I need advice to help make a decision.......

Hi @jeffmarc . I didn't say it no longer needs testosterone. What I said it doesn't need YOUR testosterone. The way my oncologist explained it was that the cancer evolves to a point where it makes its own small amount. ZYTIGA® works by interrupting the androgen-making process at an important step. It inhibits androgen at 3 sources—the testes, the adrenal glands, AND the tumor itself. This is the difference from other ADT therapies.

That's a good point. Abiraterone acetate (Zytiga) isn't ADT at all; it's a first-generation reception inhibitor (from the mid-1990s) meant to work together with ADT or physical castration to inhibit testosterone uptake by cancer cells, as you mention.

The second-generation -lutamides (Apalutamide, Enzalutamide, etc), which have come out over the past 5 years or so, do the same thing more effectively, but they're not suitable for all cases, which is why oncologists still often recommend Zytiga.

For mCRPC, I think @jeffmarc mentioned that some oncologists like to sequence, starting with Zytiga and then escalating to a -lutamide when Zytiga stops working, but he can fill in the details there; for mCSPC, the TITAN study showed that starting with Apalutamide+ADT immediately is highly effective (that's what they did for me right at diagnosis in 2021, and my PSA is still undetectable, < 0.01, as we enter 2025).

Disclaimer: not a medical professional, etc etc

It's also worth mentioning that because Zytiga is older, it's out of patent and cheap generic versions are available, driving down the price. The -lutamides can be very expensive, and some insurance plans in the U.S. might not want to cover them if they decide that Zytiga (or generic equivalent) is "good enough" for a specific prostate-cancer situation.

I will share my case and offer what I choose to do.
Had Gleason 6 in 7 core and one upgraded upon second opinion to G7 so after a year on AS I had SBRT
First thing my doctor did was stopping my testosterone replacement. My T levels are rock bottom hence my need for TRT
I was a basket case and eventually found a clinic and went back to testosterone. Yeah yeah, I heard about "Gas on fire" with PCA and testosterone but I happen to live in my skin and could not deal with the emotional toll. My T had dropped to 25 and I was a sad crying emotional wreck so that was why I found a clinic and BTW withheld my PCA diagnosis out of fear. I did alert my oncologist and PCP
So yes I might have taken a chance but it was my choice.
I cannot give advice as you know but I will add the PCA is usually very slow growing and second a undetectable PSA is a great sign!
I know what I would do in your case but that is your choice

Glen

I'm on forever meds, it's in my bones and for right now I won't be stopping my meds. Trying to say I can understand your decision. We may all have the same cancer but we are all different. It's your life and you decide how you will live it. I wish you the best on your journey. Best to all.

Age 72. 2017 Stage 4. Gleason 9. I had a very similar conversation with surgeon and radiation oncologist. Given same choices. Went to lunch with wife and came back to them with choice of surgery, then radiation starting 5 months later for 90 sessions. PSA was undetectable after surgery and remained so until last year. Now detectable and creeping slightly for two years. Back to 6-months checks. Watching carefully and contemplating next steps. It’s been a good 7 years since diagnosis. Just hoping to keep going, whatever this brings.

Are you on ADT? That is the first step to get your PSA down, With the Gleason nine they also might want to give you a second level Drug like Zytiga or one of the lutamides.

If it above .2 you should be doing something, by .6 your doctor should have put you on at least ADT. That would drop your PSA back down to undetectable probably.

Have you had a PSMA PET scan? If your PSA is above .6 you should ask for one. It is the standard According to the NCCN for finding cancer metastasis

Thanks for the insight. The PSA remained undetectable for five years, tested annually. It shows up last year and slightly higher this year in October. But not above the .2 threshold, Not on any meds. Scheduled another check in 6 months to determine rate of change. If above . 2 a PET Scan will be done. That’s all I know at this point. So we wait.

90 sessions?? That seems very wrong. Even the old timer RO’s only do 39; and the newest recommendation is 25 treatments in most cases.
Please get some clarity on this before you commit to anything.