PSA on the rise after RP, ADT and SRT: next step?

Need to determine what to do next . Do nothing and wait for mets? Try ADT again? Look for clinical trial with immunotherapy? I have no Cancer symptoms and none has been located. But PSA is rising quickly despite Avodart ( see signature). I hated Lupron. Is there a better type of ADT?
Any suggestions?
Bob

Bob,

My husband is now on Degarelix second round with little SE.
He had been on Lupron with bad SE.

By the way how were you able to get your signature so expanded?

BOOGEE

Avodart has proved to be useless in cases like yours. Drugs like Lupron or Firmagon are effective, but I doubt you'll like any of them. You might like better taking high dose Casodex, which has its own SE profile.There aren't a hell of a lot of recruiting clinical trials right now for men who are non-metastatic and hormone sensitive with recurrences. There's a couple of clinical trial of hormonal agents you might qualify for, but the SEs are likely to be worse. I don't know of any currently open clinical trials of immune therapies for those who are still hormone sensitive.

Xtandi + Lupron

ARN-509

- Allen

You should be seeing a medical oncologist now. A MO can guide you through HT vacations

Mel

I agree with Compiler, it's past time to see a Medical Oncologist..Urologists tend to work outside their job descriptions a little too long..

It's a lot easier to keep the cat in the bag than to let him out and try to catch him and put him back in the bag.....

68Ga-psma scan https://clinicaltrials.gov/ct2/show/NCT02282137 Looks like you were too early on the C-11 scan. PSA needs to be higher. The 68Ga psma Pet scan might be better. C-11 acetate is more sensitive than choline. Most Uros won't start ADT till PSA reaches 4 and some are higher. The only way I can think to stay of ADT is find it and kill it.

What I'm saying is that Avodart has no demonstrated benefit at all as part of the hormone therapy for men with recurrent PC. There were two important randomized clinical trials (RCT) in the last few months that put the "nail in the coffin."

In the AVIAS trial, men with recurrent PC on intermittent ADT did not benefit from the addition of dutasteride to the combination of a GnRH agonist and Casodex (Avodart was continued throughout). Klotz speculates that continuous dutasteride may be exerting selective pressure on the cancer to become DHT resistant sooner. They had planned a larger trial but stopped it for futility.

Effect of dutasteride in men receiving intermittent androgen ablation therapy: The AVIAS trial

The other RCT was among men with non-metastatic CRPC. They all got a GnRH agonist (e.g., Lupron) and Casodex, but some got Avodart too (the rest got a double-blinded placebo). There were no significant differences in the time to disease progression.

A randomised, double-blind study comparing the addition of bicalutamide with or without dutasteride to GnRH analogue therapy in men with non-metastatic castrate-resistant prostate cancer.

- Allen

Bob-
This is all fairly new info - it's easier for me to stay up to date than for most Uros who have a full patient load. I should also say that for any study, there will always be exceptions. The study tells us what happened across the population but can't predict for a specific individual. It can provide a "best guess."

I echo what others said about finding a good MO now. You have exhausted your traditional surgical and radiation curative treatment options, and you're ready to begin lifelong management of the disease. That's what MOs specialize in.

There is no hard and fast relationship between detectable mets and castrate resistance. Men can become CRPC with or without detectable mets. They can also be HSPC with or without detectable mets. PC is a very heterogeneous disease, so there's no single standard natural history of progression.

There are some very complex mathematical models that may some day be able to find an optimal individualized iADT treatment schedule. Until then, some doctors do the treatment schedules based on arbitrary PSA thresholds, some use time, some project from previous cycles, a lot just use judgment.

- Allen

David:

Does Dr. Dat. also do SBRT for such cases?

Mel

Mel: I don't believe so, when I went to Sarasota SBRT was just a twinkle in the eye of most of the Rad Docs. ( just kidding but it wasn't very well known at the time.) Dattoli does something he calls D.A.R.T. you can go to his website to get the true skinny on it.

David

Although I don't know any medical oncologists in South Carolina I can recommend, I am very impressed by Emmanuel Antonarakis at Johns Hopkins. He is one of the top researchers in the world, and the medical oncology breakthroughs coming out of Johns Hopkins in the last few years have been very impressive. An interesting contrast is with Snuffy Myers in Virginia (who does not accept insurance). I think they are both excellent, but they couldn't be more different. I think the contrast illustrates how to choose an MO - it's not them, it's you.

Snuffy Myers is a maverick. He will go for therapies at just the first hint that they might be useful. Some will work out, some won't. If it doesn't, he'll try something else. He comes across with very strong convictions about what will work and what won't and even puts himself in videos. So if you see yourself as a risk taker, and you want a take-charge kind of doctor, someone like that might be your cup of tea.

Antonarakis is a great medical researcher. He has loads of clinical trials going, and they are well designed. He is also a stickler for research - he won't advocate anything that hasn't passed the rigorous hurdles. So if you see yourself as someone who takes an approach only when there is solid evidence for it, someone like him may be better.

The other aspect you have to gain by self examination is how you like to work with doctors. If you want a "paternalistic" doctor - one who will tell you with assurance that THIS is the right way to go, you have to find a doctor who likes to operate that way. But if you prefer that the doctor present you with alternatives and objectively describes their risk and benefits, and then leaves the decisions up to you, you will want a different kind of doctor. Do you personalities match? What's his ego like? Does he listen to you? What's his communication style - does he talk over your head or talk down to you? Will he respond to emails? ou can also ask if there are any patients you can talk to.

In general (there are some notable exceptions), the best MOs are at tertiary care facilities. Their resumes are often online. Look for ones with specialties in urologic oncology. Check their publications they've written (you can do a pubmed search)- do they write about prostate cancer in particular? Also, you can check Google Scholar to see if his studies are often referenced.

Another approach is to have two oncologists. One who you maybe visit only occasionally or have a telephone consult with, and a local guy who gives you the shots, monitors you, but basically follows the plan laid out by the consulting oncologist. Someone in my support group uses Oliver Sartor in New Orleans that way because he is one of the few experts in the rare kind of PC he has.

You have several important tertiary care facilities within a few hours drive - Duke, Wake Forest, UF Shands, Emory, etc. You may want to start there.

- Allen

I'm thinking that I should let my psa rise then get another type of pet scan as indicated above to see if I can isolate the mets. I'm intrigued by David's experience with Dattoli.

Meanwhile I've contacted Johns Hopkins and a local MO for a discussion.

By the way, if I am stage pt3b with the pathology shown in my signature does that mean that I had mets at the time of RP because the prostate had been breached? Or are mets defined as pca beyond the pelvic region? I ask because studies show much longer survival for guys with no mets at RP or RT as original treatment.

Bob

Allen
Actually pt3b in my case meant SVI. Ten nodes were removed all benign.
Bob