSMA Pet scan showed nothing in the lungs or vital organs. My radiology oncologist and another medical oncologist I know have both told me that chemo is usually NOT very effective in treating bone mets. I have significant bone pain in my pelvic area, but otherwise I'm doing okay. Repeated palliative radiation therapy to my pubic and ischial bones has been ineffective.
I'm not sure if I should start a docetaxel/chemotherapy protocol to reduce bone mets, especially if that treatment has a low success rate. I live in the USA, and I sense my primary oncologist wants to get me in to chemo so I will be eligible for Pluvicto later this year.
Which doctor is right about the effectiveness of chemo on bone mets? My current PSA is about 0.7, and more than doubled between November 2024 and January 2025.
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"My radiology oncologist and another medical oncologist I know have both told me that chemo is usually NOT very effective in treating bone mets." That's ridiculous. It is absolutely indicated for bone metastases.
Consider combining a lower dosage of docetaxel (60 mg/m2) with Xofigo as in this:
Thanks, Allen...I appreciate your input...it looks like your link is still in the trial phase...is it possible to combine the two drugs in the USA? Would insurance cover that?
Yes, there is a clinical trial where patients are randomized 2:1 to get the combo or to get full-strength docetaxel only. You can see if any of the sites are nearby:
Later this year you will probably get Pluvicto without having Docetaxel before. This on the basis of the PSMAfore trial. Novartis mentions: “Our focus right now is really laying the foundation for the PSMAfore launch in 2025, which would triple the number of patients eligible for Pluvicto,”
Castrate resistant...After 7 taxotere cycles and 3 months PSMA pet/ct scans L3 verterbral body went from 7.5 to 6.5 SUV max, Right iliac bone 6.7 now 4.9 Anterior right iliac bone 6.3 now 5.3....Right clavicular was 2.9 now gone.So far good results. I understand your concern, could be wrong, saw somewhere 40% chance taxotere can be effective at this stage. I wish you well. I hope to get spot radiation at some point, but my oncologist wants to do 10 cycles of chemo PSA down to 2.1
I have widely spread bone mets.I had triplet therapy (adt+6x docetaxel+Nubeqa(started after 3th doce).Here are,some of the results for me:
.."A response to treatment is also noted in the skeleton. The sclerotic bone has become more sclerosed throughout and the sclerosis has thickened, but in agreement with the treatment response, the soft tissue mass associated with bone metastasis, which was most recently bone-destroying, has disappeared. This soft tissue mass is visible in the last imaging in the left wing of the sacrum and also at the SI joint level in the posterior cortex of the left iliac bone where the tumor mass is destroying the cortex. The cortex is now intact in the subjects and the soft tissue mass seen in the bone has been repaired by sclerosis.".
Hi petrig, I'm intrigued by the level of detail you report about the nature of your mets. What type of imaging did they use? Standard bone scan (technetium or other tracer) or was it some other technology? Stay brave!
Computed tomography scan with contrast agent Iodine.Iodine-containing contrast agents are used in computed tomography examinations. The contrast agent is administered through a cannula into a vein .
The reports I am receiving from my CT scans contain a lot of detail about soft tissue, but not as much about bone health aspects. I suspect that the contrast agent is the determining factor in getting a detailed overview of bone mets.
Every 3 months, I am getting a full skeleton SPECT scan with 99mTc-HDP as tracer (740 MBq). All reports contain the same comment: "The scan was followed by a CT scan without contrast. The SPECT images were corrected for tissue attenuation using this CT scan." I could ask if a CT contrast agent could be added as well.
Interesting...my doctors have repeatedly stressed the PSMA PET scan with the Gallium-68 tracer as the 'gold standard' of prostate cancer scans. I've had other CT scans, but the oncologists don't trust them as much as the PSMA scan.
Computed tomography is commonly referred to as a CT scan. A CT scan is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body. It shows detailed images of any part of the body, including the bones, muscles, fat, organs and blood vessels.
PSMA PET imaging is a critical tool in the management of prostate cancer due to its high sensitivity and specificity in detecting disease. Here are its key roles:
- **Accurate Staging**: PSMA PET/CT provides superior accuracy compared to conventional imaging (CT or MRI) in staging high-risk prostate cancer and identifying metastases, particularly in lymph nodes and bones[2][4].
- **Biochemical Recurrence Detection**: It is highly effective in localizing recurrent disease after initial treatment when PSA levels rise, even at very low values, enabling timely intervention[4].
- **Theranostic Applications**: PSMA-targeted radioligands, such as 68Ga-PSMA-11 for diagnostics and 177Lu-PSMA-617 for therapy, allow combined diagnostic and therapeutic approaches (theranostics), which can delay progression in advanced cases[2][4].
- **Guiding Biopsies**: In metastatic prostate cancer, PSMA PET improves the success rate of obtaining tumor samples for molecular analysis by identifying optimal biopsy sites[7].
Overall, PSMA PET imaging has revolutionized prostate cancer care by enhancing diagnosis, treatment planning, and precision medicine.
