mCSPC: Patient Variables and Treatment Selection


Ralph V. Boccia, MD: We always have to consider all the potential comorbidities that patients have when we try to target the specific therapy that would be best for them. With abiraterone, as I mentioned to you, you must use an additional steroid, hydrocortisone. When you use androgen blockade, you can potentially decrease corticosteroid synthesis, and you have the potential to cause adrenal crisis in those patients. We always give additional corticosteroids in patients now who are given abiraterone. The patient who we’re talking about has diabetes, so anytime we give a corticosteroid to a diabetic patient, the gluconeogenesis that occurs can often cause havoc with controlling the patient’s blood sugar. This would not be the best patient to go ahead and give abiraterone to with his androgen deprivation therapy. I’d much rather give either enzalutamide or apalutamide rather than abiraterone.

We like to risk stratify our patients with almost any disease. Whether we’re using monotherapies or multiagent chemotherapies, they’re often going to be defined by what our goal is for that particular patient, the volume of disease they have, and the outcomes and goals we’re looking for, just as we talked about earlier. This is a man with high-volume disease. If we use single-agent monotherapy with androgen deprivation therapy, I quoted you the data, this patient has a short progression-free survival, and then we’ll be on to other things anyway. We want to look at the data for the other clinical trials and see whether we can get around some of those short progression-free survival and potential overall survival issues that we’ve already talked about.

Transcript edited for clarity.

Case: A 66-Year-Old Male with Metastatic Castrate-Sensitive Prostate Cancer

Initial presentation

  • A 66-year-old man presented with mild intermitted back pain
  • PMH: DM; medically controlled; OTC analgesics for pain
  • FH: No known family history of cancer
  • PE: DRE revealed an enlarged prostate; otherwise unremarkable

Clinical Workup

  • PSA 70 ng/mL
  • Core needle biopsy with TRUS showed adenocarcinoma of prostate
    • Gleason score (4+4)
  • Bone scan revealed 4 spinal lesions (T8/T9, L1/L2) and 1 in the right femur
  • Chest/abdominal/pelvic CT scan was negative for distant metastases
  • Diagnosis: stage IV mCSPC
  • ECOG PS 1

Treatment and Follow-Up

  • He was started on ADT + apalutimide 240 mg qDay
  • At 2-month follow up: PSA 10 ng/mL
  • No new lesions on repeat imaging
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