What is the initial treatment approach for a patient with stage 4 metastatic prostate cancer with metastases to the lungs and bones?

From the Guidelines

The initial treatment approach for a patient with stage 4 metastatic prostate cancer with metastases to the lungs and bones should involve androgen deprivation therapy (ADT) as the cornerstone of management, combined with a bone-targeted agent such as denosumab (120 mg subcutaneously every 4 weeks) to prevent skeletal-related events, as denosumab has shown superiority over zoledronic acid in preventing SREs 1. This treatment, also known as hormonal therapy, aims to reduce testosterone levels which fuel prostate cancer growth. ADT can be achieved through surgical castration (bilateral orchiectomy) or medical castration using LHRH agonists (such as leuprolide 7.5 mg monthly, goserelin 3.6 mg monthly, or triptorelin 3.75 mg monthly) or LHRH antagonists (such as degarelix 240 mg loading dose followed by 80 mg monthly). For patients with extensive metastases, combination therapy is often recommended, adding either docetaxel chemotherapy (75 mg/m² every 3 weeks for 6 cycles) or a novel hormonal agent such as abiraterone (1000 mg daily with prednisone 5 mg daily) or enzalutamide (160 mg daily). Some key points to consider in the management of these patients include:

• The use of bone-targeted agents to prevent SREs, with denosumab being a preferred option due to its superiority over zoledronic acid 1
• The importance of early identification and intervention in patients with bone metastases to prevent SREs and improve quality of life 1
• The need for a multimodal approach to manage metastatic prostate cancer, including systemic treatment, testosterone suppression, and supportive measures such as pain management and radiation therapy for symptomatic bone lesions. It is also important to note that the treatment of patients with bone metastases should be individualized, taking into account factors such as the patient's overall health, the extent of their disease, and their personal preferences. In terms of specific treatment options, the choice of bone-targeted agent will depend on the patient's individual needs and circumstances, with denosumab being a preferred option due to its efficacy in preventing SREs 1. Overall, the goal of treatment for patients with stage 4 metastatic prostate cancer with metastases to the lungs and bones is to improve their quality of life, reduce their symptoms, and slow the progression of their disease.

From the FDA Drug Label

ZOLADEX is indicated in the palliative treatment of advanced carcinoma of the prostate In controlled studies of patients with advanced prostatic cancer comparing ZOLADEX 3.6 mg to orchiectomy, the long-term endocrine responses and objective responses were similar between the two treatment arms. Additionally, duration of survival was similar between the two treatment arms in a major comparative trial.

The initial treatment approach for a patient with stage 4 metastatic prostate cancer with metastases to the lungs and bones may include hormone therapy with goserelin (ZOLADEX) as part of palliative treatment. The recommended dose is 10.8 mg administered subcutaneously every 12 weeks into the anterior abdominal wall below the navel line using an aseptic technique under the supervision of a physician 2.

From the Research

Initial Treatment Approach

The initial treatment approach for a patient with stage 4 metastatic prostate cancer with metastases to the lungs and bones typically involves a combination of therapies.

• Androgen deprivation therapy (ADT) is often the primary treatment, as it has been shown to improve survival in patients with metastatic prostate cancer 3.
• Chemotherapy, such as docetaxel, may also be used in combination with ADT to treat metastatic disease 4.
• Bone-targeted therapies, such as zoledronic acid, may be used to reduce the risk of skeletal-related events 4.

Treatment Options

Several treatment options are available for patients with stage 4 metastatic prostate cancer, including:

• ADT with leuprolide acetate or other luteinizing hormone-releasing hormone (LHRH) agonists 5, 3
• Chemotherapy with docetaxel or other agents 4
• Abiraterone acetate, a CYP17 inhibitor that lowers serum testosterone 5
• Relugolix, an oral gonadotropin-releasing hormone antagonist that has been shown to be superior to leuprolide in achieving rapid and sustained testosterone suppression 6

Considerations

When selecting a treatment approach, several factors should be considered, including:

• The patient's overall health and performance status
• The extent and location of metastatic disease
• The patient's PSA level and Gleason score
• The potential benefits and risks of each treatment option
• The patient's preferences and values 7