New treatment Pluvicto (radioligand therapy) for prostate cancer

Pluvicto is available in Ontario, at least: my oncology team told me about Pluvicto in late 2021 or early 2022 as a future option if/when ADT and Apalutamide stopped working and my cancer became castrate-resistant. As the article says, it's just not available routinely as an *early* intervention yet.

It's possible that because they're a major cancer research centre, they have easier access. They were able to get me special approval for Apalutamide before it was in the Ontario formulary, for example (it took less than a week).

Oh, that is better. I misread the article, then--thanks for setting me straight. I'm not sure Pluvicto is available for early-stage patients in the US either.

I feel like a “Commodity or an article of trade .
There is no known or established treatment for Stage 4.
I am an Internist (Internal Medicine, Categorical) practicing in NJ since 1995.
My father was a general surgeon and died with his prostate cancer at age 84.
I was not surprised when my PSA was found to be 4.2 at age 47. I was in absolute denial but new for certain I did not want to go through what I’ve seen people live through just to stay alive.
I refused a biopsy.
About 2 years later my PSA was up to 11. I was just not going to deal with this as a busy, solo physician in private practice; no way I could. Again, I let things ride.
It turned my entire life upside down and robbed me of any and all ambition.
I eventually consulted a Urologist at age 54 BECAUSE I was in acute retention of urine. My PSA was then 64. Still, I went back to work; I had a staff of 6FTEs and my bills didn’t care that I had to carry an in dwelling catheter for a while.
I then agreed to try Lupron and Bicalutamide. After the most miserable 6 months of my life, I decided to discontinue the hormone therapy. No words can describe the fatigue and other side effects I suffered from ADT. Every possible side effect I found in the texts and Google was me.
At age 56 after a year off ADT, my PSA was 264. No need for tissue biopsy then; it was unquestionably an aggressive Stage 4 cancer.
Next manifestation was a rather acute T7 compression syndrome from tumor in my thoracic vertebrae confirmed by MRI with contrast for which I had emergency surgery.
Before I could recover from the surgery, including T5 - T9 fusion after laminectomies, I suffered a massive 98% blockage of my LAD, the so-called widow-maker (I had resumed ADT). I waited 4 days at home hoping to die but the pain was so severe that I eventually called 911. The artery was stented within 1 hour of my ER arrival and I was back home and at work 6 days later.
2 months after my heart attack and almost exactly one year after my spinal fusion I had another acute compression syndrome, same location. Apparently the cancer came back 4 times as large and much more aggressive than the initial episode. The surgery took about 6 hours and I couldn’t believe I was still alive when I recovered from anaesthesia.
This last surgery on March 1st 2024 was the last straw for me; I don’t qualify for Hospice care, Pain management means I can’t work because of the amount of narcotics required to barely take the edge off.
The worst part for me is not the pain in my spine from all the rods and other hardware in my back but the worst gastrointestinal complications known to science. My insides stopped working entirely and I had severe diverticulitis and peritonitis that required 6 weeks of antibiotics post-op. I was in the hospital for 6 weeks.
I looked at my EOBs for the first time 2 days ago just for 2024. I don’t know how doctors survive, or hospitals for that matter.
The Neurosurgeon billed $57,000 but Medicare paid $2000. My secondary, AETNA, paid $800. Yes, those numbers are accurate.
The total hospital bill for all the 6 weeks, testing, imaging and all direct work done by the hospital was $285,000; Medicare approved and paid $18,000 while my secondary, AETNA paid just short of $1,800. These payments were approximately less than 5% of the cost of care. Same applied to the various physician Consultants who were involved in my care.
How can this be possible in the USA where we blow up 2 Billion Dollar Missiles for naught? How?

I feel like a “Commodity or an article of trade .
There is no known or established treatment for Stage 4.
I am an Internist (Internal Medicine, Categorical) practicing in NJ since 1995.
My father was a general surgeon and died with his prostate cancer at age 84.
I was not surprised when my PSA was found to be 4.2 at age 47. I was in absolute denial but new for certain I did not want to go through what I’ve seen people live through just to stay alive.
I refused a biopsy.
About 2 years later my PSA was up to 11. I was just not going to deal with this as a busy, solo physician in private practice; no way I could. Again, I let things ride.
It turned my entire life upside down and robbed me of any and all ambition.
I eventually consulted a Urologist at age 54 BECAUSE I was in acute retention of urine. My PSA was then 64. Still, I went back to work; I had a staff of 6FTEs and my bills didn’t care that I had to carry an in dwelling catheter for a while.
I then agreed to try Lupron and Bicalutamide. After the most miserable 6 months of my life, I decided to discontinue the hormone therapy. No words can describe the fatigue and other side effects I suffered from ADT. Every possible side effect I found in the texts and Google was me.
At age 56 after a year off ADT, my PSA was 264. No need for tissue biopsy then; it was unquestionably an aggressive Stage 4 cancer.
Next manifestation was a rather acute T7 compression syndrome from tumor in my thoracic vertebrae confirmed by MRI with contrast for which I had emergency surgery.
Before I could recover from the surgery, including T5 - T9 fusion after laminectomies, I suffered a massive 98% blockage of my LAD, the so-called widow-maker (I had resumed ADT). I waited 4 days at home hoping to die but the pain was so severe that I eventually called 911. The artery was stented within 1 hour of my ER arrival and I was back home and at work 6 days later.
2 months after my heart attack and almost exactly one year after my spinal fusion I had another acute compression syndrome, same location. Apparently the cancer came back 4 times as large and much more aggressive than the initial episode. The surgery took about 6 hours and I couldn’t believe I was still alive when I recovered from anaesthesia.
This last surgery on March 1st 2024 was the last straw for me; I don’t qualify for Hospice care, Pain management means I can’t work because of the amount of narcotics required to barely take the edge off.
The worst part for me is not the pain in my spine from all the rods and other hardware in my back but the worst gastrointestinal complications known to science. My insides stopped working entirely and I had severe diverticulitis and peritonitis that required 6 weeks of antibiotics post-op. I was in the hospital for 6 weeks.
I looked at my EOBs for the first time 2 days ago just for 2024. I don’t know how doctors survive, or hospitals for that matter.
The Neurosurgeon billed $57,000 but Medicare paid $2000. My secondary, AETNA, paid $800. Yes, those numbers are accurate.
The total hospital bill for all the 6 weeks, testing, imaging and all direct work done by the hospital was $285,000; Medicare approved and paid $18,000 while my secondary, AETNA paid just short of $1,800. These payments were approximately less than 5% of the cost of care. Same applied to the various physician Consultants who were involved in my care.
How can this be possible in the USA where we blow up 2 Billion Dollar Missiles for naught? How?

