Prostate Cancer Case Studies - Episode 5

Case Study: Initiating Androgen Deprivation Therapy

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Moderator, Raoul S. Concepcion, MD, continues a case-based discussion exploring the treatment of a 62 year-old Caucasian patient with prostate cancer (Click here, to view Part I). At approximately 3 to 6 months following surgery, the patient elected to receive adjuvant radiotherapy. The PSA was monitored every 3 months and at 6 months following radiotherapy the PSA nadir reached 0.01 ng/mL.

Eventually, the PSA began to rise with a doubling time of approximately 7 months, Concepcion notes. The patient began to grow anxious, once the PSA reached 5 ng/mL, resulting in an attempt at staging by bone scan and CT, which returned negative findings. At this point, Concepcion notes, many urologists will typically refer this patient to a medical oncologists, rather than begin androgen deprivation therapy (ADT). As such, medical oncologists, Mark C. Scholz, MD, and Evan Y. Yu, MD, provide their insight into the management of this patient.

There is retrospective data suggesting that a rapid PSA doubling time confers a poor prognosis, Yu notes. In general, a doubling time of less than 3 months indicates a very poor prognosis with an upper cutoff of 8 months to 10 months. With a PSA doubling time of 7 months, the patient in the case study is increasing at a reasonable rate, Yu suggests. Based in part on this prognostic factor, the patient may be a candidate for treatment with ADT. However, Yu adds, since the PSA is 5 ng/mL and the imaging is negative, an intermittent ADT dosing strategy can be utilized for this patient rather than continuous to reduce the side effects of treatment.

In addition to this treatment approach, Scholz indicates he would begin treatment with denosumab along with a rigorous exercise program, to avoid some of the muscle and bone loss associated with ADT. These interventions may have a dramatic impact on a patient's quality of life, Scholz notes. Moreover, he adds, new imaging techniques may help manage patients more effectively. These techniques increase the ability to detect metastatic disease through the utilization of PET scans that are enhanced by sodium fluoride or carbon-11 acetate.