At treatment crossroads having had docetaxel,abiraterone and cabazitaxel

[15Golfer]

I live in England and so far have been treated on the NHS. I was diagnosed 3 years ago at the age of 70 and apart from the cancer I am generally quite fit and play golf, go walking and enjoy gardening. Apart from some occasional tenderness when sitting down I am lucky not to have any pain. I am once again at a treatment crossroads, so any ideas or insights are welcome. I do not have any issues with the treatment I have received so far but have not ruled out a private consultation if there appear to be worthwhile treatments unavailable on the NHS.

March 2022 Biopsy & CT Scan, PSA 154 , Gleason 4+5 = 9, widespread bone metastases - Spine -L2, T7, rt.acetabulum, rt.ischium, pubic ramus & sacrum; lymphadenopathy but no visceral disease.

Hormone therapy is the backbone of treatment - initially 10 weeks bicalutamide, then quarterly Prostap ( Leuprorelin ) injections for life. PSA down to 40 after end of bicalutamide tablets.

Started Docetaxel ( Taxotere ) with prednisolone in late June 2022, 6 cycles to October 2022 when stopped both; PSA down to 0.6, and continued to decline for another 6 months when got to its lowest at 0.3.

PSA started rising again by August 2023; CT & Nuclear Medical bone scans showed no disease progression then, and lymph nodes had shrunk, but a further CT scan in December 2023 showed a new lesion in pubic bone and some soft tissue thickening.

By end January 2024 PSA was up to 38, and started Abiraterone ( Zytiga ) with prednisolone.The lowest that PSA came down to was 8.2 I stayed on abiraterone for 8 months until PSA started rising again, but kept taking prednisolone. CT & NM scans in August 2024 showed some additional pelvic tumours and one under left armpit.

Started Cabazitaxel ( Jevtana ) ( 75% dose ) with prednisolone in October 2024 and have recently completed 8 cycles. Lowest PSA got down to was 16.5 in December 2024, and PSA now up to 34. Cabazitaxel stopped but now taking daily dexamethazone steroid instead of prednisolone.

( A BRCA test on the prostate samples was negative, so Olaparib was not an option ).

My Oncologist is looking at what clinical trials may be available for me, and has also said that I could have Radium 223 ( Xofigo ) if I started getting bone pain.

Some specific questions I have:-

I have been told that you either have Abiraterone ( Jevtana ) or Enzalutamide ( Xtandi ). I am not clear if this is because if one drug stops working then the other is unlikely to work, or whether it is an NHS funding issue. Does anyone know, or has anyone had enzalutamide after abiraterone ?

Having just reviewed my treatment history, docetaxel seems to have been the most effective, but this may just have been because it was one of the early ones. Is re-treatment with docetaxel a viable option?

I like the idea of a radioligand treatment which targets cancer cells rather than healthy cells and I wonder why radium 223 ( Xofigo ) is only offered if you have pain - if it is effective then why not use it ? - perhaps an NHS funding issue. ( Having seen some of the posts on this website about Lutetium 177 ( Pluvicto ), I am not sure that that would be a good option for me ).

Many thanks in advance to anyone who takes the time to read all this and reply!

[Tall_Allen]

Bone pain was indicted for Xofigo only because they wanted success in the trial. Docetxel often prevents bone pain. So if you tell your oncologist you have pain, you should be able to get it.

[15Golfer in reply to Tall_Allen]

That did occur to me!

[15Golfer in reply to Tall_Allen]

Thanks - not sure I fully understand - are you saying that the trial showed that Xofigo was successful in reducing bone pain, but that its success in killing off cancer cells was not tested?

[Tall_Allen in reply to 15Golfer]

No - I'm saying that you may have avoided bone pain because of the docetaxel.

[15Golfer in reply to Tall_Allen]

Ok, thanks.

[Newtonmore]

Hi

It says in PCUK information on its website that Enzalutamide often doesn’t work for those who have already had Abiraterone. I presume it means for those who Abi has stopped working

I’m not reading the site currently but it is in the information sheet on Hormone Therapy section New Generation

[15Golfer in reply to Newtonmore]

Thanks I'll check that out.

[lcfcpolo]

Hi. UK as well here. You can pay for a second opinion at The Royal Marsden in London if you search their website. They might have some more thoughts on trials and sequencing.

I've read of some on this site who have switched ok from Abiraterone (Zytiga) to Enzalutamide (Xtandi) so it's worth asking your oncologist on this.

Actinium treatment does seem to be more effective when you read anecdotal accounts on here when compared to Pluvicto. I think the Royal Marsden might even be trialing it. It is available overseas though, Germany are the pioneers but it's also available in India, Turkey. If you search this site. A form of Actinium, J591, seems to be available in Australia.

Finally, can you ask your oncologist if they can test for any mutations such as BRCA2 but also others like msh I. If present then this might open immunotherapy options.

[15Golfer in reply to lcfcpolo]

Thanks. I don't have the brca2 mutation; not heard of the msh1 one - I'll look it up. I'll enquire further about enzalutamide, and look into the Royal Marsden.

[lcfcpolo in reply to 15Golfer]

MSI-H is the correct way to write it I think, sorry for my error. It's an I not a one. It opens up Pembrolizumab. Good luck with everything mate.

