Best order to take treatments, one after the other or take them all together ?

This is about treatments for Metastatic Castrate Resistant Prostate Cancer (mCRPC).

There is currently a whole list approved drugs (Jevtana, Novantrone, Provenge, Taxotere, Xofigo, Ztandi, Zytiga) and nobody seems to know in which order they should be used !.

Recent publications of small-scale research gives some indication, for example for Xtandi taken after Taxotere and Zytiga www.ncbi.nlm.nih.gov/pubmed/24074764‎ , the PSA-response was only 13% (PSA-response is the percentage of patients that get 50% or more reduction of PSA). The same conclusion was reached in another publication: www.ncbi.nlm.nih.gov/pubmed/24255983‎

In lab-experiments (in vitro) it was shown that after using Zytiga, and having failed on it, the results for Taxotere, Jevtana and Xtandi were less good (they called it: cross-resistance).
www.ncbi.nlm.nih.gov/pubmed/24200698

One of the advantages of Zytiga, when used before Taxotere, has been said that it increased the time that chemotherapy was required (Results of trial COU-AA-302, presented by C J Ryan at ASCO 2012).

Dr. R L Leibowitz, however, says that as soon as ADT ('chemical castration' by Lupron, Zoladex, etc.) and anti-androgen(AA) treatment(Casodex or Xtandi) have failed, you should start chemotherapy. According to him, not just Taxotere, but that combined with 6 other drugs (2 other chemos, carboplatin and estramustine, 2 anti-angiogenics, Leukine, and a bloodthinner).

Somebody who would agree that you should start chemo early is the urologist Marc, who got suddenly PC himself, metastatic to bone, G9, PSA=5.6. advancedprostatecancer.net/?p=2336#more-2336
After just 3 months of ADT and AA (Lupron and Casodex), he received both Taxotere and carboplatin chemos, for 3 months (4 times 3-weekly). And Neulasta to raise his white blood cell counts. And he got Provenge. His PSA became 0.01 and after 20 months it was still 0.01. Marc: 'I had no difficulties with the chemotherapy, perhaps as I did it upfront while I was relatively healthy.'

But why wait 3 months ? In 1977, yes, 37 (thirty-seven !) years ago, the Israeli urologists drs Mukamel and Servadio already observed that the results are very poor when single-treatments are scheduled after the previous therapy has ceased to be effective. And inevitably they do. ' ... an aggressive combined systemic therapeutic approach from the start, would give such a group of patients--already with generalized disease--a better long-term result'.
www.ncbi.nlm.nih.gov/pubmed/7423702 , 6857889, 3660524 , and the most recent
www.ncbi.nlm.nih.gov/pubmed/1532103

They applied, right after DX of metastatic PC:
- ADT: castration (could now be 'chemical castration' with Lupron, Zoladex, etc.)
-AA: Androcur (could now be Casodex, Xtandi)
-oestrogen: DES (at too high dose; could be ethylene estradiol (patches, Lynoral)
-chemos: 5-fluoracil(F) and cyclophosphamide(C), both 10mg/kg weekly.

After 15 years 28 % of the patients had died of other causes, but only 28% died of PC and 40% were still alive ! (it is a one-institute result with a small number of patients, not all of them were involved for the whole time).

Compare this with the result of the Taxotere trial (TAX327): after 19 months 50% survived, and after just 3 years, only 15% were alive (from the start of the treatment).

N.B.1. The combination of chemos FEC, where E stands for Epirubicine, and the others mentioned above, is still sometimes used for BreastCancer patients.
N.B.2. 4.25 years after DX this knowledge comes too late for me. Hopefully it might help you in taking your decisions.

Now more med oncs are moving to Provenge as soon as possible as early indications are that the subsequent treatments with other drugs become more effective and durable than without or before Provenge. Too soon to really know anything long term. Also some are combing Provenge with other drugs like zytiga on an adjuvant basis instead of sequential.

My team holds the view that combination therapies are better than sequential therapies, thus I did adjuvant radiation (HDR Brachytherapy and IMRT) and HT (Lupron/Eligard, Casodex and Jalyn). They also hold the current view that Provenge should be introduced as early as possible and before other treatments like Taxotere. They set up the high risk patients an a system that allows them to recognize the earliest opportunity to introduce Provenge. Again, too early to really assess the results.

From what I read, the sequencing of treatments is also highly dependent on the individual as we know this disease can act remarably differently from man to man. I agree with Logo that we should attempt to get with very experienced doctors that can demonstrate positive results and are willing to do what it takes to get the results.

My Oncologist plans on using Provenge as the first treatment after CRPC is detected...I'm still coasting along on ADT, PSA under 1.0, enjoying my last hurrah's as it was...My onco feels he now has the tools to keep me going for a fair number of years...Since I can't do too much about it, I don't worry too much about it....