Initial Diagnosis PCa Stage 4 Mets to Bone (Pelvis)

[6357axbz]

Age 68 at diagnosis July 2018, prostate biopsy showed 12 segments positive, Gleason=8, subsequent biopsy of pelvis bone positive. Stage 4 metastatic at original diagnosis probably attributed to no PSA test for several years. On degarelix 3 months then switched to Lupron 1 week ago and will continue, for convenience of multi month injection, if PSA continues to lower past current 2.xx (originally 8.xx at diagnosis). Scheduled for IMRT in early April as part of a trial. Am interested in hearing from folks with similar original diagnosis about their treatments and how long it’s been since diagnosis. Thank for your consideration.

[Tall_Allen]

Is this the trial at MD Anderson? Do they irradiate the whole pelvis with a boost to the bone met?

[6357axbz in reply to Tall_Allen]

Yes, the acronym is EXTEND

[6357axbz in reply to Tall_Allen]

The IMRT targets the prostate. I don’t believe it targets the entire pelvis. Half the group will receive additional targeted radiation to the bone Mets, in my case that would be the tumor in the pelvis bone.

[Tall_Allen in reply to 6357axbz]

Maybe you can request it.

[6357axbz in reply to Tall_Allen]

I thought I already sent this reply but it didn’t seem to post. I’ll try again:

I’ll ask but normally one gets randomized in trial with 50% getting the control therapy, in this case IMRT, and the other 50% getting the additional treatment (targeted zapping of bone met). At least the trial gets me the IMRT which isn’t the “standard of care” (ADT alone) for my cancer. The parent trial (see link below) shows significant survivability benefits with IMRT over ADT alone for some with “low metastatic load” Pc4, which I seem to be.

thelancet.com/journals/lanc...

[Tall_Allen in reply to 6357axbz]

Some features of treatment (like the field size) are sometimes left to the discretion of the treating physician.

[6357axbz in reply to Tall_Allen]

He did express great confidence in being able to completely eliminate that pelvic tumor so, hopefully, that’s the case.

[6357axbz in reply to 6357axbz]

He convinced me but that still leaves all those potential cancerous swimmers in your system (blood, lymph??) waiting to alight in some new location. However, that being the case it will take some time for any new bone Mets to grow to the point they become problematic to your QOL.

[6357axbz in reply to Tall_Allen]

For newly diagnosed mPCa are there clear pros/cons regarding RP versus radiation versus ADT alone? I have been told by one urological surgeon that no clear evidence exists saying which path is better for OS.

[Tall_Allen in reply to 6357axbz]

Well, in men who are not metastatic, brachy boost (whole pelvic external beam + brachytherapy boost to the prostate) does a better job than external beam radiation alone. And probably better than surgery. But surgery+ePLND and whole pelvic external beam alone are probably about equal.

In men who are already metastatic but only with 1-3 detectable metastases, like yourself, we know there is a survival advantage to radiation of the prostate, so there is probably also a survival advantage to surgical removal of the prostate, but we don't have confirmation of that yet. That's one of the things your clinical trial may tell us.

We have no idea yet if SBRT of individual bone mets affords any survival advantage for prostate cancer.

[6357axbz in reply to Tall_Allen]

Thanks TA

[6357axbz in reply to Tall_Allen]

TA,

Being new here I’m not aware of your situation. I think I saw somewhere you are a prostate cancer patient. I’d be interested in hearing about your situation and how you’re doing.

[Tall_Allen in reply to 6357axbz]

It's all in my profile. Click on my name.

[6357axbz in reply to Tall_Allen]

Thank-you again TA.

If I understand correctly the ARCHES trial shows very positive results for mHSPC patients, like me, by adding Xtandi my ADT. That being the case I need to look into the cost based on my Medicare and supplemental insurance.

[Tall_Allen in reply to 6357axbz]

Because abiraterone is now available as a generic and Xtandi isn't, I'm pretty sure that your co-pays on abiraterone will be lower.

[6357axbz in reply to Tall_Allen]

Are they comparable? I googled into some controversy about that.

[Tall_Allen in reply to 6357axbz]

In terms of quality of life, Zytiga was better than Xtandi in these randomized trials:

europeanurology.com/article...

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

These non-randomized studies suggest that Xtandi may be more effective than Zytiga, perhaps not so much on overall survival but on progression-free survival:

onlinelibrary.wiley.com/doi...

