Treating Prostate Cancer with Low-Volume Metastatic Disease


Bobby Liaw, MD, explains the potential treatment strategy for a prostate cancer case with low-volume metastatic disease.

Bobby Liaw, MD: If this patient had recurred with his Gleason score 8 prostate cancer with low-volume disease, then off the bat, I’d say that chemotherapy would be a much less considered option, only because the data for docetaxel use in low-volume metastatic castration-sensitive disease aren’t as appealing as for high-volume disease. When you think about apalutamide and enzalutamide, both of these studies included patients with low-volume disease. About a third of cases were considered low-volume disease by CHAARTED trial criteria. And looking at the subgroup analysis, both drugs—apalutamide and enzalutamide—retained good consistency in terms of disease control and survival advantage in the low-volume patients. Certainly, in low-volume disease, I wouldn’t consider chemotherapy, but apalutamide remains a good option with good data to support its use.

In an alternate situation where there are no signs of radiographic disease on scans, oftentimes after prostatectomy, we have the consideration for whether they’d be a good candidate for salvage therapy. By salvage therapy, I’m usually talking about salvage radiation combined with hormone therapy. It could be argued that for anyone who still has a PSA [prostate-specific antigen] that’s as elevated as 12 ng/mL following a prostatectomy, salvage radiation is unlikely to give you a second chance at a cure. But usually, that would be one of the things that we’d at least first consider and discuss with radiation oncology about.

Outside of the prospect of salvage radiation, for someone who has a rising PSA after prostatectomy, this patient just had monitoring of his PSA levels. The other tactic that we’ll often utilize in biochemical recurrence is hormone therapy. But more specifically, we’d consider a patient for intermittent use of hormone therapy. For patients with biochemically recurrent disease, there have been studies looking at intermittent vs continuous use of hormone therapy, for which intermittent use was shown to be noninferior to continuous use and noted to have some potential improvements in quality of life. The more time that we can give people off of hormone therapy to have normalized testosterone levels goes a long way to making men feel generally physically better. I would’ve considered intermittent hormone therapy for this patient outside of just monitoring.

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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