My Prostate Cancer came back — what are my options now

Understanding Your Prostate Cancer Recurrence: Treatment Options

I'm sorry you're facing a recurrence. This is a challenging situation, but there are multiple treatment pathways available today. Let me help you understand your options and what questions to ask your care team.

Understanding Your Situation First

What "recurrence" means depends on your specific situation:

According to the CancerPatientLab webinars featuring prostate cancer experts, your treatment options depend on several key factors:

• Where is the cancer? (localized to the prostate, regional lymph nodes, or metastatic/spread to distant sites)
• Is it hormone-sensitive or castrate-resistant? (Does it respond to testosterone-lowering therapy, or has it learned to grow despite low testosterone?)
• What treatments have you already had? (This determines what's still available)
• What biomarkers does your cancer have? (Genetic mutations that might respond to targeted drugs)

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Your Main Treatment Pathways

1. HORMONE-DIRECTED THERAPIES (If Your Cancer is Still Hormone-Sensitive)

If your cancer still responds to hormone deprivation, you have several options:

Androgen Deprivation Therapy (ADT) + Newer Hormone Blockers:

• Lupron (injection that lowers testosterone)
• Darolutamide, Apalutamide, or Enzalutamide (pills that block androgen receptors on cancer cells—these are more potent than older options)
• Abiraterone (blocks testosterone production)

According to Dr. [removed] Sartor's webinar on prostate cancer treatments, these novel hormone treatments are increasingly being used earlier in treatment, and combinations of these drugs are becoming standard of care.

Questions to ask your doctor:

1. Is my cancer still hormone-sensitive, or has it become castrate-resistant?
2. Which hormone therapy combination would you recommend for me?
3. How will we monitor whether it's working?

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2. CHEMOTHERAPY

If your cancer has progressed despite hormone therapy:

• Docetaxel (standard chemotherapy, often combined with hormone therapy)
• Cabazitaxel (used after docetaxel)

Important note: According to the webinars, some patients have had success with "rechallenge"—going back to docetaxel after a break—and getting additional months of benefit.

Questions to ask:

1. Am I a candidate for chemotherapy at this stage?
2. Would combining chemotherapy with hormone therapy be better than either alone?
3. What side effects should I expect, and how can we manage them?

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3. GENETIC TESTING TO FIND TARGETED TREATMENTS

This is increasingly important. About 20% of prostate cancer patients have actionable mutations that respond to specific drugs.

Key mutations to test for:

• BRCA1/BRCA2 mutations → PARP inhibitors (olaparib, talazoparib) that block DNA repair
• CDK12 mutations → PARP inhibitors + potential immunotherapy benefit
• PSMA expression → Lutetium-177 (Pluvicto), a radioactive treatment
• Mismatch repair deficiency → Immunotherapy (pembrolizumab/Keytruda)

According to Dr. [removed] Armstrong's webinar, most men in community practices are not getting genetic testing—you should specifically ask for both germline (inherited) and tumor testing.

Questions to ask:

1. Has my tumor been tested for genetic mutations (DNA sequencing)?
2. Do I have any actionable mutations that would change my treatment?
3. Should I get a liquid biopsy (blood test) to look for circulating tumor DNA?

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4. RADIOPHARMACEUTICALS (Radioactive Treatments)

If your cancer has spread to bones or soft tissue:

Lutetium-177 (Pluvicto) - A radioactive particle that attaches to PSMA (a protein on prostate cancer cells)

• About 1/3 of patients have excellent responses, 1/3 have modest responses, 1/3 don't respond well
• Requires PSMA PET scan to confirm your cancer "lights up" with PSMA

Questions to ask:

1. Do I have PSMA-positive disease (confirmed by PSMA PET scan)?
2. What are my SUV values (Standard Uptake Values)—higher values suggest better response potential?
3. Am I a candidate for Pluvicto?

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5. IMMUNOTHERAPY

Immunotherapy helps your immune system recognize and attack cancer cells. Options include:

• Checkpoint inhibitors (pembrolizumab/Keytruda) - especially if you have mismatch repair deficiency
• Sipuleucel-T (Provenge) - a vaccine made from your own immune cells
• Combination approaches - immunotherapy + hormone therapy or + chemotherapy

According to Dr. [removed] Subudhi's webinar on immunotherapies, the field is moving toward combination approaches rather than single drugs, and immunotherapy may offer more durable responses than traditional treatments.

Questions to ask:

1. Does my tumor have features that suggest immunotherapy would work (T-cell infiltration, mismatch repair deficiency)?
2. Would combining immunotherapy with my other treatments be beneficial?
3. Are there clinical trials combining immunotherapy with other approaches?

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6. CLINICAL TRIALS

According to the webinars, clinical trials are exploring:

• Newer hormone degraders (ARV-110, ARV-766)
• Antibody-drug conjugates (combining antibodies with chemotherapy)
• Bispecific T-cell engagers (bringing immune cells to cancer cells)
• Combination approaches (multiple drugs targeting different pathways)

Questions to ask:

1. Are there clinical trials I'm eligible for?
2. What new treatments are being tested that might apply to my situation?
3. How do I find trials through ClinicalTrials.gov or my cancer center?

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The Decision-Making Framework

According to the CancerPatientLab webinars, here's how oncologists typically think about your next step:

STEP 1: Understand your disease biology

• Hormone-sensitive or resistant?
• Genetic mutations present?
• Where has it spread?

STEP 2: Consider treatment intensity

• Single drug or combination?
• Earlier use of potent drugs vs. saving them for later?

STEP 3: Monitor response

• PSA levels (though these can be tricky)
• Imaging (CT, bone scan, PSMA PET)
• Symptoms and quality of life
• Liquid biopsies (blood tests for circulating tumor DNA)

STEP 4: Plan ahead

• Keep some treatment options in reserve
• Allow time for new therapies to become available
• Balance disease control with quality of life

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Critical Questions to Ask Your Oncologist NOW

1. What is my cancer's current status? Is it hormone-sensitive or castrate-resistant? Where has it spread?

2. What genetic testing has been done? Do I have BRCA, CDK12, mismatch repair deficiency, or other actionable mutations?

3. What imaging should I get? (PSMA PET scan, FDG PET, bone scan, CT, or MRI?)

4. What is your recommended next treatment, and why? (Ask them to explain the reasoning)

5. What are the expected benefits and side effects? How will we know if it's working?

6. Are there clinical trials I should consider?

7. How will we monitor my response? (PSA, scans, symptoms, blood tests?)

8. What happens if this treatment stops working? What's the backup plan?

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Important Perspective from Patients

According to the webinars, patients emphasize:

• You have multiple "shots on goal" (treatment options)—don't waste them on treatments unlikely to work
• Get comprehensive testing early—genetic testing and advanced imaging inform better decisions
• Quality of life matters—treatment should extend both survival AND quality of life
• Find a genitourinary medical oncologist—specialists in prostate cancer make better treatment decisions than generalists

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Next Steps

1. Request genetic testing if not already done (tissue biopsy analysis + liquid biopsy)
2. **Get appropriate imaging