Integrating Prostate Cancer Trial Findings Into Practice: A Case-Based Discussion - Episode 5
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Patient Case: Part 1
The patient is high-risk, but staging negative, and historically this type of patient would have received radiotherapy with androgen deprivation therapy (ADT) based on the possibility of microscopic disease, explains Christopher P. Evans, MD, FACS. Currently, the approach is more multimodal, and assessing pathologic staging can help determine what type of therapy to use, such as adjuvant therapy of radiation, or androgen deprivation for node-positive disease. In terms of stratifying high-risk patients, younger physicians usually send healthier patients to surgery, while advising them they will still likely require radiation later, states Joseph F. Renzulli II, MD, FACS.
Patient Case: Part 2
The doubling of the patient’s PSA within the first 3 months post-surgery is indicative of metastatic disease, according to Evans. This development, Evans says, would make him doubt that adjuvant radiotherapy will provide any benefit to this patient. In terms of using radiation therapy, Renzulli suggest that it may have been delayed with the goal of improving his continence.
Several factors could trigger the need to look for metastatic disease. Along with a PSA doubling time of less than 10 months, changes in bone scans can prompt further investigations. A baseline bone scan is useful in gauging changes over time, and in ruling out other issues, such as fractures or temporomandibular joint disorders, notes Evans. Finding metastatic disease would drastically change the options for the patient, and therefore is important to detect. From a urology standpoint, explains Evans, it is necessary to be aware of and monitor for changes, to ensure that patients have access to the most appropriate portfolio of treatment options.
The patient’s short duration of response to ADT usually indicates that something has gone awry, adds Celestia S. Higano, MD, FACP. In this situation, she again stresses the need for identifying metastatic disease as soon as possible. According to Higano, one effective way of identifying metastatic disease earlier would be to bypass a regular technetium bone scan but utilize an F18 PET bone scan. Alhough Renzulli concurs with the sensitivity of the PET scan, he adds that it is more challenging to receive insurance approval for that level of imaging.