CASE 2: A 53-year-old man with a history of colon cancer whose PSA level rose from 3.8 to 7.9 ng/mL in one year, with pathologic T3 Gleason 4 + 5 prostate cancer with extracapsular extension, negative nodes, seminal vesicles and margins after nerve-sparing prostatectomy (from the practice of Michael A Simon, MD)
| Tracks 1- 8 |
| Track 1 |
Case discussion: A 53-year-old
man with Gleason 9 prostate
cancer and extracapsular
extension |
| Track 2 |
High-volume versus low-volume
Gleason 9 disease |
| Track 3 |
Hormonal therapy after radical
prostatectomy for high-risk
prostate cancer |
| Track 4 |
Trials of chemotherapy in the
adjuvant setting |
|
| Track 5 |
Combined androgen blockade
as adjuvant therapy after radical
prostatectomy |
| Track 6 |
Role of postoperative radiation
therapy after radical prostatectomy |
| Track 7 |
Incidence of sexual dysfunction
with postoperative radiation
therapy |
| Track 8 |
PSA threshold for initiating
hormonal therapy |
|
|
Tracks 1-8
DR MOUL: Without question, he will need something beyond radical prostatectomy.
I would try to get him onto SWOG-S9921, on which he’d be randomly assigned to two years of combined hormonal therapy or two years of hormones and mitoxantrone-based chemotherapy.
Some would argue that if he doesn’t want to go on the trial, you could use two years of complete hormonal therapy. He’s only 53 and probably wants to maintain his libido. This might be a patient for whom you would consider adjuvant bicalutamide. The high-risk pT3 patients in the trials seemed to benefit from two years of adjuvant bicalutamide.
DR PETRYLAK: He is an excellent candidate for SWOG-S9921, and a second study, evaluating docetaxel, is being opened nationally and internationally. The docetaxel study is very similar to the SWOG study, but the question of early versus delayed therapy is being addressed.
Patients receive immediate hormones or chemotherapy with hormones versus delayed hormones or chemotherapy with hormones at the time of PSA progression. The androgen deprivation used is combined blockade.
We don’t know whether starting the hormones at the first rise in PSA level is the same or worse than starting the hormones immediately. For a 53-year-old patient like this, you consider maintenance of sexual function as well as the long-term chronic effects of hormones on bone mineral density and muscle mass. It’s difficult without the actual data to make any real conclusions.
DR MOUL: If a patient is not concerned about hormonal therapy side effects and is not interested in a protocol, I have no qualms about putting him on a year or two of complete hormonal therapy adjuvantly, in the immediate postoperative period. I don’t do it routinely, but if this is truly Gleason 9 disease, it probably is systemic disease. If he wants something done, it wouldn’t be wrong to give him a year or two of complete hormonal therapy.
DR PETRYLAK: I agree with Judd on the issue of early hormone therapy.
It’s very reasonable to consider a year or two of combined blockade. The chemotherapy issue is somewhat more problematic because of the possibility
of toxic deaths.
In the rare cases in which patients absolutely insist on chemotherapy, I always raise the issue that you can potentially die from neutropenia or neutropenic sepsis. I’m a little less inclined to give patients off-protocol treatment. Again, we also don’t know how this will affect the disease in the long term.
DR LOVE: What is your threshold to treat PSA-only disease? What would it take for you to initiate endocrine therapy, Dan?
DR PETRYLAK: If I started seeing a rapid doubling time or if it started getting up into the range of an absolute value of two to three ng/mL, I would treat.
DR MOUL: We’re all biased by the fact that this patient had Gleason 9 disease. Any jump in PSA level is likely to be real. However, I agree with Dan. The key would be trying to follow PSA velocity. In this case, we were arguing back and forth about whether we wanted to use two years of hormone right from the get-go with an undetectable PSA. You might “pull the trigger” quicker with this patient than you would with another.
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