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Which treatment to start for Advanced Metastatic Pca?


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Hi Everyone,


My dad aged 53 years has recently been diagnosed of Advanced Metastatic Prostate Cancer.

PSA Score = 149

PET CT = Light up spinal bone, ribs, pelvic area || Bone Marrow Biopsy = Metastatic and infiltrated into the bone marrow 

Hemoglobin = 9


Doctor 1's Treatment Plan: Tells me it is aggressive & needs to be treated asap.


1. On 29th June -> Gave 2 Firmagon shots of 120mg each. Need to take a 80mg shot every 28 days from now on

2. Ultracet (Pain Killer) - twice or thrice a day

2. MO wants to start Chemo soon


Doctor 2's Treatment Plan: Tells me not to worry & follow his steps asap & that its possible to live long by continuing several different medications throughout the life


1. Get a Orchidectomy immediately.

2. Suggested Bicalutamide 50mg (Known as Casodex) everyday.

3. Post Orchidectomy, he wants to start Harmone therapies to suppress adrenal glands etc.

4. He does NOT want to start chemo now. He tells me that Chemo can reduce the life span to a year or so and that Chemo must come into the picture only later on.


I plan to visit a third doctor just to be safe. But would appreciate any thoughts / opinions based on your knowledge and experience.




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Dear Cher,

Doctors 1 & 2 are both advising treatments that aim to reduce your father's testosterone levels and cut-off the "fuel" to his prostate cancer.

His PSA score is very high and Firmagon injections are most commonly used in his situation to reduce the cancer burden before surgical, chemical or radiological treatment can be contemplated/attempted. An Orchidectomy would further contribute to removing fuel by removing the testicles where testosterone is produced. I believe that Casodex and Zoladex are used together as a substitute to Firmagon.

Suggest he speaks with a radio-oncologist for a third opinion (+ PET-PSMA scan) and discuss radiological treatment options after his hormone levels drop and his total cancer burden is reduced.  He may prefer this option to chemotherapy?

Our thoughts and prayers are with you and your family during your father's difficult journey.


Canook (not a doctor just a young man diagnosed PCa T3b age 53 and treated with RARP in 2016...still going strong) 


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Hi Cher, 

first - I’m not a doctor so this is not medical advice!

but I agree with your first doctor. 2nd doctor doesn’t make much sense to me. 


Firmagon and orchiectomy (castration) achieve the same thing - rapid reduction of testosterone which inhibits prostate cancer growth. Orchiectomy is irreversible, at 53 I would worry about that.  Firmagon can be stopped (temporarily) to alleviate side effects of testosterone suppression.  Orchiectomy is very unusual these days since the creation of drugs that achieve low levels of testosterone similar to castration.  


recent drug trials (CHAARTED and STAMPEDE) have shown benefit of starting docetaxel chemo therapy at same time as ADT (firmagon)


secondary hormone treatment (firmagon is primary hormone treatment) is usually started after primary hormone treatment (ADT) fails 


bicalutamide is also often used with firmagon or other ADT drugs to enhance its effect


your fathers situation is serious so I think it’s irresponsible for doctor to say “don’t worry” as if it’s no big deal 


cancer council have some great brochures on the various treatments available for advanced prostate cancer.  PCFA also have a great information kit which they will send you if you phone them. 



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I endorse @stevecavill's response. Ask Doctor #2 for his evidence that "Chemo can reduce the life span to a year or so and that Chemo must come into the picture only later on." This is 'old' thinking - in fact clinical evidence over the past 7 or so years suggests just the opposite!


Chemo first is the standard of care today for high volume metastatic disease; it seems to have the longest outcomes for overall survival. If he is not high volume, recent studies appear to favor 2nd line anti-androgens before chemo. You can listen to some highly reputable genitourinary doctors (one surgeon, two med oncs) discussing this here . And you may want to listen to some of the other discussions listed under 'Advanced Treatments' on this page: https://ancan.org/prostate-cancer-resources/


Androgen Deprivation Therapy is equally as good as orchiectomy and reversible. Only if the ADT is not reducing testosterone as it should, would I consider an orchiectomy.


Cher - you are doing a great job advocating for your dad. FYI we offer a free, drop-in advanced cancer caregivers virtual support group . I'm not sure what time it would meet in your part of India, but you are very welcome. 




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I agree with Steve's comment "recent drug trials (CHAARTED and STAMPEDE) have shown benefit of starting docetaxel chemo therapy at same time as ADT (firmagon)". In fact, I can personally vouch for it! My cancer is Gleason 9, and after adjunct chemotherapy (Docetaxel) and ADT (Zolodex) my PSA has gone from 9 to <0.01, i.e. undetectable. (This may not sound like a big drop, but 9 was the PSA score after a radical open prostatectomy. As I understand it, without a prostate, the score should have been 0.0. So it was just the cancers producing it.) I have been in remission for about 6 months now, and my oncologist says I should remain so for years as long as the PSA stays at this level.


