Treating Biochemical Recurrence of Prostate Cancer with High-Volume Castration-Sensitive Metastatic Disease


A prostate cancer expert reviews the treatment approach in the presented case of biochemical recurrence of prostate cancer with high-volume castration-sensitive metastatic disease.

Bobby Liaw, MD: Circling back on our case and thinking a little about some of the treatment decisions that were made following the surgery, for a patient to still have a PSA [prostate-specific antigen] that’s elevated to about 12 ng/mL after a curative intent prostatectomy, even though bone and CT scans at the time didn’t necessarily show anything, I personally would’ve tried to get him some more advanced imaging. Like I mentioned before, it’s not always the easiest thing to obtain, depending on where you are, but an Axumin PET [positron emission tomography] scan or a PSMA [prostate-specific membrane antigen] PET scan are both going to be much more specific and sensitive for picking up stray residual, perhaps even more microscopic-size disease that the CT and bone scans will not pick up. I bring this up only because if we were able to capture the disease at an earlier point, perhaps we would’ve tried to start him on at the very least ADT [androgen deprivation therapy] alone first.

But going with what we have once the disease is shown to be metastatic, now that we know that it’s in bone and liver, and taking into consideration some of the patient’s personal priorities—he wanted to make sure he was going to be able to remain active and involved in his family life—and also some of his personal history of baseline LFT [liver function test] abnormalities due to his alcoholic cirrhosis, it was a pretty good idea to go with apalutamide. The reasoning is that chemotherapy can be difficult for some patients to tolerate.

Certainly, whenever I offer chemotherapy to any of my patients, they always understand that docetaxel is generally pretty well tolerated, and because we have so much experience in using it, we feel pretty confident that we should be able to support them through some of the potentially mild or difficult adverse effects they might come across. But there’s going to be something, such as the LFT abnormalities, that we don’t have as much control over. Knowing that we run into LFT abnormalities at times with abiraterone, it requires more frequent laboratory testing to make sure we don’t run into electrolyte abnormalities or LFT abnormalities. For someone who really wants to prioritize their home life and not always be tied to the office for follow-up and laboratory tests, apalutamide is a very good drug to select in this type of a context.

I’ll also mention that when we look at his particular case, liver metastases aren’t the most typical presentation for prostate cancer recurrence. You can make the argument that for a Gleason score of 8, these are more high risk, you might be at a higher likelihood of having visceral metastases. But whenever I see visceral metastases, we know that these typically portend a worse overall prognosis. I usually will find a way to be a little more aggressive and try to find ways to offer chemotherapy in this type of a context, as I feel like that’s something that’s possibly pretty valuable in terms of this patient’s long-term treatment. That’s not to say that there weren’t patients with hepatic metastases on the TITAN study, which was the phase 3 study that got apalutamide its FDA indication. But the number of cases of patients with hepatic metastases in the TITAN study was relatively low.

We do see that in the subgroup analyses of people with visceral metastases, apalutamide still performed very well. But at the same time, knowing that this is perhaps something that’s going to be a little more on the poor prognostic side of things, I generally try to take a much more aggressive stance on it. But as always, individualizing treatment decisions to patient characteristics, disease characteristics, but also according to the patient’s preference, also need to be considered. All in all, I still think it’s a very solid and reasonable decision to go with apalutamide.

Transcript edited for clarity.

Case: A 73-Year-Old Man With Biochemical Recurrence of Prostate Cancer and Metastatic Castration-sensitive High-volume Disease

January 2018

Initial Presentation

A 73-year-old man presents with urinary retention, fatigue and decreased appetite

Patient History, Lifestyle and Clinical workup

History of mild alcoholic liver cirrhosis

No family history of prostate cancer

Patient is active and is very involved in his grandchildren’s activities

TRUS and biopsy revealed adenocarcinoma of the prostate gland, Gleason score 8 [4+4] with disease in 10/12 cores.

PSA 150 ng/mL; Hb 9.7 g/dL; ANC 1.9

Liver function tests are abnormal

Initial Diagnosis and Treatment

Patient is diagnosed with localized prostate cancer

He undergoes robotic radical prostatectomy with subsequent PSA decrease (12 ng/mL)

CT and bone scans showed no residual disease

October 2019

Presentation at Recurrence

Patient complains of right hip pain and abdominal pain

Imaging with CT and bone scan showed multiple metastatic bone lesions in the pelvis and diffuse liver lesions

PSA 90 ng/mL; Hb 9.4 g/dL; ANC 1.5

Liver function tests continue to be abnormal

Diagnosis of Recurrence

Patient is diagnosed with biochemical recurrence of prostate cancer with high-volume castration-sensitive metastatic disease

Germline genetic testing is negative

Treatment for Recurrence

Patient wishes to receive oral treatment with good quality of life so he can continue to be involved in his grandchildren’s activities

Due to his abnormal liver function tests and desire to receive oral treatment, he is started on ADT + apalutamide

At his 1-year follow-up, the patient’s PSA remains undetectable

Follow-up imaging shows stable disease, and he continues to report a good quality of life

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