Prostate Cancer Update 2

CASE 5: A 71-year-old man with a PSA rising from five to 18.1 ng/mL in the year prior to diagnosis of Gleason 6-7 prostate cancer, with 9/13 positive cores (85 percent) and DRE abnormal bilaterally. Bone and CT scans were negative (from the practice of Benjamin M Tripp, MD)

Tracks 1-11

Track 1	Case discussion: A 71-year old man with high-risk prostate cancer
Track 2	Treatment options for patients with high-risk disease
Track 3	Difference in quality of life on androgen deprivation therapy and bicalutamide monotherapy
Track 4	Side effects of androgen deprivation therapy
Track 5	Clinical use of bicalutamide monotherapy
Track 6	Adverse effects associated with bicalutamide monotherapy

Track 7	Clinical use of therapies without definitive clinical trial data
Track 8	Cardiovascular morbidity in patients receiving androgen deprivation therapy
Track 9	Use of PSA and PSA doubling time to determine treatment approach
Track 10	Challenges of accruing patients to clinical trials in prostate cancer
Track 11	Tolerability of single-agent docetaxel

Tracks 1-11

DR MOUL: This is an interesting case. He had a high PSA velocity the year before diagnosis. We now know that this rapid doubling time is a poor prognostic factor. Clinically, this is probably T2b/T2c disease, but realistically, he probably had T3 disease and a negative metastatic workup.

He’s a healthy individual with no other comorbidities. My favored approach would be radical prostatectomy. However, in fairness to our colleagues in radiation oncology, he is more than 70 years old and he probably has locally advanced disease.

I suspect if he had a family member who was a radiation oncologist, they would probably lean toward a combination of external beam radiation therapy and two to three years of hormonal therapy.

The role of brachytherapy with external beam radiation therapy is controversial, but certainly it should be mentioned, along with some form of hormonal therapy for a period of time.

DR PETRYLAK: He’s an active, vigorous, healthy man, with a rapid increase in PSA velocity. I believe he will eventually get into trouble because his life span may be another 10 or 15 years. This is a common dilemma: How do you approach a patient who is potentially at high risk?

Radical prostatectomy is the one way to conclusively stage this case, with the caveat that this patient should strongly consider a high-risk adjuvant protocol, such as SWOG-S9921 — a randomized trial of two years of hormones versus two years of hormones with mitoxantrone and prednisone.

DR LOVE: Dr Tripp, can you follow up on what happened with the patient?

DR TRIPP: He was treated with external beam radiation therapy, IMRT and a boost with seed implants. In addition, an initial decision was made to administer a total of three years of hormonal therapy — the first year he received leuprolide, and during the last two years we changed to bicalutamide monotherapy.

A huge difference in his quality of life occurred between the first year and the second and third years of treatment. During the first year — while receiving the LHRH agonist — the patient gained 25 to 30 pounds, his exercise tolerance was severely impaired and his sexual functioning and interest were nil. He really had a tough year, with depression, anxiety and the other changes in his life.

We changed to bicalutamide after one year. Remarkably, within three or four months, he shed his weight and his energy level, sense of well-being and sexual functioning were much better. The improvement in quality of life was dramatic. He received external beam radiation therapy for breast tenderness and enlargement and responded well.

DR LOVE: Judd, what are your thoughts about this strategy?

DR MOUL: I want to applaud Dr Tripp and his colleagues’ multimodality approach to this patient at high risk. This patient was treated with a twist on the Bolla trial (Bolla 1997).

The patient received radiation therapy, although as opposed to external beam, only his local dose was increased with the implant. Then, “á la Bolla,” he would have received three years of hormonal therapy, but for this patient it was adjusted nicely to improve his quality of life.

DR PETRYLAK: He was having severe difficulty after his first year. Obviously, you want to cure the patient, but you want a reasonable quality of life. In that he couldn’t tolerate androgen blockage, I believe it was reasonable to try the next best step — peripheral blockade with bicalutamide.

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