Charles Ryan, MD: The Role of Chemotherapy and Local Therapy

Is chemotherapy appropriate in this patient? What about local therapy?

This is a patient who’s presenting at a relatively young age of 61 with a very high-risk situation. He’s got symptomatic disease, lower urinary tract symptoms. He’s got a large prostate with a high Gleason score. He’s got multiple sites of bone metastasis. We’ve known for a long time that hormonal therapy is going to be very effective in the beginning and sort of putting all of this into a remission, if we can use that term. But ultimately, patients do progress, and this is a person who’s at very high risk, ultimately, for mortality from his prostate cancer. We have learned over the last couple of years from a couple of very pivotal studies that the early integration of chemotherapy is likely to prolong survival by quite a significant margin. Chemotherapy compared to no chemotherapy in a setting like this reduces the risk of death by about 40%, so that’s quite a significant reduction in the long-term hazard of this. The survival benefits for a population treated with chemotherapy extend well beyond a year. So this is really an important consideration for this patient.

CASE: Metastatic Prostate Cancer (Part 2)

Mathew J is a 61 year old African American male who presented to his primary care physician with lower urinary tract symptoms, including sporadic hematuria. He complains of abdominal pain and low back pain starting four months ago and increasing in frequency. Prior medical history includes non-insulin dependent diabetes mellitus, well-controlled on metformin since 2006. The patient was referred to urology for further evaluation. ng/ml.

During his most recent follow-up exam, the patient complained of intermittent back pain and increasing fatigue.

• Digital rectum exam revealed nodular prostate /L
• Serum PSA level; 129 ng/ml
• Alkaline phosphatase, 258
• TRUS/prostate biopsy: 53 gram prostate, 12/12 cores (+), Gleason 4 + 5
• CT indicates blastic lesions to lumbar spine and pelvis
• Bone Scan positive for T/L spine, pelvis, right femur, scapula
• ECOG performance status, 1