San Diego, California (UroToday.com): The panel was a discussion on the following four cases:
Case 1: Hormone Sensitive low-volume M1 prostate cancer:
65 yo M s/p prostatectomy with pathology showing pT3a Gleason Score 4+3, margin + s/p adjuvant radiotherapy. He presented 3 years later with PSA rise from nadir 0.1 to 0.9. CT showed bulky retroperitoneal nodes up to 7.7 cm, no visceral metastasis. Bone scan showed 3 subtle bone lesions. ADT was initiated at this point with shrinkage of retroperitoneal nodes on repeat imaging. Recent PSA was < 0.1.
The discussion in this patient centered on whether initiating docetaxel at the time of ADT was warranted at this time or ADT alone is sufficient. The CHAARTED trial indicated benefit in overall survival with early docetaxel chemotherapy, however that benefit was mainly in the high volume group. Even though this patient has low volume metastatic disease, the concensus was to still offer docetaxel, if he is fit and may tolerate it. Steriod with docetaxel is not warranted as thenCHAARTED trial did not include steroids.
Case 2: Hormone Sensitive high-volume M1 prostate cancer:
78 yo M with PSA of 10 in 2012. He declined biopsy at the time and subsequently presented with PSA 288 in 2014. CT scan shows an enlarged prostate with no nodal or visceral disease. Bone scan shows up to 10 lesions with diffuse bone metastatic disease. He was started on ADT and PSA declined to 0.9 after 12 months.
The discussion in this patient centered on whether this elderly man should be started with docetaxel now 12 months later when PSA has decreased to 0.9. The concensus was to offer docetaxel initially to any medically fit patient with high volume metastatic disease per CHAARTED trial. Given that 12 months have passed at this point, the concensus was to hold off from offering Docetaxel currently along with ADT.
Case 3: Non-metastatic Castrate-Resistant Prostate Cancer (CRPC):
Patient with GS 7, 8/19 cores positive prostate cancer diagnosed in 2010. He had negative metastatic workup and underwent ADT + XRT. He had biochemical recurrence with metastatic w/u (including NaF PET) showing no metastatic disease. He had a biopsy proved localized cancer in the primary prostate gland. He underwent salvage XRT. His PSA continued to rise to 26. He was then started on Bicalutamide and failed. He was then started on ADT and PSA initially responded but continued to increase. Repeat standard imaging was negative for any metastatic disease. He is now in mid-80’s years of age.
The discussion centered on whether the patient would benefit from systemic therapy in the setting of no metastatic disease. Currently, we do not know whether earlier intervention is better. In the absence of data, these patients should be considered for clinical trial randomizing patients to placebo versus Androgen Receptor targeted therapy.
Case 4: Metastatic, minimally symptomatic prostate cancer (mCRPC):
75 yo M who presented with PSA 1685. Prostate biopsy showed Gleason Score 8+8 in 12/12 cores. Bone scan showed diffuse metastatic metastasis. CT scan was negative for nodal or visceral metastasis. He was treated with LHRH and denosumab. He also underwent early Docetaxel x 6 cycles per CHAARTED trial. His PSA nadir was 4.4 ng/ml after 8 months and then rose again to 7.4 months. Repeat bone scan shows diffuse skeletal metastasis with slight increase. Pelvic MRI shows minimally enlarged bilateral iliac chain lymph nodes. He is anxious and desires treatment.
Discussion centered on whether a baseline DEXA scans was warranted when this patient presented with metastatic disease. Bone metastasis artificially elevate bone density so it was thought that the DEXA would not be useful.
Second point of discussion was whether denosumab was warranted in this patient at the state of hormone sensitive metastatic prostate cancer. Per STAMPEDE trial, bone-targeting therapy does not improve outcomes in patients with hormone -sensitive prostate cancer. If the outcome is to prevent a skeletal related event, there is no harm is starting per the medical oncologist. Usually when the PSA responds, they may consider stopping bone targeting agent to prevent risks and side effects of these agents.
Options in patient treatment with metastatic CRPC with minimal symptoms include sipuleucel-T, radium-223, abiraterone + prednisone, enzalutamide or re-treatment with docetaxel. This patient elected sipuleucel-T and tolerated it well.