Quantitative Total Bone Imaging in Prostate Cancer: Novel Technology, and a Promising Biomarker – Thought-provoking study provides hypothesis-generating data by Kriti Mittal MD, MS, FACP June 23, 2021
This is an example of doctors using the newly approved 18F-Sodium Fluoride PET/CT to help tailor treatments based on individual patient responses, in this case, that of Enzalutamide. From the interview with Dr Lui linked in the article:
"While much of drug development is focused on gaining new approvals for novel agents or combinations, we were interested in optimizing use of existing agents to increase benefit for patients now. Just as not all patients respond the same to a treatment, not all lesions within an individual will respond similarly, and eventually, non-responding lesions will result in clinical progression."
"This has led us to identify that what drives outcome in a non-curative, non-palliative setting is not treatment response, but rather treatment resistance, and minimizing resistance may be a better strategy to prolong benefit in patients with cancer."
The Interview is here:
Glenn Lui, MD, on Variations in mCRPC Response to Enzalutamide
– Spatial-temporal information can better guide next treatment decisions
by Jeff Minerd , Contributing Writer, MedPage Today June 23, 2021
The Study Abstract is here with full paper also available as PDF download:
Exploring Spatial-Temporal Changes in 18F-Sodium Fluoride PET/CT and CTCs in Metastatic Castration-Resistant Prostate Cancer Treated With Enzalutamide – An ASCO Reading Room selection - Journal of Clinical Oncology - June 23, 2021
An incremental step towards the personalized medicine we all want and need. It also recognizes the importance of disease resistance in developing treatment strategies. Stay Safe & Be Well - K9
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cujoe
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This is a great find and post.... The fact that people may still be benefiting at the time of failure of enzalutamide, and the possibility to use SBRT or some radiation to treat resistant lesions and continue the medication is good news.
The Take Home Message-- For those failing a treatment, hitting lesions with an increasing SUV and growth can potentially allow a patient to continue their current med regimen and not have to move on to another drug/treatment. Slowing down the rate at which drugs are discarded for failure will add YEARS to treatment protocol.
In my opinion, hitting resistant lesions as early as possible also delays the spread of resistance through mRNA signaling passed between tumor sites.
Folks, if you started out with a bunch of mets, and now have only ONE met, then maybe the answer is to use SBRT and see what happens to to your PSA and scan over 3 months. ALL IMHO !!!
NP - I seem to remember that you have been a proponent of SBRT for quite some time. (Against contrary opinions but some "others"?) Looks like a small study proof of concept in action. Now, if we can get quick access to 18F PET/CTs, we can maybe keep the mCRPC beast at bay - while we wait for the silver bullet.
Thanks... One of the philosophies that Nalakrats and I share is that hitting it hard early delays resistance caused by mRNA information exchange--taking out the mothership...
In my case and Josh's, we took out the mothership and the secondary mothership... I believe this has long term benefits adding years and likely delaying castrate resistance..
As for those "contrary opinions" by "some others" about SBRT, the ORIOLE and STOMP trials pretty much laid those issues to rest in my favor. I eagerly await RAVENS-early SBRT plus Xofigo for micromets in Oligometastatic patients, and SABR COMET 10. Will RAVENS result in some percentage of cures-say 40% I am guessing?? I believe so.. STOMP had about 30% ADT free survival off the top of my head at 5 years...
The 18F-DCFPyL scans are supposed to be available nationwide by years end... better scanning improves treatment decisions and outcomes.
This article is very pertinent and timely for us. My only concern is, that perhaps serious consideration in Ron's case, should be given to reviewing Lupron ('current med regime') as the ongoing addition to the SBRT, that is of course, if SBRT is the treatment offered to Ron next month.
Although, at first blush Lupron seems to have done the trick for him... resolving most previous bone and lymph node metastases, an upward trend in monthly PSA, including the most recent x 6 and an SUV of 57 on remaining met, indicate as the latest PSMA clearly confirms and as noted in the article... "not all lesions within an individual will respond similarly, and eventually, non-responding lesions will will result in clinical progression".
Guess the bottom line for me, as I have thought for some time is that Lupron... or at least Lupron alone... is no longer the best ADT in this situation.
Think you probably would agree that now there might be some better options.
Exactly....I think SBRT to the rapidly progressing one met.... then the experts need to decide whether to start Erleada or Nubeqa with Lupron followed by Lu-177 or the reverse... That would be my choice....I think finding something effective for Ron with the least SE is so important for QOL.
Thanks Dave, your well informed and wise advice is always appreciated and valued. Thanks for keeping across all the science and developments in this space and prompting me to check out what is relevant.
Hi Marnie, It was good to read that Dave agreed with what we discussed re SBRT. He also suggests adding a 2nd line treatment with either Erleada or Nubeqa but it may have to be Zytiga + Pred or Enzalutamide, as neither of the former are available on the PBS in Australia. The cost of either would be in the range of $3500 + / month ongoing. Lu 177 is , of course, available at a cost of about $10 000 / treatment and as I said for mCRPC can be had with Veyonda at Genesis Care on compassionate grounds. All worth discussing with your RO and MO. Very best, Gail
Yes Gail, what Dave considered might be a good option fitted very neatly with what you suggested might be the way forward. I'm not very familiar with the medication costs except for Lu 177 so that information has been helpful both in this response from you and what you've told me previously.
Knowing what's PBS funded is a bonus as no doubt the day might come when the $$'s are needed for Lu 177. Dave wasn't sure if Veyonda is available in Australia but I know you've told me previously it is...I'd just forgotten to tell him.
I feel very fortunate in having the benefit of your superb research skills, knowledge and understanding of the complex situation here coupled with the scientific input and support from Dave. What a combination! I'm very thankful.
Although, as you will have heard, a lot of Sydney Metro is in 'lockdown'...(but we won't call it that as Gladys doesn't like that word)... fortunately the North Shore has been spared so it doesn't affect us except for the mask wearing, limitations on visitors and unnecessary travel. It is 'hinted' that the whole of Greater Sydney could be in lockdown sometime next week.
Paddy's had to cancel his trip to your part of the world to catch up with his school friend as he lives in a 'hot spot' and he'd have to quarantine but needs to be back for Uni and work.
Enjoy you weekend....and thank you for all the invaluable advice you share so willingly.
Thanks K9 for this great post. As mentioned to Dave couldn't have come at a better time and very relevant. Appreciate all the time you take to research and share. Most appreciated.
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