From the Guidelines
The prognosis for a patient with a decline in PSA from 0.2 to 0.17 in 30 days after starting ADT plus apalutamide is favorable, but requires continued monitoring to assess the durability of the response. This 15% reduction in PSA suggests that the treatment is having some effect, though a more substantial decline would typically be expected with effective therapy. For patients with castration-resistant prostate cancer who have already undergone surgery, radiation, and previous ADT, any PSA decline is generally considered positive 1.
Key Considerations
- The patient's history of rising PSA after surgery, radiation, and 18 months of ADT indicates a high risk for disease progression, making the initial response to apalutamide encouraging.
- The mechanism of apalutamide, which blocks androgen receptors, takes time to fully suppress cancer cell activity, particularly in cells that may have developed partial resistance after previous treatments 1.
- Continue the current treatment regimen of ADT plus apalutamide for at least 3-6 months before making definitive conclusions about efficacy, as PSA responses can be delayed and variable.
- Monthly PSA testing is recommended during this period to establish a clear trend, as suggested by guidelines for prostate cancer surveillance 1.
Next Steps
- If the PSA continues to decline or stabilizes at a low level, this would indicate treatment effectiveness.
- However, if PSA begins rising again despite treatment, additional imaging and possibly changing to a different therapy like enzalutamide, darolutamide, or chemotherapy may be necessary.
- Monitoring for adverse events associated with apalutamide, such as fatigue, hypertension, and rash, is also crucial to ensure the patient's quality of life is maintained 1.
From the FDA Drug Label
Apalutamide 240 mg daily in addition to ADT in patients with mCSPC (TITAN) reduced PSA to undetectable levels (<0.2 ng/mL) in 68% of patients compared to 32% of patients taking ADT alone. Apalutamide 240 mg daily in addition to ADT in patients with nmCRPC (SPARTAN) reduced PSA to undetectable levels (<0. 2 ng/mL) in 38% of patients compared to no patients (0%) taking ADT alone.
The prognosis if Prostate-Specific Antigen (PSA) declines from 0.2 to 0.17 in 30 days after starting Androgen Deprivation Therapy (ADT) plus apalutamide is uncertain, as the provided information does not directly address this specific scenario. However, the fact that PSA has decreased in response to treatment is a positive sign. It is essential to continue monitoring the patient's PSA levels and overall condition to determine the effectiveness of the treatment. 2
From the Research
Prognosis with PSA Decline
- A decline in Prostate-Specific Antigen (PSA) levels from 0.2 to 0.17 in 30 days after starting Androgen Deprivation Therapy (ADT) plus apalutamide in a patient with rising PSA after surgery, radiation, and 18 months of ADT may indicate a positive response to treatment 3, 4, 5, 6.
- Studies have shown that a deep PSA decline (≥90% PSA reduction or PSA ≤0.2 ng/ml) is associated with improved outcomes, including longer survival time and delayed progression of the disease 4, 5, 6.
- The rate of PSA decline can also be an important factor, with faster declines often associated with better outcomes 7.
- In the context of apalutamide treatment, a deep PSA decline at 3 or 6 months has been linked to improved clinical outcomes, including overall survival and radiographic progression-free survival 4, 6.
Factors Influencing Prognosis
- The degree of PSA decline is a significant predictor of clinical outcomes, with deeper declines associated with better prognosis 4, 5, 6.
- The timing of PSA decline is also important, with earlier declines often associated with improved outcomes 7.
- Molecular subtypes and other prognostic markers may also influence the prognosis, but the association between PSA decline and outcomes appears to be consistent across different subtypes 4.
- The combination of ADT and apalutamide has been shown to produce rapid, deep, and durable PSA responses, which are associated with improved clinical outcomes 3, 4, 5, 6.