Newly diagnosed stage 4, how long on ADT before adding ARSI?

When I was diagnosed with Stage 4. I was immediately put on both types of drugs. I first received an injection of Firmagon, as it does not spike testosterone, that same day my urologist gave me a sample bottle of Nubeqa, which is an ARSI. After a month, I had a Trelstar (this is a 6 month injection and filled my prescription for Nubeqa. This treatment started in September 2024, starting PSA was 62, as of March 4th my PSA is undetectable. My urologist explained the dual therapy should be the standard of care. My stage 4 is Gleason 9 and had spread outside the prostate to my pelvic bones and one lymph node. So glad I was treated quickly as the prostate tumor was progressing towards my bladder and rectum. No symptoms now, and tumor has shrunk significantly.

Sorry to hear your cancer had spread. Did you have any treatment before it spread? Like radiation or surgery? or hormone treatment. I also have been diagnosed with Gleason 9 but so far it has not spread?? I have had radiation and am on hormone treatment.

Thank you so much for sharing. This aligns with what I was expecting and I will definitely bring up at our next meeting. So happy to hear you responded well to treatment!!

No treatment prior. I just went to the doc last July and my blood work came back with a PSA of 62. Had a DRI, tumor in upper part of prostate, biopsy the next week, confirmed highly aggressive cancer in both upper lobes. Started on ADT same day when the biopsy results came back. Had a PSMA Pet scan a few weeks latter, cancer in right pelvic lymph node, and both sides of pelvis. Recent scans indicate the growths have shrunk, will be on ADT for at least 3 yrs, Radiation may be an option, but docs are not sur, yet, they can radiate me safety.

It is very likely that ADT alone will bring your PSA down to very low levels and adding an ARSI at this point may not be essential, yet. ADT It is pretty hard on the body and at 83. The doctor is thinking about that.

The thing is though, your father’s situation is what would normally call for triplet therapy. ADT plus an ARSI plus chemotherapy. What has your doctor discussed doing?

One alternative would be to use Pluvicto to try and eliminate the cancer in the whole body. The problem is, it has only very successful in about 1/3 of the patients.

You might talk to the doctor about using Darolutamide as the ARSI. It has the least side effects of all of the ARSI drugs, so it may work well if the doctor is concerned about side effects due to age. If your father has any heart issues, you do not want to go on Zytiga. I never had high blood pressure and Zytiga gave it to me, and many other people using it.

Both chemo and Pluvicto can be hard on the body, But they do give the best chance of eliminating most of the metastasis from his body. The thing is ADT can really cause a lot of fatigue for some people and then going on chemo or Pluvicto Ccn greatly increase that fatigue. As long as your father stays active and exercises fatigue May not be a major issue. I’m 77 and was on ADT for eight years, Had very few problems with fatigue.

Instead of ADT, you want to talk to the doctor about Estradiol patches instead of ADT. They work just as well as ADT as the patch study showed, but have many fewer side effects. Much better for the cardiovascular system fewer hot flashes, less brain fog, and less deterioration of your bones. Estradiol comes in patches as well as in a gel and other forms.

How long will you be on ADT or do you know yet?

In my case, they started me on ARSI (Erleada/Apalutamide) at the same time as ADT, and I also received radiation to the metastasis and a high dose to the prostate.

However, I was only 56 at the time, and I had made it clear I wanted to pull out all the stops. At age 83, aggressive doublet or triplet therapy might not always be indicated, because some of the side-effects are tough even on a relatively young man.

There's no right choice, just an ongoing conversation with his medical team. It's helpful to make it clear to the doctors, repeatedly, what his preferences are, so that they don't just assume based on his age.

Best of luck!

Hi Jeff, thanks for lots of good info for me to look into! Triplet therapy was one of my direct questions to the oncologist based on my previous research. To summarize, he basically said my dad was too old and he had never prescribed docetaxel to anyone over the age of 76. My dad's in pretty good health and travels internationally multiple times a year and stays decently active, but is unquestionably in the elderly category. It's not a stretch for me to understand that might be too aggressive on him at this stage. However, the lack of ARSI seemed not aggressive enough and which drove me here (amongst other places) to do some more research. I've taken some notes and will look into some of the more specific drugs you've mentioned instead of the general treatment paths I've been investigating. More to learn, appreciate your help!

Thanks for the perspective North! I think the next time I meet I will just directly ask if he is delaying due to my dad's age or because that is his standard practice. I think that will at least make me understand his reasoning more clearly and I can make my assessments/judgements from there. He didn't phrase it that way when explaining, but maybe he was just trying to sugar coat my dad's age in front of him. Which is totally ok, but I took it more as not being as aggressive as I'd like to attack the situation. Obviously, he is just starting to get to know my dad and so I can sympathize from his standpoint not wanting to over prescribe a 83 year old that might not be in the best health for all he really knows. I'm obviously bias, but think my dad is doing good for a 83 year old and just has the normal slightly elevated stuff common for his age that is easily managed (blood pressure, cholesterol).

I was in a webinar today and they were discussing chemotherapy versus Pluvicto. They said that the side effects for Pluvicto were much easier to handle than with chemo.

It still may be too much as far as the doctors concerned, but it can’t hurt to ask.