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A case study presented by Roy E. Berger, MD, was discussed by a panel that included doctors Daniel Petrylak, David Crawford, Howard Sandler, and Robert Dreicer. This real-life scenario consisted of four parts, and the audience was invited to vote for the treatment option they would use.
1. The patient is a 65-year-old, moderately obese man (115 kg), who is hypertensive and has hypercholesterolemia. Seven years ago, he had an iPSA level of 6.3, a Gleason score of 3 + 3 = 6, and underwent radical prostatectomy for adenocarcinoma. He experienced PSA failure 3.5 years after surgery and underwent salvage radiotherapy when his PSA level reached .85 ng/mL. After an initial decline, PSA values have increased over the past 3 years and are now 15.5 ng/mL, with a PSA doubling time of 4.5 months. The patient is asymptomatic but is worried and wants something done. He notes he has two primary goals in life: to see Ireland in the World Cup and to get his PSA down.Which of the following do you recommend?
A. Bone scan and CT scan of the abdomen and pelvis
B. Androgen deprivation therapy (with a plan to go to intermittent therapy)
C. PET-CT scanning
E. Pelvic MRI
Half the audience basically recommend an extended disease workup, and ~50% say they would treat with intermittent androgen therapy.Sandler:
My question is do you really need the abdomen when you are doing this? Doesn’t that cost twice as much?Dreicer:
Well, depending on how your center operates, it can cost more if they are billed as two separate procedures. I think you do need the abdomen because it is not uncommon for nodes to show up above the bifurcation, even in the absence of nodes in the pelvis.Petrylak:
One of the first patients I imaged with ProstaScint, in 1993, was a 38-year-old man whose supraclavicular lymph nodes lit up like a Christmas tree. We really did not know what to do with him at that point. We had a long discussion about whether he should be on hormones or whatever else. About 3 years ago, I received a letter from him saying he never relapsed in that spot, so there are clearly false positives with ProstaScint.
2. The physician involved in this patient’s care ordered a bone scan and a CT scan of the abdomen and pelvis. The bone scan showed no evidence of metastatic disease—only degenerative joint disease. The CT scan showed a positive right pelvic node.What would you recommend next?
A. Androgen deprivation therapy (ADT) + LHRH agonist to maximum response, then intermittently
B. Radiosurgery to the node
C. Expectant management
D. ADT plus 6 cycles of docetaxel
E. ADT + LHRH agonist continuously
There is not an indication for docetaxel in this situation. If this were a trial, I would say it is appropriate. Outside the context of a clinical trial, there is no evidence that giving up-front chemotherapy is going to improve somebody’s survival. An ECOG study is looking at the question of whether to give ADT with or without docetaxel. This is not a patient I would give docetaxel to.Sandler:
The logic for radiosurgery to the node might be that although he had salvage radiation, he had unifocal nodal disease that has grown out and because it is his only site of disease, you can attack it with radiosurgery to try to minimize any radiation overlap. It is a nice story, but pretty much a fable at this point. I would like it to be true, but I think it is unlikely. I am not saying radiosurgery would be wrong, but I would only do it in the context of long-term androgen ablation if you are trying to make a survival argument.
3. LHRH agonist therapy is initiated, and the PSA nadirs to .9 ng/mL. Over the next 38 months, the patient receives 3 cycles of intermittent androgen blockade. Now the patient has PSA progression up to 22 ng/mL in the setting of serum testosterone of 22 ng/mL. The patient remains completely asymptomatic. A CT scan shows a mild increase in adenopathy, and a bone scan is obtained, which is positive throughout the axial skeleton and pelvis.Which of the following would you do at this point?
A. Start bicalutamide at ≥50 mg/day
D. Refer to a clinical trial
E. Expectant management
This is an asymptomatic patient, and I think it’s appropriate to consider secondary hormonal manipulations or something like Provenge (sipuleucel T). The issue is when it is optimal to give chemotherapy. It is somewhat controversial as to whether you should administer chemotherapy when patients are progressing rapidly but remain asymptomatic or wait until they develop symptoms. I would probably hold off on chemotherapy at this point. It is certainly appropriate to consider a clinical trial. I am a little perplexed by the 13% who selected mitoxantrone/prednisone. In 2010, I do not really think that has a role for this patient in front-line therapy.Berger:
This would be the ideal patient for Provenge, in line with the indication for it. Bob [Dreicer], would you start other secondary hormonal therapies first and what would they be?