Post DaVinci, Post Salvage, PSA 1.82

Hi All!

Would love to hear your thoughts on a go-forward strategy in advance of my oncology visit this afternoon.

I have searched this site and couldn't find posts similar to this.

I suspect we will discuss ADT and body scans to identify any metastatic disease.

Concerning ADT, there seems to be inconsistent views on when to start, early or late and even more confusion about what statistical parameters define what is early or late. That is, does the PSA level, or PSA doubling rate define early or late.

I currently lead a fairly active life style (particularly tennis) and ADT would seemingly bring that to an end based on what I have read.

Thanks all!

Allen,

I will do research on the imaging options you site and compare those that are offered locally. I am in the Eugene (OR) area and never considered OSHU as an option. I shall do that, as well.

I had my DaVinci done as UCSF by Peter Carroll.

I will research the drug suggestions you made - if I run into a snag over in finding them the next week I may ask you for an assist.

Thanks!

Gary

Gary,
I have nothing useful to add to what has been said. But, may I ask, if you know:
What was you 1st post op PSA, and/or what was the low point you finally reached aka the nadir? Also, was your Gleason a 7?
Bill

The treatments available for treating advanced PC are changing everyday! Your Oncologist really has to stay on top of things to guide you properly...ADT is no fun but you can live with it as long as you aggressively limit any weight gain..It's hard to play tennis if you pack on 20 or 30 pounds....

Thanks OP,
I will check that out. Sounds like a great event!
Good luck to you too and just be careful jumping the net.

Both C-11 PETs are very similar. Kwon, of course, thinks Choline is better, Almeida advocates Acetate. There has never been a randomized direct comparison, but here is an indirect analysis:

18F-Choline, 11C-choline and 11C-acetate PET/CT: comparative analysis for imaging prostate cancer patients

A big issue is paying for it. Mayo says that most Medicare plans will pay for it at his clinic, but check with your plan first. Most insurance plans will not cover either, in my experience - get pre-approval!

The newer PSMA PETs in clinical trials are probably more accurate, and, may be covered by the clinical trial - I think that's the best option.

- Allen

Thanks Tall Allen and logoslidat.

I met with my oncologist this afternoon, after my post above and he reported my current PSA at 2.82. That implies a doubling rate of 12.5 months, the previous doubling rate was 15.6. Taking another PSA test in one month.

He too said next step is a scan. He indicated that 11C-acetate was preferred over the 18F-choline, even though the 18F-choline is available here in Oregon. So I told him that I would get into UCLA to have that done.

I asked if based on the results of the scan, radiation was indicated if there was sufficient technology local to do the radiation local, since if the mets were small the radiation would have to be precise. He said that there was the correct equipment local to do so, if warranted.

Concerning the PSMA PETs, I need to read that link. Wondering if after I do so I would conclude I would be compelled to try to get into the trial, in lieu of UCLA.

Yes, even with HT one has to get out there and exercise.

Great forum and wow, appreciate your comments!!

In fact, there's been a lot of new information and new clinical trials since you began this thread.

Having looked at the aggregated data on oligometastatic treatment, I am not as sanguine about the prospects of a cure as I once was. For men with 5 or fewer mets, only 15 % of men who had the SBRT treatment were in remission 5 years later, and the trend was downhill. If they couldn't find any mets with a C-11 PET at a PSA>2 and rising, it's likely that the cancer is micrometastatic and systemic, and zapping even small mets with SBRT isn't really likely to do much good.

However, if you want to do more imaging, I'd recommend the following clinical trial at Stanford. Because it uses a PET/MRI and not a PET/CT it should be able to detect even smaller mets. It also uses a bombesin-receptor antagonist, which theoretically should detect mets that may not show up on metabolic (choline, acetate or NaF) scans.

68Ga-RM2 PET/MRI in Biochemically Recurrent Prostate Cancer

At any rate, it's an NCI study, so costs should be covered. If they find some mets, and they are in a safe place to zap with 1-3 SBRT treatments (Stanford can do it, or you can do it locally), it seems there is little to lose in pursuing that avenue. You can take short-term hormone therapy with the radiation in the hopes of augmenting it. Because it's short term, there's no need to prevent bone loss with Zometa or Xgeva.

If 5 or more mets are found, then , yes, HT, taxotere, and Zometa/Xgeva could all be started at the same time.

- Allen

Gary
I had similar situation. PSA rose to 1.22 so I called Dattoli Cancer Center in Sarasota which only treats PCa. They sent me to Sand Lake Imaging in Orlando where MRI found two highly suspicious iliac lymph nodes. So I went to Dattoli and had all pelvic lymph nodes done with DART which is a highly accurate version of IMRT. I'm also on ADT3 for 13 months. No doubt that it makes active exercise more difficult, but Dattoli prescribes meds which offset most SEs. I golf three times a week and go to gym on off days.
I'm now in remission.
Call Dattoli or a free one hour consult. Most guys I met there were having recurrence, many much worse with mets.
Bob

Since I have similar statistics I offer my experience as a sample, of course we are all different. After SRT with rising PSA:
1. On short-term HT in conjunction with radiation my time in the mile slowed by 20%. Lots of threads attest to the value of exercise during HT.
2. The nano-ferro MRI in Nijmegen showed eight lymph-node metastases.
3. My top radiologist and Oncologist agreed on IMRT with four months of Firmagon. IMRT so as to do the area around the two target areas, the common iliac right and left para-aorta. As the Tall One has said, not much in the way of guidelines to follow, but if nothing else one hopes this will knock it back for a while.
No result yet.

Thanks again for this info.

Trying to get the trial at Stanford but they require a bone and PET scan OR a C-11 Acetate PET/CT Scan within 3 months of their scan. I have asked if the Sodium Fluoride PET/CT scan is satisfactory but have not heard back yet.

In this tread I see no discussion of the use of docetaxel concurrent with ADT. I see this National Cancer Institute study 12/5/2013 showing benefits of this approach. Any comments?

Gary

Thanks Allen, again

I reread that article and find, not surprisingly, you are correct.

I will be more careful in the future about my posts.

I did receive a response this afternoon from Stanford on the study: For the Bombesin study, you would need to have a bone scan and CT of the abd/pelvis. The NaF PET CT wouldn't qualify you in this study.

So anyone in my category needs to do this within 3 months prior to the Bombesin study.

The contact person is:

Pam Gallant, BSN | Clinical Research Coordinator
CCTO | Department of Radiology
800 Welch Road, FC3C90
Stanford, CA 94305-5757
Tel: 650.725.6409 | Fax: 650.736.2558

So I am planning now after my oncologist meeting this afternoon:

meeting criteria for the Stanford study, doing it

If no mets: try to enter the EMBARK clinical trial, which includes Lupron with a opportunity to have Xtandi/enzalutamid

I understand Xtandi/enzalutamide is $10K a month if purchased outside trial, is this price correct?

Gary

Post Edited (OregonPinot) : 2/2/2016 6:53:45 PM (GMT-7)

EMBARK: all procedures associated with this trial are done locally.

Stanford: 1) the NaF Scan does not satisfy their criteria, and
2) I also asked if the F-Choline or C-Choline PET/CT qualify, they do not, and
3) they reiterated that the CT scan of the abd/pelvis and a bone scan were the requirements

Post Edited (OregonPinot) : 2/3/2016 2:09:01 PM (GMT-7)