Castrate-Sensitive Prostate Cancer: Treatment Planning

Nicholas Vogelzang, MD, FASCO, FACP: If we think about using a full androgen receptor-targeted therapy, in this case we are getting the leuprolide and apalutamide regimen, that gives us options for care. When he relapses, which is hopefully not for a long time, we still have docetaxel, we have radium, and we have sipuleucel-T. I should also mention that this patient should have at least some attempt made to obtain BRCA-targeting data. We should know whether he has PARP inhibition therapy options. I always tend to get germline testing and somatic testing done. I routinely get germline testing done, and I get somatic testing done on the tissue itself, so if he relapses down the road, then I have the opportunity for both olaparib and rucaparib therapies, depending upon which DNA repair deficiency enzyme the patient has. For example, I saw a patient the other day who has Bloom syndrome, and he has a rapid PSA [prostate-specific antigen] doubling time, so I am preparing to give him olaparib if his symptoms rapidly worsen. That is the treatment planning sequence, if you will.

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