A 76-Year-Old Man With Recurrent Castrate-Sensitive Prostate Cancer - Episode 2

Managing Castrate-Sensitive Prostate Cancer

February 9, 2021
Nicholas J. Vogelzang, MD, FASCO, FACP

Important considerations for oncologists who manage prostate cancer when establishing a treatment plan for a patient with castrate-sensitive disease.

Nicholas Vogelzang, MD, FASCO, FACP: The hormone-sensitive patients do extremely well. SWOG [Southwest Oncology Group] and others have shown that, if by 9 months, or 6 months after start of therapy, somewhere in the 6- to 9-month period, the PSA [prostate-specific antigen] gets to be below a certain level; there are 3 categories. If the PSA gets to be undetectable, the median survival is on the order of 7 to 9 years. If the PSA, on the other hand, does not go below 4 ng/mL, then the median survival is only 2 years or less. If the PSA is between 4 ng/mL and above 0.1 ng/mL, the median survival somewhere is ranging between 2 and 4 years. What we want is a time-dependent landmark analysis. At 3 months, a PSA of 2 ng/mL is quite good. I would like it lower, but it is quite good, and we expect it to decline even further.

The goals of treatment are that the patient dies of something else, not prostate cancer. That is my goal. at 76 years of age, the patient’s life expectancy is probably about 10 years. If we can get him to that 10-year mark with prostate cancer disease free, then we would be doing well. Remember that he does not have a lot of disease, so we would also integrate the consideration of radiation into his treatment for all disease. That would be another approach. Given that he has already had radiation to the prostate, the bones could be radiated. Whether the lymph nodes could be radiated is somewhat unclear, so it would be something to consider but not in a routine fashion.

I do not think that we need to do too much with advanced imaging. We have good data that the bone scan and the CT scan are accurate. If we were to do radiotherapy to all sites of disease, then we might consider advanced imaging with either the Blue Earth [Diagnostics] or the PSMA [prostate-specific membrane antigen] scan. I do not think that advanced imaging plays a big role. As long as we are going to be doing hormone therapy for this patient, I would not put a big role for advanced imaging in this particular patient.

Transcript edited for clarity.


Case: A 76-Year-Old Male With Recurrent Castrate-Sensitive Prostate Cancer

History

  • A 76-year-old man diagnosed with localized prostate cancer, 4 years ago
  • At that time, he underwent EBRT


Currently

  • Patient was lost to follow-up; returns due to intermittent hip pain
  • PMH: obese, BMI 32; prostate cancer; otherwise unremarkable
  • FH: No known family history of cancer
  • PE: left hip tender to palpation, slight limp and evidence of decreased weight bearing on left lower limb

Clinical workup

  • PSA 10 ng/mL; doubling time 3 months
  • Core needle biopsy with TRUS showed adenocarcinoma of prostate
    • Gleason score (4+4)
    • Bone scan revealed 2 bone metastases: 1 in the left femur 1 in the left pelvis
  • Chest/abdominal/pelvic CT scan positive for 4 pelvic lymph node metastases
  • Diagnosis: stage IV mCSPC
  • ECOG PS 1
     

Treatment and Follow-Up

  • He was started on ADT + apalutimide 240 mg qDay
  • At 3-month follow up: PSA 2 ng/mL
  • Repeat imaging showed no new lesions