From the Guidelines
For a 79-year-old patient with high-volume metastatic prostate cancer and biochemical recurrence, the recommended first-line treatment is androgen deprivation therapy (ADT) combined with either docetaxel chemotherapy or novel hormonal agents, as this approach has demonstrated significant survival benefits compared to ADT alone 1.
Treatment Approach
The treatment plan should consider the patient's performance status, comorbidities, and potential side effects.
- ADT with a GnRH agonist/antagonist (such as leuprolide 22.5 mg every 3 months or degarelix 240 mg loading dose followed by 80 mg monthly)
- Plus docetaxel 75 mg/m² every 3 weeks for 6 cycles, or
- ADT plus an androgen receptor pathway inhibitor like abiraterone acetate (1000 mg daily with prednisone 5 mg daily) or enzalutamide (160 mg daily)
Rationale
The addition of docetaxel or novel hormonal therapy to ADT has shown improved overall survival in high-volume metastatic disease, as defined by visceral metastases or ≥4 bone lesions with ≥1 beyond the vertebral column and pelvis 1.
Monitoring and Assessment
Regular monitoring of PSA levels, imaging studies, and assessment for treatment-related toxicities are essential components of management.
- PSA doubling time (PSADT) should be considered, with a PSADT of ≤10 months indicating a more aggressive disease course 1.
- Imaging tests, such as CT or MRI, along with 99mTc-methylene diphosphonate bone scintigraphy, remain the standard imaging approaches for post-treatment biochemical recurrence 1.
Considerations
Treatment selection should consider the patient's age, overall health, and potential side effects.
- Docetaxel may be preferred for patients who can tolerate chemotherapy and need rapid disease control.
- Novel hormonal agents might be better for those with contraindications to chemotherapy. This approach is supported by the most recent guidelines and clinical trials, including the NCCN Clinical Practice Guidelines in Oncology for prostate cancer 1.
From the FDA Drug Label
XTANDI is an androgen receptor inhibitor indicated for the treatment of patients with: • castration-resistant prostate cancer. (1) • metastatic castration-sensitive prostate cancer. (1) • non‑metastatic castration‑sensitive prostate cancer with biochemical recurrence at high risk for metastasis (1)
The best treatment approach for a patient with high-volume metastatic prostate cancer and biochemical recurrence is to consider enzalutamide (XTANDI) as a treatment option.
- The patient should receive 160 mg of XTANDI administered orally once daily with or without food.
- Additionally, the patient should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently or should have had bilateral orchiectomy 2.
From the Research
Treatment Approach for High-Volume Metastatic Prostate Cancer
The best treatment approach for a patient with high-volume metastatic prostate cancer and biochemical recurrence is a complex decision that involves considering several factors, including the patient's overall health, PSA doubling time, Gleason score, and timing of recurrence 3.
- Androgen Deprivation Therapy (ADT): ADT is a common treatment approach for advanced prostate cancer, and it can be used in combination with other therapies such as docetaxel 4. The type of ADT to be used can range from oral-only peripheral blockade to complete hormonal therapy, and the choice of therapy should be made based on the patient's individual needs and disease characteristics 3.
- Gonadotropin-Releasing Hormone Agonists: Gonadotropin-releasing hormone agonists (GnRH-A) are a type of ADT that can be used to suppress testosterone levels, and they have been shown to be effective in improving overall survival in patients with prostate cancer 5.
- Darolutamide: Darolutamide is a novel oral agent that has been shown to improve overall survival in patients with metastatic hormone-sensitive prostate cancer when used in combination with ADT and docetaxel 4.
- Salvage Therapy: Salvage therapy, such as radiation therapy or surgery, may be considered for patients with biochemical recurrence after primary treatment, but the best approach will depend on the individual patient's disease characteristics and overall health 6.
Factors to Consider
When deciding on a treatment approach, several factors should be considered, including:
- PSA Doubling Time: The rate at which the patient's PSA level is increasing can help guide treatment decisions 3.
- Gleason Score: The patient's Gleason score can help determine the aggressiveness of the cancer and guide treatment decisions 3.
- Timing of Recurrence: The timing of the recurrence can help determine the best treatment approach, with earlier recurrences potentially requiring more aggressive treatment 3.
- Patient's Overall Health: The patient's overall health and any comorbidities should be considered when deciding on a treatment approach 6.
Treatment Goals
The goals of treatment for high-volume metastatic prostate cancer and biochemical recurrence are to:
- Improve Overall Survival: The primary goal of treatment is to improve the patient's overall survival 4.
- Delay Disease Progression: Treatment should aim to delay the progression of the disease and improve the patient's quality of life 6.
- Manage Symptoms: Treatment should also aim to manage any symptoms associated with the disease, such as pain or urinary symptoms 6.