Recurrence, in lymph nodes only? Treatment?

[Adendino]

I'm on this forum because my husband has Gleason 9 prostate cancer with a number of high risk factors like ECE, PNI, SVI, IDC, but he's completed 28 EBRT sessions and 2 yrs of ADT+Abiraterone, and he's doing well. No signs of a recurrence yet, thankfully!!!

I'm writing this post on behalf of a great friend who was diagnosed in 2019 at age 69, Gleason 4+3, PSA in the teens. He was diagnosed before PSMA pet scans were widely available. It was assumed from imaging at the time it was localized.

In 2019, he did EBRT to the pelvic region after original diagnosis.

In 2023, PSA gradually climbed and PSMA Pet scan found a recurrence in 3 lymph nodes. He did SBRT to the nodes and 6 months of Orgovyx and Abiraterone. PSA was undetectable and T went to 0. The emotional/physical side effects from the 6 months of ADT was REALLY horrible (way worse than my husband's 2 yr stint). He is a famous engineering author/speaker and ADT was so debilitating, he couldn't effectively do his work, yet we're grateful the ADT and radiation worked.

In March/2025, his PSA climbed to 2.x and new PSMA Pet scan this week found a recurrence in 5 new lymph nodes, but no bone/organ metastasis. One node in his neck, a few near his heart, and 1 in the pelvic region.

I know there are different schools of thought about hitting it hard up front vs a slower/wait and see approach. His oncologist doesn't seem concerned, and today wrote a note saying "overall good and stable, some nodes to watch, discuss in 3 weeks?" Does this seem aggressive enough or should he push for more immediate attention and treatment?

We are thinking they'll want to put him back on ADT and Abiraterone since it originally worked well and knocked his T to 0, but based on the significant depression, severe brain fog, and the extreme fatigue he experienced with the previous 6 months of ADT, he's wondering if there are other options.

A couple questions?

Would Docetaxel be recommended for lymph node metastasis w/o bone/organ involvement as part of hitting it hard up front? Maybe a few infusions would be more tolerable than months and months on ADT? Or, maybe he has to keep this in his back pocket for down the road?

Would other flavors of ADT potentially have less side effects for him, perhaps Lupron instead of Orgovyx?

Would other ARSI's potentially have less side effects for him, perhaps Darolutimide instead of Abiraterone?

What about mono therapy with an ARSI and skip the ADT?

Any insight from this amazing group would be appreciated.

Thanks so much, Adrienne in Colorado.

[mrscruffy]

mental health issues need to be addressed by a shrink. They gave me meds that made all those problems go away

[street-air]

Your friend has stage 4 (systemic) and even though there is no sign of any non lymph mets, they can already be there and growing so playing around with more spot treatment is really no solution. He needs systemic treatment and it will have to be permanent. I would guess that the answer from others is that trying to minimise treatments now for the sake of side effects is a mistake, and instead put that effort into trying to minimise the side effects of an aggressive treatment. via exercise programs, anti depressants if appropriate and so on.

[Tall_Allen]

Docetaxel is always given with ADT, never alone.

Most ADT side effects are caused by loss of testosterone, so they all do that.

Anti-androgens block the AR receptors. A weak blocker like Casodex is better than nothing and may be more tolerable.

[Hawk56]

From what you describe, doublet or triplet therapy may be his best options, he may be on treatment continuously now vs intermittent.

MDT alone seems to not be an option given the clinical history you describe.

As to the side effects, as TA says no T is an issue with any form of ADT.

As others have said if he is experiencing depression then discuss with his medical team bringing a specialist in to diagnose and treat, there are medical options though finding the "right" one may take more than one try..

As to the exhaustion and brain fog, on the surface it seems counter intuitive but exercise may mitigate those. I'm not saying he has to be an Olympic athlete but find something he likes, walking, biking, go to the gym and swim, lift weights...

Another factor may be managing stress. Again, counter intuitive when you have PCa and are on treatment for it, but my medical team says it can and does play a role. I can testify to their advice.

You can discuss the EMBARK trial with his medical team, there was part of that which did ARI monotherapy.

You could also discuss the PATCH trial with his medical team.

Is chemotherapy in play, possibly, but as TA says, in 11 years I have never seen it as mono-therapy. There are side effects that are additive to the ADT and generally are cumulative as you go through the six cycles.

Same "rules" regarding exercise apply with chemotherapy from my experience.

From my experience and understanding Orgovyx has "advantages" over Lupron:

No flare

Faster to castration

Higher sustained castration rates while on it

Lower CV side effect profile.

A drawback may be the self discipline to take it every day, especially if one is dealing with psychological side effects of treatment.

Kevin

Clinical History

[Hawk56]

Here's one reference on ADT, fatigue and exercise, you can find others - urotoday.com/conference-hig...

[j-o-h-n]

To Adendino,

Refer to a post entitled "Terrified" in Advanced Prostate Cancer from 2 or 3 days ago. It may help with responses you're looking for.

Good Luck, Good Health and Good Humor.

j-o-h-n

[London441]

Since alternatives to systemic therapy are really not a good option at this point, lessening ADT side effects should be a priority. It need not be the miserable experience he’s having, but the solution requires a distinct life shift for most men.

How much does he exercise and what kind? Cardiovascular and weight bearing exercise is basically a must, and the change in energy and mood ranges from palpable to transformative. It would likely enable him to do and enjoy the work and speaking he clearly loves during an otherwise onerous and exhausting time of his life and career.

[RoseDoc]

From what you describe, triple therapy would be indicated. As for ADT drugs, discuss the concerns with his oncologist to determine the best combination.

[Mgtd]

Easy to say but most of us had to adjust to our new “normal lives” with ADT, etc. The alternative is not one most of us were willing to accept. He may need some professional help making this transition to his new life.

[Bellalana]

you might want to check out the website PCRI, prostrate cancer research institute. There you’ll find informative videos covering most aspects of prostrate cancer and its treatments by a Medical Oncologist, Dr Sholtz, with over 30 yrs experience. You can also contact the institute with questions and a volunteer (a survivor) will get back to you after having gotten the information from the doctor. I found it extremely helpful to have this complex disease explained in layman’s terms. Good luck.