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Prostate Cancer Case Studies

E. David Crawford, MD: Considering Immunotherapy

E. David Crawford, MD
Published Online:Jun 18, 2015
Frank B. is a married, 69-year-old real estate attorney from Lancaster, Pennsylvania. He also works as a part-time basketball coach and church volunteer.

Metastatic Prostate Cancer: Case 2

Dr. Crawford thinks that while one could certainly try immunotherapy, he would advise against, due to the amount of pain Frank is experiencing. Had the diagnosis come a few years earlier, immunotherapy may have been a more viable option. Dr. Crawford thinks that the best options for Frank right now include chemotherapy, enzalutamide, abiraterone, and even radium 223.

CASE 2: Metastatic Castration Resistant Prostate Cancer (mCRPC)

Frank B. is a married, 69-year-old real estate attorney from Lancaster, Pennsylvania. He also works as a part-time basketball coach and church volunteer.
  • His prior medical history is notable for hyperlipidemia, controlled with statins and diet
  • In February 2007, he underwent radical prostatectomy after presenting with a PSA of 19.7 ng/mL; patient was asymptomatic at the time of surgery
  • Pathologic evaluation of the radical specimen revealed prostate adenocarcinoma Gleason grade 7 (4 + 3), stage T3aN0M0
  • Following a biochemical recurrence in July 2012, the patient was initiated on ADT with depot leuprolide and bicalutamide
  • Within 6 months, his PSA reached a nadir of 0.4 ng/mL
  • ADT was associated with periodic hot flashes and erectile dysfunction, which were managed with vardenafil
In January of 2014, he was admitted to the hospital for moderate to severe back pain and spinal cord compression; his PSA at the time was 15 ng/mL, and his testosterone level was 37 ng/dL.
  • MRI revealed the presence of multiple abnormalities in the L1-L2 region; subsequent biopsy of these lesions was consistent with prostate adenocarcinoma
  • Palliative external beam radiotherapy was administered and ketoconazole was added to the patient’s ADT
  • Within 3 months, his PSA had declined to 9 ng/mL and patient is using NSAIDs for pain management
In December 2014, the patient’s PSA had again risen to 25 ng/mL; his testosterone level was 22 ng/dL.
  • Patient was asymptomatic, and MRI showed the spine lesions to be stable
  • He declines further treatment at the time due to his daughter’s upcoming wedding in December
  • Pain is managed sufficiently with NSAIDs
In February 2015, he presents to his oncologist with increasing PSA and worsening performance status (PS2); his back pain is no longer sufficiently controlled by NSAIDs.
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