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).
Postop PSA is undetectable. At 16 months postop, the patientâ€™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 patientâ€™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 patientâ€™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