BTW if you dad has a prostatectomy, I recommend an open operation, not robotic. The head of the Victorian College of Surgeons says there is no evidence that robotic procedures give better outcomes than the traditional open operation. And they can cost much more. Apparently the surgeon needs to do 250 of them to get up to speed, so if a surgeon pushes this option, ask him how many of them he has done!


Best of luck


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12 hours ago, Cher said:

Chemo can reduce the life span to a year or so and that Chemo must come into the picture only later on.

If you are 53, and with Psa 149, and with many mets it is possible your Pca is aggressive, and is what my doctor called mine, "aggressive and young man's cancer" implying that it would grow and spread fast. But he could not give me a time for how long I had left to live, and that was in 2009, Gleason 9, Psa only 6, at age 62.

Most men don't like having testicles removed ( orchiectomy ) and drug companies like to supply drugs that cost about usd $3,500 a year instead, but effect is same to reduce testosterone by about 95%. Some T is made by adrenal glands, so its difficult to suppress all T. Even with complete T suppression, Pca stays alive, but usually with very much slowed down growth. But as time goes by it learns to mutate and grow without T supplied, and to make its own T supply.

Some docs say chemo would work well at beginning of treatment where Psa is high like yours, my doc said there would be no benefit and I had ADT ( hormone treatment ) with added Cosadex and abiraterone which worked for 14 mths, and by then it was 2018, Psa 12, with mets in bones and soft tissues and then I began chemo. But that did not work, after 5 chemo shots the Psa went to 50. I quit chemo. Psa went to 25. I began Lu177 last Nov and had four shots with last one in late April this year and Psa is now about 1.6, and scan report says bone mets show signs of healing up, and all lymph node mets are gone and not mets in any organs.

So the only thing that really killed off a lot of my Pca was Lu177.

In Melbourne, a trial is being done with using Lu177 as initial main treatment instead of RP or beam radiation and I don't know how a man qualifies for the trial but I'd guess its where he has mets all over like you have. Lu177 was first trialled as an end stage treatment, but it worked on so many men they are beginning to use it soon after diagnosis and where I guess an RP would not get all the local Pca and there are a lot of mets.

There is also Ac225, another slightly more powerful nuclide like Lu177.

But depending where you live, Lu177 might be difficult to get. Its available to purchase in Perth and Sydney from Theranostics Australia and another outlet in Brisbane.

I had my Lu177 in Sydney, 300km north east of where I live in Canberra, and it was easy to travel up there.

But when I had my No 3 Lu177 shot there was one other man from Australia and two who had flown from USA.

Cost is about usd $6,800 per infusion, standard treatment is 4 shots, 8 weeks apart. Side effects are much less than Docetaxel with chemo. 

But for Lu177 to have any chance to work, you must have PsMa Ga68 PET / CT scan which shows most if not all your Pca mets bigger than 2mm dia, or 1/3 of a grain of rice. scans are about usd $500. 

The radiologist can tell if Lu177 is likely to work.

I might need more Lu177 or Ac225 when Pca begins to grow back again, because Pca is very good at surviving all treatments, and any one type of treatment does not kill all Pca cells, so what is left grows back, like weeds, and as every gardener knows, its a constant battle to keep weeds under control, and I have been doing this since 2010 when my treatment began. I know one many who has lasted 26 years since diagnosis and another who died after 3 years and who had Pca that ignored most treatments.  

Patrick Turner. 

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Hi Cher,

You probably know that we're not medically qualified to give you the detailed personal advice on this site that you're asking for. On the other hand, you're definitely doing the right thing in seeking second and third opinions from medical oncologists who are experienced and up-to-date with metastatic prostate cancer.

Given the extreme divergence of opinion between your first two docs, (I'd have grave reservations about the second one), I would certainly be wanting to get another!

There continues to be a lot of new therapies becoming available for advanced PCa. The well-established approach seems to be androgen deprivation therapy (testosterone deprivation) with a GNRH agonist (Zoladex, Lucron etc) or where quick pain relief is needed, with a GNRH antagonist (e.g. Firmagon), in conjunction with an anti-androgen like Cosadex. These are likely to drop the male hormones on which PCa feeds to lower levels than an orchiectomy.

It has become increasingly common in cases of metastatic PCa to administer a course of chemotherapy (e.g. Taxotere) up front, when ADT is started, rather than leaving it as a 'last resort'.

Beyond that (and depending on response ) come a string of very effective second generation hormone-related drugs - Zytiga, Xtandi, Earlanda and others (used in conjunction with conventional ADT), as well as Xofigo (a bone-specific radiophamaceutical) if available. where your father is located.  Lutetium -177 - another radio infusion - is on trial at a number of centres, and for many men (not all) it is giving great results.

A good oncologist will be across all of these possibilities, and should be able to match the optimum treatment to your father's condition (and the availability of the relevant drugs in his location). 

Good luck - and keep us posted!





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