Case Study: Newly Diagnosed Metastatic Prostate Cancer

Patient Case 3:

• July 13, 2013, a 59-year-old African American male presents with lower urinary tract symptoms, a of PSA 28 ng/ml, and an AUA symptom score of 24 Allergies: NKDA Medications: finasteride, 5 mg daily; terasozin, 10 mg daily; metformin; lisinopril Med: (+) HTN, NIDDM Surgical History: NONE FH: (+) Prostate cancer, HTN, DM Physical Exam: Prostate: 3+, no nodules
• August 15, 2013, he is referred to urology for TRUS of prostate, US-guided needle biopsy U/S: 43 gram prostate, mixed echogenicity Path: 10/14 cores (+), Gleason 4 + 5
• August 24, 2013, CT: (+) (B) Iliac adenopathy, (+) obturator adenopathy to right, 1-1.6 cm (+) lesions to pelvis, sacrum, coccyx, L5 Bone scan: question of L4/5 involvement CAB (leuprolide, bicalutamide instituted) ECOG: 0
• September 20, 2013, PSA 0.85 Alkaline phosphatase 236, calcium 9.7
• September 30, 2013, denosumab started for SRE prevention
• October 17, 2013, PSA 1.32, test <10; treatment options discussed
• November 14—December 19, 2013, 3 cycles of sipuleucel-T
• March 19, 2014: PSA 1.85, ALP 202
• June 20, 2014: PSA 2.14, ALP 258, new onset back pain (right SIJ) requiring NSAID, occasional opiates NaF PET/CT obtained

This is a patient with good performance status who is minimally symptomatic, not taking opioids, with a rising PSA, and a castration level of testosterone, explains Raoul Concepcion, MD. The patient, who has iliac node involvement, has been treated with complete androgen blockade and, appropriately, bone-targeting therapy. Unfortunately, bone-targeted therapy is not commonly used in the urology world, agree Concepcion and Joseph Renzulli, II, MD. Importantly, if diagnosed in 2015, the patient would have received docetaxel concomitantly.

Based on guidelines, this patient with asymptomatic, metastatic castration-resistant prostate cancer has several treatment options. This patient is a candidate for sipuleucel-T. Additionally, other options include abiraterone with prednisone, enzalutamide, and docetaxel, comments Christopher Evans, MD. Patients with a low PSA and low-volume disease appear to benefit most from early immunotherapy, adds Celestia Higano, MD.

In the pivotal phase III IMPACT trial, investigators looked at quartiles of PSA stratification. Patients with a PSA value of <22 conferred a survival advantage of approximately 13 months with sipuleucel-T. Therefore, the goal is to treat earlier when the PSA has not exceeded 22, notes Renzulli.

Radium-223 would be indicated for this patient only if he were symptomatic, continues Evans. Presently, the definition of symptomatic or minimally symptomatic is somewhat open to the clinician’s interpretation. Whether the patient is taking an NSAID versus an opioid may be a differentiating factor. The use of opioids is frequently the cut-off point, agree Higano and Daniel P. Petrylak, MD.

Six months after receiving three cycles of sipuleucel-T, the patient’s alkaline phosphatase (ALP) level rose and he reported new onset back pain requiring NSAIDs and occasional opiate medication. A restaging PET scan indicated disease progression, with new lesions present through the sacrum and sacroiliac joint. He had limited adenopathy (< 2 cm), and no visceral metastases. In addition, his PSA level was rising.

At this point, the patient has the option of considering radium-223 for his symptomatic, mostly boney disease. He could be treated with enzalutamide or abiraterone and prednisone, says Renzulli. However, at this point, it’s remains unclear how to optimally cycle these effective agents. As a result, the treatment sequence remains a matter of personal preference.