Prostate Cancer Update 2

CASE 4: An 84-year-old man who underwent external beam radiation therapy 10 years ago for Gleason 7 prostate cancer and was treated with an LHRH agonist and then MAB therapy for PSA recurrences. Currently, he has bone metastases, with a PSA of 50 ng/mL, and he is receiving docetaxel and prednisone for bone pain (from the practice of Dr Nieder)

Tracks 1- 5

Track 1	Case discussion: An 84-year-old man with hormone-refractory metastatic prostate cancer
Track 2	Symptom improvement associated with docetaxel
Track 3	Side effects of docetaxel

Track 4	Future directions in immune therapy of prostate cancer
Track 5	Benefit of input from medical oncologists in management of prostate cancer

Tracks 1-5

DR LOVE: How did this older man tolerate the docetaxel?

DR NIEDER: He did relatively well. He looks relatively robust and feels okay.

DR LOVE: Dan, what do we know about the ability of chemotherapy, particularly the docetaxel regimens, to relieve tumor-related symptoms?

DR PETRYLAK: Bone pain improved in both large randomized studies of docetaxel. It was more pronounced in the TAX-327 study, which showed significant improvement in bone pain compared to mitoxantrone and prednisone (1.2, 1.3).

We didn’t see it in the SWOG study, but the experimental arm did not have prednisone. So it’s a little bit of an unfair comparison. Nonetheless, there is a better palliation of bone pain with docetaxel and prednisone versus mitoxantrone and prednisone.

DR LOVE: In patients with measurable disease, how often do you see objective tumor shrinkage?

DR PETRYLAK: In the SWOG study and the TAX-327 study, it was in the range of 15 percent — a little bit lower than what we had seen in our Phase II experience. But we do see objective responses.

DR LOVE: Judd, another interesting aspect to this case was that he had PSA progression on an LHRH agonist. The PSA further decreased when bicalutamide was added. How often do you see that, and what do you think the implications are?

DR MOUL: The literature more strongly supports using MAB up front and then withdrawing the oral anti-androgen when the patient progresses. In this case, they used the LHRH at the beginning and added the anti-androgen when he progressed.

Many urologists do that. If you evaluate the data on objective progression rates, you’re better off using MAB up front and then pulling it away, to save you money later. My argument would be if you’re going to use MAB, use it up front and then pull the anti-androgen away if the patient progresses.

DR PETRYLAK: An interesting question is, “When is the optimal time to administer chemotherapy to these patients?” Clearly, in this case, the chemotherapy was administered when the patient was symptomatic. Can you achieve a better response with these patients using docetaxel earlier? We really don’t know the answer to that question.

I think the best way to think about this is using an analogy to baseball. You can use your best pitcher in the first couple of innings of the game and then move other pitchers in as needed, or you can save your best pitcher for later and try more experimental approaches to begin with.

I’ve treated a 92-year-old with chemotherapy, and he’s lived three years with a good quality of life. I think every patient with metastasis really should be offered this. It’s up to them to decide whether it’s appropriate. If the oncologist is experienced in administering the treatments and knows when to push and when not to push, I believe the patient certainly can benefit.

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