“There are many new scientific advances in our field when it comes to treating prostate cancer, much of it has to do with precision, allowing us to deliver radiation to the prostate in a very precise manner, and sparing normal organs such as the rectum, the hips, bladder, and allow us to really minimize the side effects that used to worry us, especially the long term side effects.” – Dr Andy Chen, a Radiation Oncologist, at Sugar Land Texas Oncology and Texas Medical Center, told SurvivorNet
At SurvivorNet, we want you to know that you are not alone on this journey. We know that receiving a prostate cancer diagnosis can feel incredibly daunting, bringing with it a whirlwind of questions and anxieties about what lies ahead.
Read MoreWhat is Pluvicto?
Imagine a “microscopic delivery truck” that can find and precisely deliver medicine only to the cancer cells, wherever they are in your body, while leaving your healthy cells mostly untouched. That’s essentially how Radioligand Therapy, specifically a drug called Pluvicto (lutetium Lu 177 vipivotide tetraxetan), works. It’s an innovative and promising option for some men with advanced prostate cancer.“For patients with metastatic prostate cancer, meaning cancer that has spread to bones. We now have options of providing very targeted treatment, meaning targeting the cancer cells that express Prostate Specific Membrane Antigen (PSMA).” – explains Dr Chen.
“And the technique is coupling a radioactive source to this marker and the drug can be directly delivered to these cancer cells that reside in bone. It’s another tool in our toolbox when it comes to treating advanced prostate cancer, in addition to chemotherapy or hormone therapy, this is a another option that has been very helpful.”
How Pluvicto Finds and Fights Cancer
Pluvicto delivers a small but powerful dose of radiation directly to prostate cancer cells.
How does it do this?
It targets a specific protein called PSMA. PSMA is often found in large amounts on the surface of prostate cancer cells, especially in advanced or aggressive stages. While normal prostate cells have some PSMA, cancer cells have a significantly higher concentration of it, making it an excellent target.
Pluvicto consists of two parts:
1. A ligand: This acts like a “postal code” or a homing device. It binds tightly and specifically to the PSMA protein on the surface of the cancer cells.
2. A radioactive isotope (lutetium-177): once the ligand is attached to the cancer cell, this radioactive part emits beta radiation over a very short distance, typically just a few millimeters. This localized radiation damages the DNA of the nearby cancer cells, causing them to die.
“Traditional Radiation Therapy is a focused treatment to one or two sites, very limited. Now, if a patient has many bone sites that are involved, then the better option would be to offer this treatment.”
“It’s a much more specific delivery, where you’re delivering the treatment through a patient’s veins and it goes through the patient’s circulation. And effectively just targeting the cancer cells that express the PSMA. So that is definitely a good option for patients with multiple bone metastases.” – says Dr Chen.
Who is Eligible for Pluvicto?
Pluvicto is a prescription treatment approved by the FDA for adults with PSMA-positive metastatic castration-resistant prostate cancer (mCRPC). Eligibility for Pluvicto hinges on whether your cancer expresses PSMA.
Before receiving Pluvicto, patients must undergo a specialized imaging test called a PSMA PET scan. During this scan, a radioactive tracer that binds to PSMA is injected into the body. Areas that “light up” on the scan indicate PSMA-positive disease, helping doctors determine whether Pluvicto is likely to be effective.
Originally, Pluvicto was approved for men with mCRPC who had already undergone other hormone-based treatments (like androgen receptor pathway inhibitors, or ARPIs) AND chemotherapy. However, there’s been a very significant recent advance:
New FDA Approval Brings Hope for Earlier Use As of March 28, 2025, the FDA expanded the use of Pluvicto. This means an innovative treatment approach is now available to significantly more men with advanced prostate cancer. Pluvicto is now approved for adults with PSMA-positive mCRPC who have been treated with an androgen receptor pathway inhibitor (ARPI) and are eligible to delay taxane-based chemotherapy.
This is a major step forward, as it means Pluvicto can now be used earlier in the treatment journey, before chemotherapy is required.
Newer Scientific Breakthroughs
“So I would say the most common scenario where we use combination therapy would be for high risk prostate cancer and more advanced prostate cancer, such as lymph node positive prostate cancer. And in those situations, we would combine the use of hormone therapy, which is actually androgen deprivation, meaning removing testosterone along with radiation therapy.”
Testosterone: The Fuel for Prostate Cancer
To understand treatment, imagine prostate cancer cells needing a specific fuel to grow. That fuel is primarily a male hormone called testosterone. This is why treatments for advanced prostate cancer often focus on reducing or blocking these male hormones, an approach known as Androgen Deprivation Therapy (ADT).
Simply put “ADT is the backbone of prostate cancer management or treatment”. Decades ago, this was achieved surgically, but now it involves injections or daily pills that stop testosterone production or block it from reaching cancer cells. While ADT doesn’t typically cure prostate cancer, it’s very effective at controlling its growth, especially when the disease is aggressive or has spread.
Initially, most prostate cancers are hormone-sensitive, also known as castration-sensitive. This means the cancer cells still rely on testosterone to grow and respond well to ADT. Your doctor’s goal at this stage is to starve the cancer by significantly lowering your testosterone levels,
“Another advance is combining the precision radiation with new agents, such as newer generation anti androgen type treatments that have very successful outcomes. Also utilizing it in combination with other agents like in the setting of oral anti-androgen therapies and oral hormone therapy agents. This has helped the quality of life of men undergoing prostate cancer treatments.” – says Dr Chen.
