Prostate Cancer Case Studies - Episode 6
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In this segment, moderator, Raoul S. Concepcion, MD, continues the third installment of a case-based discussion focused on a 62 year-old man with prostate cancer. Despite surgical intervention followed by adjuvant radiation therapy, the patient's PSA eventually rose to 5 ng/mL, with a doubling time of approximately 7 months. As a result, 4 months of continuous androgen deprivation therapy (ADT) with lupron depot was administered.
To address the bone and metabolic issues associated with ADT, many institutions establish specialized clinics, explains Lawrence I. Karsh, MD. At the initial visit to these clinics, a DEXA scan is utilized to assess bone density followed by metabolic panels for diabetes, hypertension, and other syndromes. Additionally, baseline vitamin D and calcium levels are obtain and weight-bearing and balance focused physical therapy is initiated.
In addition to these items, Evan Y. Yu, MD, stresses the importance of vitamin D and calcium supplementation and recommends assessing a patient's risk for developing a fracture before administering prophylactic denosumab. To help in this evaluation, the World Health Organization developed the Fracture Risk Assessment Tool (FRAX) to provide guidance on a patient’s risk level based on several factors, such as DEXA scan and bone marrow density. However, Yu notes, utilizing an intermittent ADT dosing strategy may result in less decrement to the bone marrow than a continuous strategy, which could decrease the need to administer prophylactic treatment.
Adding to this, Leonard G. Gomella, MD stresses the importance of a multidisciplinary environment that includes both medical oncologists and urologists. This becomes exceptionally important in states that do not readily provide reimbursement for DEXA scans. Additionally, in some situations, a medical oncologist may have more ease in administering denosumab and may feel more comfortable managing cholesterol, diabetes, and hypertension, Gomella adds.
For those who cannot complete a DEXA scan due to reimbursement issues or question its accuracy, Mark C. Scholz, MD, recommends utilizing a specialized CT scan that examines bone density in the vertebra. This approach is labeled QCT and utilizes a software package for an existing scanner. In addition to this scanning approach, Scholz recommends utilizing prophylactic PD5 inhibitors, such as Viagra or Cialis. Moreover, he notes a concern over breast enlargement related to ADT, which can be addressed by administering aromatase inhibitors, such as letrozole and anastrozole.