What level PSA before moving on to second line treatment?

In the U.S., insurance companies will only approve Zytiga or Xtandi after drugs like Zoladex stop working..If his PSA jumps one more time, then, in the U.S., they would approve it...There are exceptions to every rule, so you need to talk it over with his U.K. doctors....They may try adding bicalutamide first and see if that helps before moving on to the Zytiga or Xtandi...

A judgment of metastatic castration resistance (mCRPC) is made on several factors:a continuous rise in PSA while on ADT, the radiographic progression of existing disease, the appearance of new mets, and symptoms. It can also include progressive biopsies, and other blood tests (like bone alkaline phosphatase and Chromogranin A). Docetaxel, Xtandi, Zytiga, Provenge and Xofigo are approved in the US for this. There are many more drugs in clinical trials.

As Tall Allen mentioned, the decision can turn on multiple factors - some from the doctor/medicine side and some from the patient side. Seems to me there can be a kind of "art" to it. Some try to whack the cancer with more treatments at the earliest possible chance. Some do "pick a number" as a trigger to seek something else. Some try to stretch as much time as they can between treatments that may still be partially working.

I was first diagnosed with a PSA a little over 5,000. Had a nice run on Lupron and Zometa. PSA nadir was 1.0. I started consulting at more than one place when my PSA was going back up again higher than 5.0. One was glad to offer Xtandi or Zytiga at PSA higher than 10.0-ish, or a clinical trial (for an agent that subsequently hasn't had the best of track records). Another took time for some familial genetic testing, some Provenge, and a Ga-68 PSMA PET scan, and also offered another clinical trial involving the same agent.

Eventually, I did go on a secondary treatment, and have done well, so far, with a PSA drop from around 95 to around 1.4.

Charles