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

When one fails, the patient usually tries the other (perhaps not for very long) and it doesn't seem to matter much which one tries first. There is an arm of the STAMPEDE trial that will randomly compare the two.

[6357axbz in reply to Tall_Allen]

Would Zytiga need to be used with prednisone?

[Tall_Allen in reply to 6357axbz]

Yes but only enough to replace what the Zytiga takes away.

[6357axbz in reply to Tall_Allen]

Given the very positive results from the ARCHES trial I would elect to begin that immediately before my cancer goes hormone in-sensitive. I don’t think Xtandi is the current standard of care for mHSPc. Can a doctor override that thus allowing a patient to get the $ benefits associated with “standard of care” treatment?

[Tall_Allen in reply to 6357axbz]

It depends on your insurance company. They usually won't approve a more expensive drug that is not yet FDA approved for that indication. Because it has not yet proved any increase in overall survival (only radiographic progression-free survival), it is unknown whether the FDA will approve the new indication or ask for more data.

[6357axbz in reply to Tall_Allen]

Hmmmm

“...met the primary endpoint by significantly reducing the risk of radiographic progression or death by 61% versus ADT alone ...”

If my risk of death is reduced does that not mean my OS Is improved?

Thanks again for your generosity with your time TA

[Tall_Allen in reply to 6357axbz]

No - you are misinterpreting that. They included those few men (84 out of 1150 men - about 7%) who died during the brief follow-up period (24 weeks from end of treatment) in with those who had radiographic progression, which was a much larger number (about 16% of men taking Xtandi and about 34% of men taking placebo) .

So - there were 572 men who got Xtandi+ADT and 574 men who got placebo+ADT. Median follow up was only 14.4 months. There were only 84 total deaths so far - roughly 38 deaths in the Xtandi arm and 46 deaths in the placebo arm - the difference is not statistically significant. (So if they had to judge survival benefit now - they would say it did not have a benefit.) There are only 25% of the required number of deaths (342) to evaluate this. With longer follow-up they will be able to determine if it had any effect on survival.

All they can prove right now is that it did have an effect on radiographic progression, which they defined as the detection of 2 or more new mets on a bone scan/CT within 24 weeks.

[6357axbz in reply to Tall_Allen]

Got it. Thanks for the clarification.

[6357axbz in reply to Tall_Allen]

What’s your opinion on this study as it impact OS:

renalandurologynews.com/pro...

[Tall_Allen in reply to 6357axbz]

Unfortunately, all of the studies on metformin so far have been only observational like that one. The following study at least made an attempt to correct for some of the confounding variables:

academic.oup.com/ije/advanc...

There was a small randomized clinical trial of metformin in men with mCRPC taking Zytiga - it found no effect:

clinical-genitourinary-canc...

[6357axbz in reply to Tall_Allen]

Back to ARCHES trial it seems that the relative lack of radiographic progression due to Xtandi is positive if it persists over the long haul. Isn’t death from this cancer typically preceeded by radiographic progression?

[Tall_Allen in reply to 6357axbz]

Well, it is often a step along the way. But it is also entirely possible that the delay in radiographic progression in the short run is made up for later. It is also possible to have no delay in radiographic progression but an increase in overall survival, as with Provenge.

[6357axbz in reply to Tall_Allen]

Thanks. Now I’ve got Provenge to research.

[Crabcrushe in reply to 6357axbz]

I start Provenge on Fri and would be glad to log everything for you. As of now I'll stay with Leupron\Xtandi throughout the treatment. Might mess with diet and OH a leeetle bit, but my PSA's most likely around 4-something and in the process of doubling. (I plan to ignore PSA 'til I feel like it; probably around October.

[Crabcrushe in reply to Crabcrushe]

"PH", not "OH"- GOTTA retrieve my laptop.

[6357axbz in reply to Crabcrushe]

Thanks for your response. I hope you do well with the Provenge.

[6357axbz in reply to Tall_Allen]

This is response from my MDA urological oncologist when I asked him about adding other drugs, like Xtandi to my mHSPC regime:

Combined treatments with chemo (Taxotere), Xtandi, or Zytiga, can be more toxic (especially with chemo and Xtandi), and are generally reserved for patients who are more threatened (have more cancer than he does) and given within 3 months of ADT.

He may be better served by our combined treatment protocol (DYNAMO) using Zytiga as soon as the PSA increases on ADT.

Any thoughts?

[Tall_Allen in reply to 6357axbz]

Combining treatments is a whole other discussion.