Zometa

My RO prescribed ZOMETA after the 68Ga PSMAPETCT found 2 highly suspicious locations for cancer( prostate bed & L3). He also ordered a bone scan and 3T MRI In the pelvis.I don't actually understand what he is looking for when the most sensitive PC scan,PSMA PET CT found cancer at such a low PSA=0.27.I need some info. about Zometa and it's side effects .......experiences!
Thank you all.

Almost a 10,
Thank you.is it a monthly infusion? how long you'll be on it?

Dare,
I am currently getting my infusions about every month and a half and am closing in on about a year of infusions. After my next visit on October 28th, I will be placed on a twelve week schedule. 60 Michael is right on about the fatigue. I have a part time job now and it wipes me out after five hours. Naps are definitely in the schedule.

George,
That is what I was planning after my PSMA scan . I even contacted Cyberknife center inMunich,Germany ,where they accepted to radiate both locations.Have you done anymore scans or biopsy to see if the uptakes were not false negatives?
What kind of SBRT you used.......cyberknife,true beam..any side effects?I had 78GY in the prostate &seminal vesicles fossa in 2012 and reradiating is quite a risk!!
I still think that radiation is the' wisest' option as you suggested.

Thanks George.That is what is in my mind. The idea behind my PSMA scan was to find where the bandit is hiding and then go after him!! Then as you said 'why sit and watch'.totally agree...

Allen, what you wrote about how metastasis work makes sense. However, among the billions of cancer cells traveling in the blood stream, some metastasize and grow in some parts of the body. Could those cells be the most aggressive ones? By killing those aggressive cells could we gain some time and improve OS?
I don't know, this is my opinion and I don't have any scientific backup for this theory. But I find similarities between zapping mets and debulking cancer (radical prostatectomy) in high risk patients without the aim of a cure.

Allen,

you point out that there is unsufficient evidence for treating distant mets. This evidence cannot be available since the PSMA PET/CT diagnostics are very new and without this you could not detect metastases down to 1 mm in size. There are many small institutional studies which show that a delay of the cancer progress can be achieved if the mets are radiated. For me as a patient these studies combined are sufficient to decide for this treatment. You, however, require a phase III trial which may be available in about ten years from now. I cannot wait for that and require treatment now. For me there is sufficient evidence to persue the treatment of oligometastases with e.g. CyberKnife.

Using a PSMA PET/CT more patients will be diagnosed with oligometastases than ever before and they will have to decide whether to treat their mets or not.

I also think you cannot be sure that the body is full of micrometastases when a few oligometastases are detected. Dr. Scholz writes: „Various studies are showing that a minority of patients with early stage metastases do not have widespread microscopic metastases as previously believed."

In another study Patrick Mehlen & Alain Puisieux write:
„The metastatic process is highly inefficient — very few of the many cells that migrate from the primary tumour successfully colonize distant sites.“

So there may be not that many micrometastases as suspected.

Whether you combine the radiation of mets with ADT or not is a separate question. If you radiate the mets the PSA value will usually go down a lot. I think it depends what nadir you reach whether you need to add ADT or not. If it stays so low that you would not restart ADT in an intermittent ADT schedule I would not start with ADT. When the PSA value goes up you can decide if you radiate the new mets again and bring down the PSA value this way or start ADT. This way you can combine the radiation of mets with an intermittierent ADT.

If you want to attack possible micrometastases too you can combine the radiations with a short-course ADT.

George

So at this point, widespread metastatic PCa...are ADT side effects so onerous that one would not just do it just in case?

George-

They have been seen and counted. If you are interested in counting them in your serum, you can pay for a CTC analysis from CellSearch. Of course, that only includes micromets in the serum, not in the lymph, spinal fluid, or in organs or bone that are too small to see. I don't know what anyone would do with the info, however.

No answer, I guess. That's ok with any luck at all I won't get there. But you guys that are..be smart.

Sheepguy,

I will try to explain why I prefer to radiate the mets and not just start ADT. In this study: Predictors of duration of abiraterone acetate in men with castration-resistant prostate cancer they provide data how long each of the systemic treatments for PCa are helpful. They report:

Primary ADT: median duration 23 months
Secondary ADT: median duration 17 months (Bicalutamide)
Zytiga: median duration 13 to 16 months
this are together 55 months which are typically followed by Chemo. Often there is no secondary ADT used which may shorten this schedule by 17 months.

You, as an individual, will experience different durations but one can use these as rough guidelines.

Now, as an example of many small studies regarding radiation of metastases I will use the one by Henderson which Dr. Scholz has cited: Oligometastatic prostate cancer: An evaluation of stereotactic body radiotherapy (SBRT) as an alternative to palliative androgen deprivation therapy.

Henderson writes: „Median ADT-free survival was 28 months“ if the mets were radiated with SBRT. So this will result in the following:

Radiation of oligometastases: 28 months
Primary ADT: median duration 23 months
Secondary ADT: median duration 17 months (Bicalutamide)
Zytiga: median duration 13 to 16 months
this are 83 months, so you may gain quite some survival time.

But you can also combine the radiation of mets e.g. with an intermittent ADT. To demonstrate this I will use the protocol used in this phase III study:
Intermittent androgen deprivation for locally advanced and metastatic prostate cancer: results from a randomised phase 3 study of the South European Uroncological Group
After a three months induction treatment with ADT the participants started the first pause. A pause did end when the PSA value rose above 20 ng/ml provided the patient had no symptoms. As it turned out, these breaks had a median duration of 52 weeks.

Now, Henderson writes: „All but one patient had a PSA response, with a median reduction of 84%“. So if you would radiate the mets about the end of the break you would slash the PSA from 20 ng/ml to about 3.2 ng/ml. Following the Henderson study it will then take 28 months till you need to restart ADT.

I see no additional risks with the second approach, you just add the radiation of the mets to the standard of care. However, you have to believe the results of the Henderson study and all the other small studies are true. Otherwise you have to wait for a phase III study and during that time see how you fare with standard of care.

George