Charles J. Ryan, MD: Additional Treatment Options Following Immunotherapy

Andrew has multiple options that could be considered standard: abiraterone, enzalutamide, or chemotherapy. Observation for a time is also reasonable. Dr. Ryan would not recommend radiation to the metastatic sites in this patient. He would consider starting denosumab in this patient, given that he has multiple bony metastases.

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