William Oh, MD: Comparison of Chemotherapy to a Secondary Hormone at the Time of Progression

At the time of progression, would you go back to chemotherapy or use a secondary hormone?

We know that these patients will eventually progress. If we assume that this patient may progress about two years after he completes treatment, that would not be an unusual timeline. And the question is, what should we do at that time? Should we start back on chemotherapy? Should we consider an AR-targeted therapy or something else? And this is a question that we really don’t fully know the right answer to, partly because the CHAARTED and STAMPEDE patients have not been followed long enough to know whether there’s an optimal sequence of next treatment.

I normally start metastatic CRPC patients who progress first-line with an androgen receptor (AR)—targeted therapy. In this type of patient I might use abiraterone/prednisone, or enzalutamide. Some of these patients I’ll also, if they’re relatively asymptomatic, use a treatment like sipuleucel-T.

CASE: Metastatic Prostate Cancer (Part 2)

Mathew J is a 61 year old African American male who presented to his primary care physician with lower urinary tract symptoms, including sporadic hematuria. He complains of abdominal pain and low back pain starting four months ago and increasing in frequency. Prior medical history includes non-insulin dependent diabetes mellitus, well-controlled on metformin since 2006. The patient was referred to urology for further evaluation. ng/ml.

During his most recent follow-up exam, the patient complained of intermittent back pain and increasing fatigue.

• Digital rectum exam revealed nodular prostate /L
• Serum PSA level; 129 ng/ml
• Alkaline phosphatase, 258
• TRUS/prostate biopsy: 53 gram prostate, 12/12 cores (+), Gleason 4 + 5
• CT indicates blastic lesions to lumbar spine and pelvis
• Bone Scan positive for T/L spine, pelvis, right femur, scapula
• ECOG performance status, 1