A 76-Year-Old Man With Recurrent Castrate-Sensitive Prostate Cancer - Episode 1

Case Overview: Castrate-Sensitive Prostate Cancer

An overview of the diagnostic work-up and treatment options offered to a 76-year-old male with castrate-sensitive prostate cancer who experiences recurrence.

Nicholas Vogelzang, MD, FASCO, FACP: Hi, I am Nick Vogelzang. I am a professor of medicine and medical oncology at the University of Nevada, both at Reno and at UNLV [University of Nevada, Las Vegas]. Today, I am happy to present a community-based case. This patient is a 76-year-old man who was diagnosed with prostate cancer and treated with external beam radiotherapy. We do not have a lot of information about exactly what his stage was, but it appears that it was stage T3b disease with seminal vesicle invasion. He was treated with only external beam radiotherapy, no adjuvant hormone therapy. We do not have a lot of information about his PSA [prostate-specific antigen] at the time of diagnosis. He was treated at a community hospital outside of Las Vegas.

He was not followed with PSA values, and he then presented to his community oncologist with intermittent hip pain and was ultimately found to have a PSA of 10 ng/mL. He had no family history of prostate cancer, and on examination, he had a limp and had lost weight. The PSA had rapidly escalated, with a doubling time of about 3 months. A biopsy of his prostate at the time of diagnosis had shown a Gleason Group 4, a score of 4+4. His bone scan showed 2 bony lesions, 1 in his left femur and 1 in his left acetabulum, therefore left pelvis. His CT scan of the chest, abdomen, pelvis showed pelvic lymph nodes on the left as well, so he was diagnosed with hormone-sensitive metastatic prostate cancer. Performance status was 1 because of his symptoms, limp, and decreased activity level.

The patient was then counseled about what to do. He was 76, and his choices were either 2-drug therapy with hormones and chemotherapy with docetaxel, or a 2-drug therapy with leuprolide and either apalutamide, enzalutamide, or abiraterone. We can argue about the decision: he did not want chemotherapy, although I usually recommend that. But he was instead offered one of the 3 doublet regimens and was given leuprolide therapy with apalutamide. At 3-month follow-up, his PSA dropped to 2 ng/mL. I usually see a slightly larger decrease. Imaging then showed no new lesions. If anything, the lesions were a bit brighter, showing as we would expect, some healing.

Transcript edited for clarity.


Case: A 76-Year-Old Male With Recurrent Castrate-Sensitive Prostate Cancer

History

  • A 76-year-old man diagnosed with localized prostate cancer, 4 years ago
  • At that time, he underwent EBRT


Currently

  • Patient was lost to follow-up; returns due to intermittent hip pain
  • PMH: obese, BMI 32; prostate cancer; otherwise unremarkable
  • FH: No known family history of cancer
  • PE: left hip tender to palpation, slight limp and evidence of decreased weight bearing on left lower limb

Clinical workup

  • PSA 10 ng/mL; doubling time 3 months
  • Core needle biopsy with TRUS showed adenocarcinoma of prostate
    • Gleason score (4+4)
    • Bone scan revealed 2 bone metastases: 1 in the left femur 1 in the left pelvis
  • Chest/abdominal/pelvic CT scan positive for 4 pelvic lymph node metastases
  • Diagnosis: stage IV mCSPC
  • ECOG PS 1
     

Treatment and Follow-Up

  • He was started on ADT + apalutimide 240 mg qDay
  • At 3-month follow up: PSA 2 ng/mL
  • Repeat imaging showed no new lesions