I feel like a “Commodity or an article of trade .
There is no known or established treatment for Stage 4.
I am an Internist (Internal Medicine, Categorical) practicing in NJ since 1995.
My father was a general surgeon and died with his prostate cancer at age 84.
I was not surprised when my PSA was found to be 4.2 at age 47. I was in absolute denial but new for certain I did not want to go through what I’ve seen people live through just to stay alive.
I refused a biopsy.
About 2 years later my PSA was up to 11. I was just not going to deal with this as a busy, solo physician in private practice; no way I could. Again, I let things ride.
It turned my entire life upside down and robbed me of any and all ambition.
I eventually consulted a Urologist at age 54 BECAUSE I was in acute retention of urine. My PSA was then 64. Still, I went back to work; I had a staff of 6FTEs and my bills didn’t care that I had to carry an in dwelling catheter for a while.
I then agreed to try Lupron and Bicalutamide. After the most miserable 6 months of my life, I decided to discontinue the hormone therapy. No words can describe the fatigue and other side effects I suffered from ADT. Every possible side effect I found in the texts and Google was me.
At age 56 after a year off ADT, my PSA was 264. No need for tissue biopsy then; it was unquestionably an aggressive Stage 4 cancer.
Next manifestation was a rather acute T7 compression syndrome from tumor in my thoracic vertebrae confirmed by MRI with contrast for which I had emergency surgery.
Before I could recover from the surgery, including T5 - T9 fusion after laminectomies, I suffered a massive 98% blockage of my LAD, the so-called widow-maker (I had resumed ADT). I waited 4 days at home hoping to die but the pain was so severe that I eventually called 911. The artery was stented within 1 hour of my ER arrival and I was back home and at work 6 days later.
2 months after my heart attack and almost exactly one year after my spinal fusion I had another acute compression syndrome, same location. Apparently the cancer came back 4 times as large and much more aggressive than the initial episode. The surgery took about 6 hours and I couldn’t believe I was still alive when I recovered from anaesthesia.
This last surgery on March 1st 2024 was the last straw for me; I don’t qualify for Hospice care, Pain management means I can’t work because of the amount of narcotics required to barely take the edge off.
The worst part for me is not the pain in my spine from all the rods and other hardware in my back but the worst gastrointestinal complications known to science. My insides stopped working entirely and I had severe diverticulitis and peritonitis that required 6 weeks of antibiotics post-op. I was in the hospital for 6 weeks.
I looked at my EOBs for the first time 2 days ago just for 2024. I don’t know how doctors survive, or hospitals for that matter.
The Neurosurgeon billed $57,000 but Medicare paid $2000. My secondary, AETNA, paid $800. Yes, those numbers are accurate.
The total hospital bill for all the 6 weeks, testing, imaging and all direct work done by the hospital was $285,000; Medicare approved and paid $18,000 while my secondary, AETNA paid just short of $1,800. These payments were approximately less than 5% of the cost of care. Same applied to the various physician Consultants who were involved in my care.
How can this be possible in the USA where we blow up 2 Billion Dollar Missiles for naught? How?

As for established treatment for stage 4 (curative rather than palliative intent), I think that's finally starting to emerge. My situation was similar to yours on the cancer side, but without the cardiac complications — stage 4b, metastasis to thoracic spine, relatively young (56 at the time). Here's how I was treated at a major Canadian teaching hospital and cancer centre:

1. Emergency debulking surgery to relieve the pressure on the spinal cord at T3 (I was paralysed from the ribs down at that point).
2. Started on ADT (Firmagon at the time; Orgovyx now), and ARSI (Erleada) a few days afterwards and will continue indefinitely.
3. 20 gy of SBRT radiation to the surgery site 4 weeks after surgery, to kill any cancer the surgery couldn't get at.
4. Extensive rehab to learn to sit up in a wheelchair, then stand holding onto bars, etc. first in the hospital, then in a specialised rehab centre attached. (It was 3 1/2 months before I went home in a wheelchair).
5. 60 gy of SBRT radiation (curative dose) to the prostate itself 6 months after the surgery.
6. Extensive blood work every 3 months for monitoring.

If I'd had many metastases rather than just one, then perhaps I would have received chemo rather than radiation to the metastasis as part of the "triple treatment" that seems to be becoming best practice for stage 4 PCa.

Did it work? I won't know until the time (if any) that it stops working, but when fall arrives I'll be 3 years with undetectable PSA, and I can walk over 14,000 steps in a day now, so it seems to have served me well enough so far.

And I do realise how incredibly lucky I am to have been born somewhere where all of this was covered by provincial healthcare — my only expense was snacks from the hospital vending machine.

Quality of life is very important to me. I’d rather move on than live in pain and misery. But, I’m Catholic…