[5] MP40-15 THE DIAGNOSTIC VALUE OF PSMA PET/CT IN MEN WITH NEWLY DIAGNOSED INTERNATIONAL SOCIETY OF UROLOGICAL PATHOLOGY GRADE GROUP 3 INTERMEDIATE-RISK PROSTATE CANCER semanticscholar.org/paper/9...
[6] A Comparison of 18F-FDG PET/CT and 68Ga-PSMA PET/CT in Detecting Osteonecrosis of the Jaw in a Patient With Prostate Cancer. pubmed.ncbi.nlm.nih.gov/381...
[7] Prior PSMA PET-CT Imaging and Hounsfield Unit Impact on Tumor Yield and Success of Molecular Analyses from Bone Biopsies in Metastatic Prostate Cancer ncbi.nlm.nih.gov/pmc/articl...
[8] Importance of magnetic resonance imaging and prostate‐specific membrane antigen PET‐CT in patients treated with salvage radical prostatectomy for radiorecurrent prostate cancer pubmed.ncbi.nlm.nih.gov/365...
Many benign and very many other cancers than prostate cancer are positive for PSMA (14-17). However, the accumulation in these tumors is usually small compared to typical high-risk metastases (table in PDF file). In addition, small accumulations are found in infections and inflammatory changes (sarcoidosis, reactive lymph nodes in the armpits and groin, among others). Usually, degenerative bone changes do not significantly accumulate this tracer. The head and neck, celiac and anterior sacral lymph nodes often accumulate the tracer. They are usually easy to distinguish from lymph nodes on CT images based on anatomy. PSMA scans also often show low-activity local bone deposits, especially in the ribs (SUVmax often <?10 g/ml), some of which may represent metastasis. However, the majority of these are benign changes without anatomical equivalents. This is currently the biggest challenge in interpreting PSMA-PET studies, as it involves the risk of overdiagnosis and false positive results. A clear high-risk prostate cancer bone metastasis is very active, and an anatomical sclerotic response develops on CT images during follow-up. Osteoblastic, lytic and bone marrow metastases of prostate cancer are well visualized with PSMA, although osteoblastic bone metastases may be associated with deposits of very low intensity (18). Prostate cancer is a very heterogeneous disease in terms of primary tumor and metastases. Visceral organ and lymph node metastases can sometimes be very low or even invisible with this tracer. The high physiological background activity of the liver can complicate the diagnosis of rare liver metastases in prostate cancer, especially with the 18 F-PSMA-1007 tracer. Tumor heterogeneity explains why not all metastases are typically active or necessarily detectable with a single PET tracer.
If you're already on Xtandi for 18 months, I'm not sure chemo would be nearly as effective unless the ADT and Xtandi have stopped working fully. Double check me on that, but it could be very important.
I've been on Firmagon for 18 months and Xtandi about 8 months...I think they are partially working. I wasn't aware that chemo might be ineffective if other treatments were in use. My oncologist says we will stay with the Firmagon throughout chemo, but discontinue Xtandi.
I was diagnosed with advanced stage 4 and extensive bone Mets through pelvis, spine and ribs. Chemo killed them all other than some spots on pelvis. Along with ADT PSA declined from 542 to 0.07. Unfortunately doesn’t get everything but helps a lot.
wow. .7 is low. I’m 12.12. I just spoke to a guy that his father had prostate cancer in the bones. Had chemo and killed it all. Been cancer free for years.
Docetaxel is a standard treatment for metastatic castration‐resistant prostate cancer (mCRPC) and has been shown in large clinical trials (such as the TAX327 study) to improve overall survival and quality of life. Its benefit is measured in slowing overall disease progression rather than by dramatic shrinkage of bone lesions.
Effect on Bone Metastases:
Bone metastases often have a complex microenvironment that can make them less responsive to chemotherapy. In practice, while docetaxel may not visibly reduce bone lesions on scans, it can still help control systemic disease and sometimes provide symptomatic relief. This is why some specialists point out that chemotherapy isn’t typically “curative” for bone mets, even though it contributes to longer survival.
Treatment Strategy Considerations:
Your primary oncologist is likely basing the recommendation on evidence that docetaxel improves overall outcomes in mCRPC and might be positioning you for subsequent therapies (like Pluvicto) that target PSMA-expressing cells in bone metastases. At the same time, the radiology oncologist and your second medical oncologist are correct that the direct shrinkage of bone lesions with chemo is limited.
Ultimately, the decision depends on balancing the systemic benefits of docetaxel (which may control overall disease and extend survival) against its potential side effects and the fact that its direct impact on bone mets is modest. Given the complexity of advanced prostate cancer treatment, a detailed discussion with your healthcare team—and possibly seeking a second opinion—is essential for making the best decision for your situation.
Please note: This information is for educational purposes and should not replace personalized medical advice.
Thanks, Seasid...I think you are correct...it seems to match most of what I am hearing about chemo and bone mets for people who have already had ADT and hormone therapy. I do know that my primary medical oncologist is looking at Pluvicto on the horizon. Thanks!
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ADT and Docetaxel worked for treating the Prostrate and Pelvic Mets, but 2 out of 3 ain't bad 
Advanced Prostate with bone mets, new to the site.
New Bone Mets Throughout Skeleton
Docetaxel forever?
Missed Bone Mets
