Clinical Pearls for Community Oncologists Treating Prostate Cancer


Daniel J. George, MD, offers closing thoughts and advice to community oncologists who treat patients with prostate cancer.

Case: A 65-Year-Old Man With Prostate Cancer

January 2018

Initial Presentation

  • A 65-year-old man was diagnosed with localized prostate cancer
  • Biopsy revealed adenocarcinoma of the prostate gland, Gleason score 7 [4+3]
  • PSA 15.7 ng/mL
  • Baseline staging: T3bN1M0 with right seminal vesicle and pelvic lymph node involvement

Initial Treatment

  • He undergoes radical prostatectomy with PLND
    • PSA nadir of 0.4 ng/mL post-surgery
    • Gleason 7 (4 + 3) confirmed
    • Positive surgical margins
    • Baseline staging confirmed – AJCC Stage IVA

February 2019

Follow-Up Notes

  • Serum PSA, 38 ng/mL; ALP, 289 IU/L
    • Metastatic retroperitoneal LNs outside resection field
    • Abdominal nodes
    • Bone mets in ribs and thoracic spine
  • Genetic testing: BRCA2 mutation-positive

Additional Treatment

  • Abiraterone + prednisone initiated
  • Improved pain, PSA, and ALP

October 2019

Follow-Up Notes

  • Patient reported bone pain
  • Laboratory testing revealed rising PSA and ALP (serum PSA, 350 ng/mL; ALP, 2500 IU/L)
  • Imaging showed radiologic progression
  • ECOG PS 1
  • PSMA PET CT: increased uptake in retroperitoneal and abdominal LNs

mCRPC Treatment

  • Treated with docetaxel x4 cycles and denosumab
    • Serum PSA, 38 ng/mL; ALP, 289 IU/L
    • Reporting bone pain increased in back, now reporting pain in hip area
  • Bone scan and CT scan:
    • Enlargement of retroperitoneal and abdominal LNs
    • Additional bone mets noted in pelvic region


Daniel J. George, MD: These drugs are still cancer drugs, and all of our cancer drugs have a toxicity profile that we need to respect. There will be patients who don’t tolerate a PARP inhibitor, and we must accept that. That doesn’t mean that the drugs are toxic. If you have a patient who can’t tolerate the drug, probably 1 in 5 patients, that’ll be the case. It might be a little bit more in our general practice [but that] shouldn’t deter you from using this, particularly in our patients with BRCA mutations. These are our patients who get a significant clinical benefit associated with the drug and novel hormonal agents, and we must find and treat these patients. So don’t be deterred if you have a patient who can’t tolerate the drug.

Secondly, some of the toxicities are not things that we’re going escalate to a grade 3 level, taste changes or feeling a little queasiness. We must recognize that we’re dealing with a patient population who in the real world in our nonclinical trial practice, have a median life expectancy of about 2 years. So, yes, it’s annoying to have some taste changes or some intermittent nausea, queasiness, or a little bit of a loose stool, but if it means disease control, not dying from the cancer, or [not] progressing on the cancer, that’s huge. Keep it in context, the population of patients we’re treating and the threshold for toxicity tolerance, because it’s different than, say, someone starting on hormonal therapy in relapse-setting prostate cancer, where they might live for 10 years. This is a different patient population. Some of these patients are going to die within a year, and controlling and slowing that disease pace for any period of time, even a few months, is going to be incredibly meaningful, and patients will be willing to put up with this if they know their disease is under control.

To me, there are 2 tricks to this. One is to watch them early in the first 3 months, every couple of weeks, check on your patients, see them every 4 weeks, have a nurse call or check on them every 2 weeks for that first couple of months, and check those blood counts regularly; every month or even sooner if you’re seeing a drop. The second thing is check results early. There’s nothing more motivating [than] for a patient to see a PSA [prostate-specific antigen level] drop, to see some disease stabilization on scans, to feel some improvement in their disease-related symptoms; so monitor for that. Reinforce that with patients every 2 months. I’m checking patients radiographically, checking PSAs every month and giving those patients the feedback they need to know, [that] this drug is changing their disease course, and it’s worth putting up with those [adverse] effects. It’s incredibly helpful for patients’ resiliency to know that their disease is under control.

Those…to me, are the 2 key lessons, and applying this now in practice and [being] prepared to do transfusions. That’s not a failure, that’s a support, even if that’s not necessarily in your practice. You must work with a hospital somewhere nearby to get that prearranged that so that it’s not a scramble when that happens. It’s something, even if it’s a night or a weekend, that you can manage that for the patients and hopefully avoid emergency [departments] as much as possible. Those would be the biggest preparations you can make for using this in your practice.

Transcript edited for clarity.

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