[15Golfer in reply to lcfcpolo]

Thanks - funny old "journey" - when I was diagnosed 3 years ago I imagined I would soon be in a wheelchair, but being on steroids with the chemotherapy improved my golf ( temporarily! )

[Mgtd in reply to 15Golfer]

Hope you got to watch the Masters. Amazing finish!

That is one beautiful course!

[15Golfer in reply to Mgtd]

Yes, I was pleased for Rory but felt sorry for Justin Rose coming second again - perhaps his turn next year!

[Mgtd in reply to 15Golfer]

Agree that was a tough one in deciding who to support on that play off. Both deserved it and a good case could be made for either golfer.

A lot of emotion between them. I imagine from the reaction of his wife with Rory they maybe more then just golfing buddies.

[Newtonmore]

also

If you have become “castrate resistant” I think the other options may be apalutamide and or duralutamide. Check spelling etc.,

[15Golfer in reply to Newtonmore]

Thanks

[Chubby42]

Hi 15 Golfer

From what I've read if you have Abiraterone first you still may get some use out of Enzalutamide but not if you have had it the other way around.

Because of the NHS once you have had one you cannot have the other unless you go private and pay for it yourself.

I think some people on here have been able to purchase Enzalutamide much cheaper from India.

Cheers

Good luck

From the sunny Cotswolds.

[15Golfer in reply to Chubby42]

Thanks - does seem to be worth looking at enzalutamide ( or one of the other ...amides) further

[Conlig1940]

15Golfer Have you researched SBRT . Typically 5 Fractions but they are doing 2 and 3 Fractions with similar results . Refer to the " TOFFEE Study ".

85 years old was playing off a 6 handicap at age 82 . PGA West , La. Quinta, California .Golf came to a screaming halt after a Dupuytrens Contracture , Vikings disease surgery . I can no longer make a fist and hold a golfclub .

[vintage42 in reply to Conlig1940]

I had two surgeries on a little finger, several years apart. It looks and works fine, makes a fist and splays flat on a table. Except for guitar fretting, where it curls under the hand and won't stretch out over the fretboard.

[15Golfer in reply to Conlig1940]

Thanks for the reply - you clearly played golf at a higher standard than me; very sorry to hear about your hand problem. A common topic of conversation at my golf club is recommendations for orthopaedic surgeons!

[Conlig1940 in reply to 15Golfer]

15Golfer Yes I played at a high level but not like my father . He had 6 brothers - the highest handicap ( all seven ) was 3 - My father played off + 4 . Shot 7 under par at ae 64 on a course 7310 yards long . My 2 sons are scratch plus players .

[15Golfer in reply to Conlig1940]

Impressive!

[vintage42]

"... has anyone had enzalutamide after abiraterone ?"

So enzalutamide is Xtandi and abiratone is Zytiga. It appears to be an option, even after your chemo, (Cabitzitaxel), based on all this (too much info):

--

When Zytiga stops working.

Alperk: RO will radiate but suggests change from Zytiga to Xtandi. I am playing whack-a-mole but want to stay on Zytiga as long as possible because Xtandi will also eventually fail and the next step is not so good.

GP24: Xtandi will work for a few months only after Zytiga.

Tall_Allen: You might get more mileage out of Zytiga by switching from prednisone to dexamethasone, and by killing off those resistant tumors with SBRT.

healthunlocked.com/advanced...

--

Go from Abiraterone to ARPI Xtandi

Conclusion: Based on the results of the current studies, abiraterone followed by enzalutamide treatment is the best sequential treatment for most docetaxel-naïve patients. This treatment achieves not only good OS, but also PFS and PSA response rates. In addition, for patients who have previously failed docetaxel treatment, enzalutamide is the best choice as the subsequent treatment.

ncbi.nlm.nih.gov/pmc/articl...

--

Go from Abiraterone to ARPI Erleada

If you want to switch to a different ARPI after Abiraterone, I would not switch to Enzalutamide (Xtandi) but to Apalutamide (Erleada) per aacrjournals.org/clincancer...

GP24 in HealthUnlocked

healthunlocked.com/advanced...

--

GP24: Most doctors switch to Enzalutamide when Abiraterone fails… After Abiraterone fails Enzalutamide will work for two to three months… Enzalutamide will not work for long and then a chemo is indicated.

Tall_Allen: Discuss using it together with docetaxel as in the PRESIDE trial: prostatecancer.news/2022/10...

healthunlocked.com/advanced...

[15Golfer in reply to vintage42]

Thanks for these links - all useful information.

[j-o-h-n]

Ahhhh Honey, I sure do miss my one in holes.....

Good Luck, Good Health and Good Humor.

j-o-h-n

[dk73]

My hubby did taxotere after surgery/radiation. It held PSA down to zero for 16 months, then it started doubling each month. Was put on zytega, 4 tabs plus prednisone. Worked about 15 months. Moved on to Xtandi. Did not lower the PSA. Went back to taxotere, 10 rounds. PSA went to .8 but he got covid so didn’t do #10. PSA rose up to 27: he started pluvicto. After 4 rounds, scan showed major bone spread: skull to femurs. PSA had climbed to 235. He started Jevtana chemo with prednisone every 21 days indefinitely until it cannot keep the PSA stable, then will go on hospice. But he endured 2.5 months of battling radiation cystitis last fall and PSA rose to over 700. He returned to Jevtana in December and PSA now 350. He does eligard shots every 6 months, zometa every 3 months. Started this journey in late 2016. So far no bone pain just fatigue