A 70-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer - Episode 1

Case Overview: A 70-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer

Alicia Morgans, MD, MPH presents the case of a 70-year-old man with progressive PSMA-positive mCRPC.

Alicia Morgans, MD, MPH: Today we’re discussing the case of a 70-year-old man with metastatic castration-resistant prostate cancer. He initially presented in May 2017, and at that time he had nocturia and a poor appetite. His work-up included a physical exam that was notable for a DRE [digital rectal scan] with an enlarged prostate but was otherwise unremarkable, and he had no significant past medical history. He underwent a biopsy of the prostate that demonstrated prostate adenocarcinoma with a Gleason score of 9, 5+4. His CT, because of the high-grade prostate cancer, showed pelvic nodal involvement, and his PSA [prostate-specific antigen] at that time was 42 with an LDH [lactate dehydrogenase] of 404. Luckily, his ECOG performance status was 1.

He initiated treatment with ADT [androgen deprivation therapy] alone and his PSA did respond, though not ideally, and [reached its lowest point] at 12. In December 2017, he developed right hip and abdominal pain and underwent CT imaging and bone scan imaging that demonstrated 2 metastatic bone lesions in the pelvis and diffuse liver lesions. His PSA was 30, his hemoglobin had fallen to 9.4 g/dL, and his ANC [absolute neutrophil count] was 1.5 per mm3.

He started docetaxel and completed 6 cycles, and he tolerated that relatively well. Follow-up imaging showed stable disease, which was particularly relevant in those liver lesions. In November 2018, his PSA was noted to have risen again, at that time hitting 40. Routine imaging showed new metastatic lesions in the bone of his pelvis. He started abiraterone and prednisone and had imaging after 6 months that showed progression of disease.

In May 2019, he underwent a PSMA [prostate-specific membrane antigen] scan because he was screening for the VISION trial, which showed several positive metastatic lesions in the pelvis as well as in those liver lesions. He was accepted in the VISION trial because he met imaging criteria for screening and was treated with 177Lu-PSMA-617 based on that protocol, in addition to treatment with enzalutamide, which was considered best supportive care. He ultimately tolerated treatment and received a full 6 cycles.

The story of this patient is common for men who develop metastatic castration-resistant prostate cancer. When I think about this case, I wish he did not get ADT alone in his initial treatment for metastatic hormone-sensitive disease. Unfortunately, we know that ADT-intensified therapy combinations are more effective and maintain quality of life, among other positive benefits, as compared with ADT alone, and the standard of care is to use a combination approach. Because he didn’t get a combination approach, he had a relatively short benefit and didn’t have an optimal PSA nadir to that initial therapy; this is not ideal but it’s not uncommon. Real-world evidence suggests that about half of men with metastatic hormone-sensitive disease receive ADT alone in that frontline setting. This is certainly something that we need to work on as a field and change to improve outcomes for our patients.

Transcript edited for clarity.

A 70-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer

May 2017

Initial presentation

A 70-year-old man presents with nocturia and decreased appetite

Clinical workup

  1. PMH: Unremarkable
  2. PE: DRE, enlarged prostate
  3. TRUS and biopsy revealed adenocarcinoma of the prostate gland, Gleason score 9 [5+4]
  4. CT showed minimal nodal involvement
  5. PSA 42 ng/mL, LDH 404 U/L
  6. His ECOG PS is 1

Treatment

  1. Patient started on ADT with initial PSA response 12 ng/mL

December 2017

  1. Patient complained of right hip pain and abdomen pain
  2. Imaging with CT and bone scan showed 2 metastatic bone lesions in the pelvis and diffuse liver lesions
  3. PSA 30 ng/mL; Hb 9.4 g/dL; ANC 1.5
  4. Patient started on docetaxel, 6 cycles completed
  5. Follow-up imaging showed stable disease

November 2018

  1. PSA 40 ng/mL
  2. Routine imaging shows new metastatic bone lesions in the pelvis
  3. Patient started on abiraterone and prednisone, after 6 months he has a restaging scan which shows continued progression of disease

January 2019

  1. Patient had a 68Ga-PSMA-11 scan when screening for the VISION trial which shows several positive metastatic lesions in the pelvis and liver metastases
  2. He qualified on screening and enrolled in a clinical trial and treated with 177Lu-PSMA-617 as per the VISION protocol (7.4 Gbq [100 mCi] every 6 weeks for 4-6 cycles)