A 70-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer - Episode 3

Follow-up and Monitoring

An overview of how patients with mCRPC are monitored and followed-up in practice and the triggers to reevaluate the treatment patient is receiving.

Alicia Morgans, MD, MPH: Patients with metastatic CRPC [castration-resistant prostate cancer] are followed in many schemata in our clinical practices. At present, there is no specified idealized way for us to follow these patients. I see the majority of my patients with mCRPC [metastatic CRPC] every 4 to 6 weeks. Typically, that’s because I want to make sure their LFTs [liver function tests] are within normal limits, they’re not having a rising PSA [prostate-specific antigen], their testosterone is adequately suppressed, and they’re clinically doing well. For patients who are on ADT [androgen deprivation therapy] plus an AR [androgen receptor]–targeted agent and who have a relatively low burden of disease, they can go longer; some of those patients don’t come in except possibly every 12 weeks if they’re stable on their combination therapy.

The duration of time between follow-up visits is dictated by the burden of disease, the symptomatology of the patient, and the location of metastatic sites. For example, if a patient has liver metastases, I’ll see them more frequently than a patient who has some pelvic nodal metastases. For patients who have a lot of pain associated with their mCRPC, I’ll likely see them more frequently to make sure their pain control remains adequate and to follow them closely for signs of clinical progression.

PSA is something we follow when we’re monitoring patients who have metastatic CRPC, but in most cases I don’t change therapy based on a rise in PSA alone. I think of PSA as being a canary in a coalmine, something that changes and signals that something ominous could be happening and alerts me to get imaging in those cases. I also consider PSA in combination with the patient’s clinical status. If a patient has a rising PSA and is also developing a change in taste or is losing weight without trying, I consider that combination particularly concerning for progression of disease and will immediately get imaging to back me up, but I’m thinking about where we need to go next in terms of treatment.

If a PSA is only slightly increasing and the patient feels quite well, there’s a good chance that imaging will demonstrate that there’s relatively little to no change and we don’t need to change treatment. These are ways that we can be signaled that something could be happening, but PSA alone in most cases isn’t sufficient for me to change treatment, at this time at least.

Transcript edited for clarity.

A 70-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer

May 2017

Initial presentation

A 70-year-old man presents with nocturia and decreased appetite

Clinical workup

  1. PMH: Unremarkable
  2. PE: DRE, enlarged prostate
  3. TRUS and biopsy revealed adenocarcinoma of the prostate gland, Gleason score 9 [5+4]
  4. CT showed minimal nodal involvement
  5. PSA 42 ng/mL, LDH 404 U/L
  6. His ECOG PS is 1

Treatment

  1. Patient started on ADT with initial PSA response 12 ng/mL

December 2017

  1. Patient complained of right hip pain and abdomen pain
  2. Imaging with CT and bone scan showed 2 metastatic bone lesions in the pelvis and diffuse liver lesions
  3. PSA 30 ng/mL; Hb 9.4 g/dL; ANC 1.5
  4. Patient started on docetaxel, 6 cycles completed
  5. Follow-up imaging showed stable disease

November 2018

  1. PSA 40 ng/mL
  2. Routine imaging shows new metastatic bone lesions in the pelvis
  3. Patient started on abiraterone and prednisone, after 6 months he has a restaging scan which shows continued progression of disease

January 2019

  1. Patient had a 68Ga-PSMA-11 scan when screening for the VISION trial which shows several positive metastatic lesions in the pelvis and liver metastases
  2. He qualified on screening and enrolled in a clinical trial and treated with 177Lu-PSMA-617 as per the VISION protocol (7.4 Gbq [100 mCi] every 6 weeks for 4-6 cycles)