@ucla2025 There is a lot here to consider and so sorry you are in this boat. The need for chemo prior to Pluvicto changed in June 2025 - and not every case is candidate for it - much depends on your PSMA uptake and other bio markers, co-morbidities, etc. ADT is still required prior.

As for doublet or triplet, this article may help - the phase III clinical trials that support these therapies are good to read, too. This one may be is helpful for your thinking. https://www.urologytimes.com/view/dr-alicia-morgans-details-decision-between-doublets-and-triplets-in-mcspc.

As for triplet therapy, it is SOC for high volume Mets. The definition of high volume doesn’t only refer to the number of ‘spots’, but also location. My hub, whose unusual Mets is lung only (no bone or nodes light up) is considered high volume because it’s in the lungs, even though the SUV on his PSMA PET scan is low. So, there are many factors that make up why each case is unique.

The same seems true with going through triplet therapy. When the lung spots were discovered, our local UG Onc suggested triplet therapy. Because of the rare presentation we went for 2nd opinion at big COE where it was suggested that a 2nd chemo (Carboplatin) be added to the triple (we called it quad therapy). Our local Onc wasn’t crazy about that so, we started with ADT (Firmagon shots) and Docetaxel + Carboplatin 6 rounds every 21 days. Prior to the 4th round we added the Nubeqa after further consulting - so he did get the quad therapy for 3 rounds.

We had some complications toward the last 2 rounds, and after #6. I think it’s updated in my profile/bio (and updating yours would be helpful to others replying to your queries, so we know your details, hint, hint). He finished the chemo mid August and I would say he is still recovering - he had a rare side effect that was likely the contributing factor. Round #6 took his breath away - blood counts were low, but ok, but he had no energy and breathing was more difficult - it turned out he had a chemo induced ‘capillary leak syndrome’ - fluid leaking from blood to tissues, so swollen ankles but for him, the lining of his lungs filled with fluid - it was discovered on the follow up PSMA PET scan and he had 2 thoracenteses in 3 days to remove 1 liter of fluid from each side - no wonder he had a hard time breathing. So, our experience is tainted and unusual.

Overall, I would say that the first rounds of chemo were cumulative but manageable - exhaustion with some expected side effects and then you build back before the next treatment. We are big DIYers and projects kept him going - he built a small yoga deck, cleared some trees, and carried on as much as possible. But it is cumulative and by #5 and #6, he was mostly resting.

We go for follow-up scans in about 5 weeks - it was hard to read the last scans due to the extra fluid, so we will see how the chemo worked. PSA dropped immediately with the Firmagon (was only 0.36 to begin with) and stayed undetectable. He is just on Orgovyx and Nubeqa since chemo.
(Sorry this is so long…).

Chemo is no small endeavor, it’s cumulative and does a number on the bone marrow - and hopefully on the dividing cancer cells too! We did the cryotherapy for hands and feet to prevent neuropathy and it worked…so far. Take the Claritin, listen to the infusion staff, and rest well. It’s intense for awhile and then it’s behind you. If you have metastasis, it’s the standard. Good luck to you and your hub and keep us posted! This road is an odyssey, not a journey, in my book. And it’s helpful to have others to connect with who know the in/outs. Some are very frank here because of many years seeing people going through various treatments and having various results - all here are well intentioned and knowledgeable, so please don’t get discouraged if the message is not touching in a way that works for you. I hope your next decisions come easily. All Best to you and yours.