Next-Generation Hormone Blockers (Androgen Receptor Pathway Inhibitors – ARPIs)
For patients who have not had an androgen receptor pathway inhibitor (ARPI) or a Taxane (a type of chemotherapy) yet, adding an ARPI to your ADT is the preferred initial approach.
These medications work by further blocking testosterone signaling inside the cancer cells, even tiny amounts that might be present. They don’t lower testosterone by themselves; instead, they block the androgen receptor or androgen production inside the tumor.
They are typically oral medications, and while side effects like fatigue can occur, many men tolerate them well and are often added to ADT to “intensify” treatment and are used across several disease states.
It’s important to note that these agents are now often used earlier in the disease course, even for castration-sensitive prostate cancer, which means the treatment pathway for CRPC has also shifted.
- Abiraterone (brand name Zytiga)
- blocks the production of androgens in the testes, adrenal glands, and even within the tumor cells themselves. It’s typically taken with prednisone to manage potential side effects like high blood pressure or low potassium.
- Enzalutamide (brand name Xtandi)
- blocks the androgen receptor directly, preventing male hormones from signaling cancer growth. It works at multiple points in the pathway. Unlike abiraterone, it doesn’t usually require concurrent steroids.
Choosing between abiraterone and enzalutamide often comes down to their different side effect profiles, your other medical conditions, and sometimes insurance coverage. For example, abiraterone might cause less fatigue but has a higher risk of affecting blood sugar, while enzalutamide has a very low risk of seizures and can interact with blood thinners. Other androgen receptor pathway inhibitor are:
- Darolutamide (brando name Nubeqa)
- Darolutamide was engineered so that very little of it goes into the brain. Early studies show it causes less fatigue, fewer muscle issues, and fewer heart‑related side effects than some older ARPIs. No drug is side‑effect‑free, but this unique profile makes darolutamide a powerful option for many men.
- It can be used in several situations, including for non‑metastatic castration‑resistant prostate cancer, or in other words, for patients with local disease who haven’t had a good response to ADT alone.
- Apalutamide (brand name Erleada)
- Similar to enzalutamide, this is used in Metastatic Hormone-Sensitive Prostate Cancer (mHSPC) and Nonmetastatic castration-resistant prostate cancer. Common effects include fatigue, rash, thyroid test changes, and falls/fractures. Bone health strategies are important.
How Do Doctors Choose Between These Medicines?
Deciding which androgen receptor pathway inhibitor is right for you is not a “one-size-fits-all” choice. Your doctor will look at several factors before recommending one of these drugs:
- Stage of the cancer: Some drugs are approved earlier (before the cancer spreads), while others are mainly used when the disease is more advanced.
- Other health conditions: If you have heart problems, seizures, thyroid issues, or liver disease, certain medicines may be a safer fit.
- Side effect: For example, darolutamide may be chosen if there is concern about brain-related side effects like seizures or severe fatigue.
“Because the combination you’re hitting the both the good and the bad, you’re getting synergistic effects of the combination treatment in the benefit, but you’re also seeing the combined side effects and hormone therapy really does come with some debilitation for men. So some of the newer agents do seem to be more well tolerated and given with radiation therapy. It makes it more tolerable.” – adds Dr Chen.
- Other treatments you’re receiving: Sometimes ARPIs are combined with hormone therapy or chemotherapy, and the choice depends on the full plan.
- Lifestyle and preferences: Since all these drugs are pills, your doctor may also consider convenience, monitoring requirements, and what feels manageable for you.
- Cost & Access:
- Many of these therapies are branded and can be expensive. Don’t be shy about asking for help! Your clinic can connect you with financial counselors, manufacturer copay programs, and foundations.
- If one ARPI isn’t covered, an equally effective alternative may be. Clinical trials can also provide access to cutting-edge combinations and should be considered at any stage of advanced disease.
Your oncologist will recommend the option most likely to control the cancer effectively while also protecting your quality of life.
Coping With Prostate Cancer: Beyond the Medicine
While advances in treatment bring hope, it’s also important to focus on living well with prostate cancer.
Coping strategies include:
- Staying physically active, even with gentle exercise
- Eating a balanced diet
- Seeking counseling or support groups for emotional health
- Talking openly with your doctor about side effects: many can be managed
- Involving loved ones in decision-making
Remember, you are not just a “patient.” You are a person, with hopes, fears, and a life worth protecting.
Questions to Ask Your Doctor
- Am I eligible for Radioligand Therapy such as Pluvicto?
- Will I need to keep taking regular hormone therapy along with this Pluvicto?
- Am I eligible to receive androgen receptor pathway inhibitor?
- Which androgen receptor pathway inhibitor is best for my specific type and stage of prostate cancer?
- What side effects should I expect, and how can we manage them if they happen?
- How will we know if the drug is working — what tests or scans will I need?
- Are there reasons one drug may be safer for me than the others, given my other health conditions?
- Should I consider a clinical trial or newer options instead of, or in addition to, this medicine?
Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.
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