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over staging

User
Posted 19 May 2024 at 12:19

My husband was diagnosed in Feb T3n1Mx G8 pPSA 67. The N1 are local sidewall lymph nodes. The Mx is a suspicious lesion in his R neck of femur ( also the site of some osteo arthritis so hoping this is cause of uptake). However we were then told he had been re staged as M1b, repeatedly shown this on med notes on screen in appointments, but every after visit summary says Mx.


Med oncologist has put him on enzalutamide and said he is incurable even if bony lesion is not cancer as local lymph nodes on both sides are affected. She gave him 5-7 years life expectancy, she seemed to think this was a great outlook. 


 We have seen two clinical oncologists, one privately, and one in the same corridor as the medical oncologist ( who runs the department) both say if no bony lesion then he is curable. The private clin onc also thought even if single met, then 5-7 years was 'very pessimistic'.


Apparently the test is to rescan after 3 months on HT, if the lesion in hip has decreased at the same rate as PCa, then it is a met, if it is still the same then it isn't, if it has disappeared, nobody is clear. 


The Med oncologist has now pushed back, the second scan, she is now saying 6 months on HT required, although original letter says 3 months, and also pushed our appointment with the clinical oncologist. 


To add to the complication he has been diagnosed with severe primary hyperparathyroidism, endocrinology badly want to put him on vit D, but have warned us this will mess up the PSMA bony lesion result, so if we don't do it now we will never know. 


We suspect that Med onc has deliberately over staged for elligability to enzalutamide, but this leaves us in an awful position not knowing. Looking for advice and to know if others are in the same boat?

User
Posted 01 Aug 2024 at 15:42

Update;


2nd NHS PSMA been pushed into the long grass so we had private repeat scan done ( £4k!) Scan shows not metastatic so has written to NHS recommending radical radiotherapy. Cautiously optimistic that he is curable. We would prefer to keep the enzalutamide for the recommended 2 years, the ENZARAD trial due out in Dec and word is that is shows strong advantage to doing so. Our private oncologist has told us that if we lose the enzalutamide (as no longer incurable and metastatic) then abiraterone is now off patent and available privately for £68 monthly compared with £3k a month for enza, said she would be able to prescribe for the next 18 months. Obviously now very happy bunnies. Nor sure if this will help others, but seemed only fair to complete story having posted original question

User
Posted 19 May 2024 at 12:19

My husband was diagnosed in Feb T3n1Mx G8 pPSA 67. The N1 are local sidewall lymph nodes. The Mx is a suspicious lesion in his R neck of femur ( also the site of some osteo arthritis so hoping this is cause of uptake). However we were then told he had been re staged as M1b, repeatedly shown this on med notes on screen in appointments, but every after visit summary says Mx.


Med oncologist has put him on enzalutamide and said he is incurable even if bony lesion is not cancer as local lymph nodes on both sides are affected. She gave him 5-7 years life expectancy, she seemed to think this was a great outlook. 


 We have seen two clinical oncologists, one privately, and one in the same corridor as the medical oncologist ( who runs the department) both say if no bony lesion then he is curable. The private clin onc also thought even if single met, then 5-7 years was 'very pessimistic'.


Apparently the test is to rescan after 3 months on HT, if the lesion in hip has decreased at the same rate as PCa, then it is a met, if it is still the same then it isn't, if it has disappeared, nobody is clear. 


The Med oncologist has now pushed back, the second scan, she is now saying 6 months on HT required, although original letter says 3 months, and also pushed our appointment with the clinical oncologist. 


To add to the complication he has been diagnosed with severe primary hyperparathyroidism, endocrinology badly want to put him on vit D, but have warned us this will mess up the PSMA bony lesion result, so if we don't do it now we will never know. 


We suspect that Med onc has deliberately over staged for elligability to enzalutamide, but this leaves us in an awful position not knowing. Looking for advice and to know if others are in the same boat?

User
Posted 20 May 2024 at 08:00

Thank you for replying. Yes that it the plan from the NHS clin onc. who says it is Mx, Its just the med onc is saying M1b, she is adamant that pelvic sidewall means still incurable ( but hasn't said M1a). She brooks no argument on the subject. Next clin onc appt  booked for August, but med onc wants to cancel this because she is pushing back the scan. If she is cooking the books a bit to get us the enzalutamide that is great, but by pushing back the next scan it leaves us not knowing. She has said " you know you are being over treated, don't you?" and " if you were locally advanced you wouldn't be elligable for enzalutamide". 


He can't put off taking the Vit d for long,  his blood Ca levels are dangerously high. 


We are considering private PSMA through private clin onc, so that we know, leaving NHS med onc 'officially'  still saying M1 and keeping him on the enzalutamide. 

Edited by member 20 May 2024 at 08:07  | Reason: Not specified

User
Posted 23 May 2024 at 10:31

Thank you for replying, 


No word has been spoken about chemo by any of the oncs, so assume they are keeping that for if other stuff fails


the clin oncs who are suggesting curable both are talking about RT, nobody has mentioned radical prostatectomy ( although I gather if no bony met this remains a possibility instead of RT, and of course cytoreductive prostatectomy also a possibility if bony met is found) we have a surgical appointment in a couple of weeks for a TURP, recommended  pre RT, but he only has mild symptoms now, so with no guarantee of RT, a unnecessary surgical procedure to prepare for RT that doesn't take place would be awful. 


As you say, hugely complex, I think falling in this middle ground locally advanced/oligometastatic means that the evidence base just fall apart. I am a clinician and a medical researcher, it looks as if the very sensitive imaging from PSMA has raced ahead of the evidence for treatment options, leaving a very chaotic field.  I saw on another post a quote along the lines of "if you are advanced then they will try everything at some point and it doesn't matter too much which order" , wise words at the moment.


