Celestia S. Higano, MD, FACP
In the ever-evolving treatment landscape in metastatic prostate cancer, healthcare providers have more options that ever before. Although guideline organizations have now incorporated the results of major clinical trials into treatment paradigms, much controversy remains over how best to sequence therapies, according to experts who participated in a recent OncLive
In recognition of this complexity, moderator Raoul S. Concepcion, MD, FACS,
and colleagues took a case-based approach to explore the ways in which oncologists and urologists can employ newly acquired evidence to manage patients whom they encounter in their practices. The Peer Exchange session, entitled “Integrating Prostate Cancer Trial Findings Into Practice: A Case-Based Discussion,” incorporated four cases, two of which are presented here.
Case Study 1
Newly diagnosed patient with hormone-naïve, confirmed metastatic prostate cancer
: A 58-year-old African American male, PSA 251.8 ng/dL, presents to emergency department in January 2015 with abdominal and lower back pain
Past medical history: Coronary artery disease; insulin-dependent diabetes
Physical exam: Cachectic, poor dentition
Digital rectal exam: Nodular prostate (B)
CT: Multiple blastic lesions to lumbar spine and pelvis but no soft tissue lesions
Biopsy: 53-gram prostate, 12/12 positive cores, Gleason score 4 + 5
Bone scan: Positive to the thoracic and lumbar spine, pelvis, right femur, and scapula
Although it may be unusual for clinicians to encounter newly diagnosed patients with high-grade prostate cancer metastatic to the bone, researchers have noted an increase in patients presenting with high-risk disease since the US Preventive Services Task Force changed its recommendations on prostate cancer screenings,1
noted Joseph F. Renzulli, II, MD, FACS
Raoul S. Concepcion, MD
He said he is seeing more high-grade cancers in his urology practice.
In the case of a newly diagnosed patient with hormone-naïve high-grade metastatic prostate cancer, initiating therapy with a luteinizing hormone-releasing hormone antagonist (LHRH) would be appropriate, said Renzulli. “We tend to use an antagonist, in this case to get rapid suppression of testosterone within about 3 days, and then based on that, we watch for his PSA response and symptomatic response to that.”
Although androgen deprivation therapy (ADT) has been the standard treatment, Concepcion noted that new evidence suggests this patient could benefit from a more aggressive approach.
Data from the CHAARTED trial suggest that early chemotherapy should be considered for this patient, said Daniel P. Petrylak, MD
. Results from CHAARTED are not yet published, and were first presented at the 2014 ASCO Annual Meeting.2
Joseph F. Renzulli, II, MD, FACS
CHAARTED demonstrated that upfront chemo-therapy with docetaxel added to ADT improved survival over ADT alone in men with hormone- sensitive metastatic prostate cancer.2
The study found there was a median overall survival (OS) of 57.6 months with the addition of docetaxel compared with 44 months with ADT alone (HR, 0.61; P
The benefit was more pronounced in patients with high-volume disease. Petrylak said that it does make sense to add another agent to ADT in high-volume disease, given that there are theoretically more genetic abnormalities, more mutations, and a higher chance of drug resistance. However, the mechanism by which patients achieved the added survival benefit in this subgroup is not known.
“How docetaxel is working in this situation, whether it’s through androgen receptor– mediated mechanism or some other mechanism that we’re not sure of, and why we are seeing such great differences, is not clear at this point,” he said.