A 76-Year-Old Man With Recurrent Castrate-Sensitive Prostate Cancer - Episode 8

Treatment Advances in Castrate-Sensitive Prostate Cancer

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

Nicholas Vogelzang, MD, FASCO, FACP, reacts to treatment advances in hormone-sensitive prostate cancer and provides advice to oncologists who work in community settings on best practices for managing these patients using newer treatment strategies.

Nicholas Vogelzang, MD, FASCO, FACP: The world of castrate-sensitive disease has moved beyond leuprolide in capsules. That is an outmoded therapy. We now use either leuprolide and Zytiga [abiraterone], leuprolide and Xtandi [enzalutamide], or leuprolide and apalutamide, and/or we use leuprolide and docetaxel. Those are the current options. There is now a study, PEACE-3, with leuprolide, darolutamide, and potentially docetaxel, and that may mean that a 3-drug regimen becomes the standard of care. We will see, data are pending.

There are now several studies that are going beyond 3-drug therapy. Merck has a trial underway in which they are allowing patients to get leuprolide and docetaxel. If they then have 2 or more bone metastases, they are randomizing the patients to enzalutamide with or without pembrolizumab. That would be taking it another step further, making it a 4-drug regimen for hormone-sensitive disease. You might imagine that would be leuprolide and docetaxel, then enzalutamide maintenance, and potentially pembrolizumab as a fourth drug. This is a push to 4 drugs earlier in the natural history of the disease. There is more interest in putting more drugs earlier in the course of hormone-sensitive therapy. That will potentially mean that, by the time you get to castrate-resistant disease, you will truly have castrate-resistant disease. There will be cancer that is harder and more resistant to treat.

In general, we will be needing more drugs, and that will leave us with the docetaxel and cabazitaxel, radium, and sipuleucel-T as our second line of therapy, if you will. For the community doctors, the benefit of this layering of therapy is that there will be more treatments given to castrate-sensitive disease earlier and earlier. This means that the urologists who are not intensifying treatment are going to give way to medical oncologists who are willing to be more intensive for the castrate-sensitive patients. I would encourage all men, and all medical and urologic oncologists, to be more intensive for the hormone-sensitive patients. I believe that is the wave of the future, and with that, we will hopefully get longer and longer survivals.

I want to thank you for inviting me to do this tonight. I appreciate your time, and I look forward to learning more about this exciting time. We are in a truly important time for these patients who need more and more treatments earlier in the natural history of their disease.

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