It wasn't clear why the repeat PSMA has been pushed back, giving head onc the benefit of the doubt i think she may trying to keep him elligable for enza, if no bony met its not clear if this would be withdrawn. She has clearly told us it doesn't make much difference to prognosis or treatment plan whether he has a bony met or not, something that seems to fly in the face of all the evidence, hence we are finding it hard to trust what she is doing.


We have book private clin onc next week, hoping for sneaky private PSMA, at least we will have the emotional advantage of some certainty, even if it doesn't change the immediate NHS treatment plan, it will help us to make more informed choices. 


 

Edited by member 23 May 2024 at 10:33  | Reason: clarity

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User
Posted 19 May 2024 at 22:47

I can't see why the med onc would want to over stage. It does sound like the plan for scanning will resolve the Mx or M1b question. Presumably if he is M0 the plan would be RT to prostate and affected lymph nodes and probably RT to the whole pelvis with a view to a cure. You can't risk vitD if it would prevent a reliable scan. 

Dave

User
Posted 20 May 2024 at 08:00

Thank you for replying. Yes that it the plan from the NHS clin onc. who says it is Mx, Its just the med onc is saying M1b, she is adamant that pelvic sidewall means still incurable ( but hasn't said M1a). She brooks no argument on the subject. Next clin onc appt  booked for August, but med onc wants to cancel this because she is pushing back the scan. If she is cooking the books a bit to get us the enzalutamide that is great, but by pushing back the next scan it leaves us not knowing. She has said " you know you are being over treated, don't you?" and " if you were locally advanced you wouldn't be elligable for enzalutamide". 


He can't put off taking the Vit d for long,  his blood Ca levels are dangerously high. 


We are considering private PSMA through private clin onc, so that we know, leaving NHS med onc 'officially'  still saying M1 and keeping him on the enzalutamide. 

Edited by member 20 May 2024 at 08:07  | Reason: Not specified

User
Posted 20 May 2024 at 16:41

I would be very interested in the outcome,  please keep posting.

User
Posted 23 May 2024 at 09:17

Hi Cathy,


You've clearly done a lot of research on Pca. 


Yours is a complex situation and I don't think anyone on here would be qualified to give you medical advice.


I think the best way to look at it is assessing where you are now and deciding what treatment path you want and the best way to try make that happen.


You believe the Onco has over staged to get you Enza, it sounds like you're correct and that can only be a good thing, for instance if there was no suspicion of a bony met and you were going down the route of HT/RT, you'd be on similar or possibly inferior HT and if you do indeed get RT after 8/9 months as opposed to 3/4 it shouldn't make a difference in fact some radiotherapists like to wait that long before starting RT.


Have either of the Oncos who are suggesting that his Pca is curable told you how they would go about curing it?
If they are suggesting chemo as part of the treatment, then perhaps you should be asking when they think that should commence?


Likewise if the head onco believes it incurable does she think he'd benefit from early chemo?


 


Has she told you why she wants to push back the scan to 6 months?


It does sound like no other treatment is likely before she's convinced he doesn't have a bony met.


All the best


 

Edited by member 23 May 2024 at 10:39  | Reason: Not specified

User
Posted 23 May 2024 at 10:31

Thank you for replying, 


No word has been spoken about chemo by any of the oncs, so assume they are keeping that for if other stuff fails


the clin oncs who are suggesting curable both are talking about RT, nobody has mentioned radical prostatectomy ( although I gather if no bony met this remains a possibility instead of RT, and of course cytoreductive prostatectomy also a possibility if bony met is found) we have a surgical appointment in a couple of weeks for a TURP, recommended  pre RT, but he only has mild symptoms now, so with no guarantee of RT, a unnecessary surgical procedure to prepare for RT that doesn't take place would be awful. 


As you say, hugely complex, I think falling in this middle ground locally advanced/oligometastatic means that the evidence base just fall apart. I am a clinician and a medical researcher, it looks as if the very sensitive imaging from PSMA has raced ahead of the evidence for treatment options, leaving a very chaotic field.  I saw on another post a quote along the lines of "if you are advanced then they will try everything at some point and it doesn't matter too much which order" , wise words at the moment.


It wasn't clear why the repeat PSMA has been pushed back, giving head onc the benefit of the doubt i think she may trying to keep him elligable for enza, if no bony met its not clear if this would be withdrawn. She has clearly told us it doesn't make much difference to prognosis or treatment plan whether he has a bony met or not, something that seems to fly in the face of all the evidence, hence we are finding it hard to trust what she is doing.


We have book private clin onc next week, hoping for sneaky private PSMA, at least we will have the emotional advantage of some certainty, even if it doesn't change the immediate NHS treatment plan, it will help us to make more informed choices. 


 

Edited by member 23 May 2024 at 10:33  | Reason: clarity

User
Posted 01 Aug 2024 at 15:42

Update;


2nd NHS PSMA been pushed into the long grass so we had private repeat scan done ( £4k!) Scan shows not metastatic so has written to NHS recommending radical radiotherapy. Cautiously optimistic that he is curable. We would prefer to keep the enzalutamide for the recommended 2 years, the ENZARAD trial due out in Dec and word is that is shows strong advantage to doing so. Our private oncologist has told us that if we lose the enzalutamide (as no longer incurable and metastatic) then abiraterone is now off patent and available privately for £68 monthly compared with £3k a month for enza, said she would be able to prescribe for the next 18 months. Obviously now very happy bunnies. Nor sure if this will help others, but seemed only fair to complete story having posted original question

 
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