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Prostate Cancer Case Studies

Philip Kantoff, MD: Safety Considerations Regarding Treatment

Philip Kantoff, MD
Published Online:Jun 18, 2015
Andrew S. is a 62-year-old real estate attorney from Tampa, Florida. He is an active golfer and church volunteer.

Metastatic Castration-Resistant Prostate Cancer Issue 2: Case 1

In general, the philosophy is to move from the less toxic agent to the more toxic agent; reserve the more toxic agents for later on. The most toxic agents that we use in the context of prostate cancer are chemotherapies and, with the exception of using chemotherapy in metastatic hormone-sensitive prostate cancer, as per the recent data from the CHAARTED trial, chemotherapy is generally reserved for the end of disease because of the issue of toxicity. Moving from least toxic to most toxic, the least toxic option would be immunotherapy, specifically sipuleucel-T. In terms of toxicity level, next would be the hormonal agents, enzalutamide and abiraterone, third would be radium-223, and fourth would be chemotherapy.

CASE 1: Metastatic Castration-Resistant Prostate Cancer

Andrew S. is a 62-year-old real estate attorney from Tampa, Florida. He is an active golfer and church volunteer.

Patient underwent radical prostatectomy 4.5 years ago (at age 58 years).
  • At diagnosis, the patient’s PSA level was 8.5 ng/mL and his Gleason score was 4+3 = 7; stage T1c
  • Patient’s prior medical history is notable for prior smoking (quit 12 years ago), kidney stones, and hypertension (well controlled)
  • Patient is currently on antihypertensives; liver function tests are normal
Postop PSA is undetectable. At 16 months postop, the patient’s PSA is 0.8 ng/mL; a repeat measurement is 0.9 ng/mL.
  • Patient receives radiotherapy (64-70 Gy in standard fractionation) without androgen deprivation therapy
One year after radiotherapy, the patient’s PSA level rose to 2.1 ng/mL; CT imaging shows a 3.2-cm lesion in an obturator and several retroperitoneal lymph nodes (LNs).
  • Combined androgen blockade (CAB) initiated with an LHRH agonist and bicalutamide
  • PSA nadirs at 0.65 ng/mL
  • Side effects of CAB noted, including hot flashes and weight gain
Following 22 months of CAB, the patient’s PSA again increases from 0.65 ng/mL to 1.1 ng/mL, and then to 3.2 ng/mL.
  • Testosterone is 20 ng/dL
  • Patient is asymptomatic
  • On CT scan, the prior LNs are unchanged
  • Bone scan is positive for multiple lesions in the pelvis
  • Bicalutamide is discontinued, and patient is enrolled in a clinical trial of an immunotherapy
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