What treatment options are available for a patient with high-volume metastatic prostate cancer recurrence after initial treatment, considering age and potential side effects?

From the Guidelines

For a 79-year-old man in good health with high-volume metastatic prostate cancer recurring three years after initial treatment, the most appropriate treatment option is androgen deprivation therapy (ADT) combined with abiraterone acetate (1000mg daily with prednisone 5mg daily), considering the potential side effects and quality of life. This recommendation is based on the most recent and highest quality study available, which suggests that abiraterone acetate plus prednisone improves radiographic progression-free survival, time to initiation of chemotherapy, and overall survival in patients with metastatic castration-resistant prostate cancer 1.

Treatment Options

• ADT (such as leuprolide 7.5mg monthly or goserelin 10.8mg every 3 months) plus one of several intensification options:
  • Abiraterone acetate (1000mg daily with prednisone 5mg daily)
  • Docetaxel chemotherapy (75mg/m² every 3 weeks for 6 cycles)
  • Enzalutamide (160mg daily)
  • Apalutamide (240mg daily)
• Bone-targeted agents like zoledronic acid (4mg IV every 3-4 weeks) or denosumab (120mg subcutaneously monthly) should be added for patients with bone metastases to reduce skeletal complications.

Considerations for Older Patients

• Treatment selection should be individualized, taking into account the patient's age, comorbidities, functional status, and personal preferences.
• Abiraterone may cause hypertension and fluid retention but avoids the fatigue of enzalutamide.
• Docetaxel offers a finite treatment duration but carries risks of neuropathy and myelosuppression.
• Regular monitoring of PSA levels, imaging, and side effects is essential.

Quality of Life

• Treatment choice depends on the patient's age, comorbidities, functional status, and personal preferences, with younger patients often receiving more aggressive combination approaches while older patients may benefit from less intensive regimens that maintain quality of life.
• The use of abiraterone and prednisone in this setting is a category 1 recommendation, with a trend toward improvement in overall survival and a significant improvement in radiographic progression-free survival 1.

In this case, considering the patient's age and good health, abiraterone acetate plus prednisone is a suitable option, as it has been shown to improve overall survival and radiographic progression-free survival, with a manageable side effect profile 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for High-Volume Metastatic Prostate Cancer Recurrence

• The patient in question is a 79-year-old man in good health with high-volume metastatic prostate cancer recurring three years after initial treatment with surgery, radiation, and 18 months of ADT.
• Considering his age and potential side effects, treatment options are available, including docetaxel, abiraterone acetate, enzalutamide, and cabazitaxel.

Efficacy of Treatment Options

• A study published in The Lancet. Oncology 2 found that abiraterone acetate plus prednisolone improves outcomes for patients with metastatic prostate cancer, with a median overall survival of 76.6 months.
• Another study published in Clinical genitourinary cancer 3 found that elderly men receiving abiraterone acetate or enzalutamide as first-line therapy for metastatic castration-resistant prostate cancer have similar survival outcomes and tolerability, regardless of previous docetaxel use.
• A study published in Journal of medical economics 4 found that enzalutamide provided greater life-years and quality-adjusted life-years than both abiraterone acetate and cabazitaxel, at a lower cost than abiraterone acetate, but at a higher cost compared to cabazitaxel.

Safety and Tolerability

• The study published in The Lancet. Oncology 2 found that grade 3-5 toxic effects were higher when abiraterone was added to standard of care, with cardiac causes being the most common cause of death due to adverse events.
• The study published in Clinical genitourinary cancer 3 found no statistically significant difference in adverse events of any grade rate or grade ≥ 3 between patients who received docetaxel and those who did not.

Docetaxel as a Treatment Option

• A study published in Clinical genitourinary cancer 5 found that the efficacy of abiraterone acetate and enzalutamide is similar regardless of previous use of docetaxel.
• The study published in Archivio italiano di urologia, andrologia 6 found that docetaxel can improve overall survival of patients with metastatic castration-resistant prostate cancer progressing after docetaxel, compared to placebo or best of care at the time of study.

Considerations for the Patient

• The patient's age and good health should be taken into consideration when choosing a treatment option.
• The potential side effects and benefits of each treatment option should be discussed with the patient to determine the best course of treatment.
• The patient's previous treatment with docetaxel should also be considered when choosing a treatment option, as some studies suggest that the efficacy of certain treatments may be affected by previous docetaxel use 3, 5.