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Cancer: Prostate Message Board


Cancer: Prostate Board Index


Hi ciorsdan and BSN100 (and welcome to the Board! :wave:),

We are all somewhat in the same territory cancer wise, though mine was 18 ½ years ago now. My initial PSA was 113.6, which rose to 125 two weeks later, probably because of a mixed effect of flare from the Lupron and growth of the cancer due to what seems to have been a fairly short PSA doubling time. My oncologist’s office still lists me as starting out with Stage 4 because of a doubtful single spot in an unlikely location per a ProstaScint scan in early 2000, but I have always thought that was probably an artificial result, and my course since then makes it a stronger likelihood that I was never Stage 4 (but definitely Stage 3). I believe that if I had waited to get that first ever PSA for another 3 to 4 months my PSA would then have been 250, and probably I then would really have had Stage 4 disease.

It appears I am now an older man than either of your husbands as I will be 75 next month, but obviously we are all just about the same age, and I know that territory well too.

I am really surprised, BSN100, that your oncologist told you what he did, for a couple of reasons. First, in just the past couple of years we have had those good results, especially from the CHAARTED clinical trial, which demonstrated that chemo started early, concurrent with hormonal therapy (the Lupron and Zytiga® in your husband’s case) instead of waiting until hormonal therapy was no longer controlling the cancer, led to substantially longer survival than waiting to start chemo later. This is a fairly recent result, and it takes a while for very busy doctors to catch up with the latest key developments, but this was touted widely as a “practice changing” result.

It is possible that I am misunderstanding what your doctor said and his/her understanding, as all of the patients in the CHAARTED trial had metastatic cancer, and the trial showed that the substantial benefit occurred for those with more extensive metastases but not for those with less extensive metastases, which might be the reverse of what you would expect to happen. Basically, those with “minor” metastases did so relatively well without the early chemo that there wasn’t’ much if any advantage to be seen. However, the fact that your oncologist is giving you a rather short-term prognosis leads me to suspect that your husband might be one of those who would benefit from early chemo. Even though he wouldn’t be starting chemo at the beginning of hormonal therapy, he would be starting it well within the time that the hormonal therapy is still working extremely well (PSA <0.05 – that’s great, and what you want!). Many oncologists treating us prostate cancer patients also treat many other types of cancer, which means they have a lot to keep up with and are not specialists who see a large proportion of prostate cancer patients, which motivates them to focus on prostate cancer developments. In fact one of the leading medical oncologist/researchers specializing in prostate cancer in the US, and a leader of many clinical trials, stated in the fall of 2016 that he is disturbed that too many oncologists are not using the insights from CHAARTED in their practices. I’m suspecting your husband’s oncologist may be a very good doctor but does not have a lot of metastatic prostate cancer patients, a fairly small group, these days even in an oncologist’s practice.

You can check results from various papers about the CHAARTED trial for yourself by going to www.pubmed.gov, courtesy of our US tax dollars hard at work, and use a search string like - prostate cancer AND CHAARTED . I just did that and got 43 hits after clicking on the filter on the left to drop any papers that did not have abstracts. By clicking on the blue hypertext you can view the abstract, and sometimes there is a link to a free copy of the complete paper (with a filter on the left for that too). Too me the results are rather eye-popping: for paper number 6 on the list (lead author Gravis, https://www.ncbi.nlm.nih.gov/pubmed/29475737 ), the two key studies showed that early chemo improved the average overall survival for patients with “high volume” disease from about 35 months for hormonal therapy (also known as ADT, for Androgen Deprivation Therapy) to an average of 51 months for the CHAARTED trial (which was a superior trial for a number of reasons) to 40 months for the GETUG trial. I can help interpret these abstracts/papers if you need help; when you start out in this game, it’s really confusing, but I’ve been at it now for 18 ½ years. I’m also suspecting that your doctor said that chemo would only improve results by about 6 months because he was looking at early data from the GETUG trial and was unaware of the tremendously significant results from CHAARTED. (It's just possible your husband's oncologist has information showing your husband to be a "lower-volume" metastatic patient, in which case he would not likely benefit from early chemo, and in which case you can extend my apology to him on my behalf.)

Finally, and this is really important, clinical trial results are designed to get a result of only a few months improvement, because that means the approach is likely to win FDA approval but can be accomplished without a much longer trial, which would add a lot of expense. What this means to us patients is that these approaches, in the hands and minds of skilled oncologists, are very likely to work [I]much[/I] better than they do in the trials! :D For instance, in the trial the hormonal therapy consisted of just a Lupron® type drug, or Firmagon®, or surgical castration. In your husband’s case, he is already on Lupron® plus Zytiga®, which is a far more potent drug than Lupron®, with the combination likely being even more potent. Moreover, the chemo drug Jevtana®/cabazataxel appears to be superior to the docetaxel chemo that was used in the CHAARTED trial. I strongly suspect that leading doctors are already using early chemo with Zytiga®, and probably also with a Lupron®/Zytiag® combo.

I’m also disturbed that in 2018 your husband’s doctor gave you what looks like a fairly short prognosis. (Actually it sounds a lot like mine in 2000: 3 good years and 2 declining years). Perhaps a half dozen years ago I would not have been disturbed, but progress in prostate cancer has taken a rather amazing turn for the better for Stage 4 patients. Prior to 2010 almost no new drugs had been approved for years, but starting then the floodgates opened; a handful of new drugs have been approved since then, with more in the pipeline, as well as repurposing of older drugs (like early use of chemo, like metformin for prostate cancer patients), much better radiation technology (including Xofigo®/radium 223 for bone only disease), really superb and ever improving imaging and testing (such as genetic) – which leads to superior individualization of treatment rather than a more one-size-fits-all approach, better understanding (effective treatment of oligometastatic – meaning few metastases – cancer), and a much improved research/drug approval pipeline system. Leading oncologists are busy finding out the best ways to sequence and combine all these marvelous new tools. I like your way of stretching out the time, but you may be able to really stretch the actual time, potentially to the point of your husband’s being able to put prostate cancer on the back burner and “succeeding” in dying of something else many years from now! :angel:

As a side topic, did the oncologist go over how to minimize the side-effects of hormonal therapy, especially including maintaining bone density while on hormonal therapy? This is also really important!

I know there are outstanding medical resources in your area, and I believe you and your husband should seek a second opinion.





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