Newly diagnosed, Gleason 9, PSA about 40 at biopsy, aggressive, PET shows low burden, two bone mets. At my age 82, although health "very good", Onc wants to avoid chemo. Just started on Casodex and will add Lupron, until PSA under control then add (switch to?) Zytiga and radiation to clean up prostate and bone. Second meeting with Onc in a few weeks
Is this too cautious?.
There is no aggressive, curative treatment for you. The therapy will prolong survival which it will for many years.
You can get your prostate radiated now and maybe the bone mets too. This in combination with ADT and Bicalutamide. After the radiation you can add Zytiga. Because of your age, I would not add chemo to all that. You may not be in good health after it.
Triplet therapy (ADT+ Zytiga/Nubeqa+ docetaxel) is certainly a good path for those with high volume of metastases. The benefit is probable, but less certain (it will take a few more years for the data to mature), for those with low volume of metastases.
I don't think that chemo should always be rejected in healthy older men, and it is always better to use it sooner instead of later. That said, the doublet (ADT+Zytiga) and debulking the prostate with SBRT should work for a while. It is really your choice.
Good point. I've read that the most aggressive first treatment results in the longest result, and I'll probably be weaker to Chemo after first round. Is there a least- worse- symptomatic Chemo to add to the doublet?
Only docetaxel is used.
Is there an ability to moderate docetaxel dosage and still get efficacy? Or is it a standard dose that is rarely/never strayed from, for approved SOC reasons?
They originally tested 70 mg/m2 every 3 weeks vs 30 mg/m2 every week. The lower, weekly dose was non-significantly different from Mitoxantrone. The benefit of the full dose in older men has been documented:
Zytiga is highly effective and has one of the longest median overall survival in metastatic PC, particularly in low volume metastatic cancer.
This therapy is usually well tolerated if the edema, hypertension and hypokalemia which may cause is well controlled by prednisone and or eplerenone. Some patients may have increased liver enzymes which could be controlled by adjusting the dose.
These are some links about these therapies:
cancertreatmentreviews.com/...
Lupron & Zytiga, or triplet per TA post, may be all you need unless your bone mets are painful. In considering radiation, be sure you have an objective clearer than to "clean up prostate and bone".
I can only add my brother’s personal experience to this. He is not newly diagnosed; he was originally diagnosed in 2007, but has been Stage IV since 2009, so obviously not a highly aggressive cancer as he has managed well with ADT, Zytiga, Xtandi, Xofigo. By late spring this year, his PSA was rising, so his MO started him on docetaxel. He is 81, will be 82 in December. He did have a reduced dose, 75%, but he tolerated it very well. He is not as active as he should be, has a pacemaker, but no other significant health issues. He is now eligible for Pluvicto, and has been referred to be evaluated for that.
Best of luck to you on your journey.
You could obtain a second opinion from an oncologist specializing in prostate cancer.
From what I have been reading on UroToday, the plan proposed to you is one supported by many experts who have analyzed the newest clinical studies; however, as you can see from the other comments, others believe in adding chemo early, even in low volume.
Thanks to everyone for putting this in perspective for me. An update. My PSA has just tested at about 11, the 42 was an error, my fault. More important, I'm now to consult a radiologist to see if treating the primary source is an option, to remove that uncertainty early on. Plus genetic testing to follow that route if appropriate. If both are negative, I'll explore chemo option again. That should happen in a few weeks
Doesnt sound cautious. Chemo will make you sick he apparently feels.
Your plan is a good one, Wgly. Yes, pursue the RT to prostate and bone Mets as well. ADT ply’s Zytiga. Adding the chemo in Low volume setting has not yet been shown to improve outcome, only in high volume. So that is more a personal choice and your tolerance for it vs. uncertain additional benefit.
I've thought about this a bit more. I crushed a vetebrae two+ years ago and the response was "we don't do that surgery at your age, because the adjacent ones will break next". I then had a bone density test that showed a -1 (normal) and also argued after several months that the spine hadn't healed itself and was shifting when I lay down, so I feared a trauma may injure the spinal cord. They decided to do it and declare it successful
When I was told out of the gate that Chemo was out of the question, I immediately thought "agism again", but went along to see and evaluate the proposed treatment, which as some say, is appropriate, The problem is that excluding it forever cuts out what may be better options. And some people have ADT treatment failure or entirely treatment-stopping reactions.
When I do the Geriatric 8 question exam for potential health problems I score 16 out of 17. My PCP says I'm in very good health. In one of the online presentations on G8 is a chart that shows for the top quartile at 80 y.o., the life expectancy is about 4 years more than the mid 50%, and would be more if the low 25% was included. Scaling and taking that to the SSA actuarial tables shows my health age to 77-78. My wife who once did geriatric nursing, without seing this, said I'm as healthy as a 75 yo.
Not arguing that chemo drugs would or would not be worse for me, but are there "chemo" type drugs with about the same level and risk of debilitation? New stuff like Lu-177 and Immune drugs seem to require failure by both ADT and Chemo. I need to look online for advanced treatments for newly diagnosed, aggressive, low load, met. I think I saw some. Trying to work up a realistic basis for a second opinion without alienating my current Dr or deluding myself.
To me, no replies strongly indicate the group thinks earlier replies are complete and sufficient, which is very useful. I've also found out more about this, so I think I'll ask my MO the following
- No Chemotherapy means I will be ineligible for options that require both ADT and Chemo failure. Is the downside of Chemo worth this loss? Given my natural life expectancy - if I can do another 5-10 yrs, should should cover that loss? I may be able to withstand triplet side effects if it used as first treament. Is triplet therapy potentially that much better?
- Looking at Drugs.com, the side effects of using Lupron is long and it appears elsewhere that Firmagon is or may be better with much fewer side effects. Can it be a substitute?
- I see the maintainance drug Zytiga is twice as effective if used intermittently, between the start PSI and stopping just below 50%, letting it return to start and repeating, is this an option?
- Can Zytiga be substituted for Lupron?
I'm looking for agressive treatment. (I think)
4th opinion Central Fl 
Input and opinions welcome
Renal failure 2nd opinions?
Radiotherapy clinical trial opinions
Advice and Opinions would be great.
