From the Guidelines
For a 79-year-old male with high-volume PSMA-positive metastatic prostate cancer who has recurrent disease after prior treatments, the recommended approach would be combination therapy with ADT plus a novel hormonal agent such as enzalutamide, apalutamide, or darolutamide, and consideration of PSMA-targeted radioligand therapy with Lutetium-177-PSMA-617 (177Lu-PSMA-617). Given his prior history and current PSA of 0.2, restarting 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) combined with enzalutamide 160 mg daily would be appropriate 1. Additionally, PSMA-targeted radioligand therapy with 177Lu-PSMA-617 could be considered given his PSMA-positive status, typically administered as 6 cycles every 6 weeks 1. Bone-targeted therapy with zoledronic acid 4 mg IV every 3-4 weeks or denosumab 120 mg subcutaneously monthly should be added if bone metastases are present. This multi-modal approach is recommended because the combination of ADT with novel hormonal agents has shown superior survival outcomes compared to ADT alone in metastatic disease, as supported by the most recent guidelines from the European Society for Medical Oncology (ESMO) 1. The patient's age should be considered when assessing treatment tolerance, but functional status rather than chronological age should guide treatment intensity. Regular monitoring of PSA levels, imaging follow-up, and assessment of treatment-related side effects would be essential components of ongoing management. It's also important to note that the patient's health status allows for consideration of both Docetaxel and LU177, but the most recent and highest quality study recommends the use of 177Lu-PSMA-617 in men with cancer expressing PSMA on positron emission tomography-PSMA and without PSMA non-expressing lesions 1.
Some key points to consider in the management of this patient include:
- The use of ADT plus a novel hormonal agent as first-line treatment for metastatic hormone-sensitive prostate cancer (mHSPC) 1
- The consideration of PSMA-targeted radioligand therapy with 177Lu-PSMA-617 for patients with PSMA-positive metastatic castration-resistant prostate cancer (mCRPC) 1
- The importance of bone-targeted therapy in patients with bone metastases 1
- The need for regular monitoring and assessment of treatment-related side effects 1
From the FDA Drug Label
2.3 Prostate Cancer For metastatic castration-resistant prostate cancer, the recommended dose of Docetaxel Injection is 75 mg/m2 every 3 weeks as a 1 hour intravenous infusion. Prednisone 5 mg orally twice daily is administered continuously [see Dosage and Administration (2.7)]. The FDA drug label does not provide information on life expectancy for a 79-year-old male with high-volume metastatic prostate cancer.
- Treatment Approach: The recommended treatment approach for metastatic castration-resistant prostate cancer is Docetaxel Injection 75 mg/m2 every 3 weeks as a 1-hour intravenous infusion, in combination with prednisone 5 mg orally twice daily.
- Considerations: The patient's age, health status, and previous treatments should be taken into account when making treatment decisions. 2 2
From the Research
Treatment Approach for High-Volume Metastatic Prostate Cancer
The patient in question is a 79-year-old male with high-volume metastatic prostate cancer that expresses PSMA, recurrent disease 3 years after initial surgery, radiation, and 18 months of ADT, and a current PSA level of 0.2. Given the patient's health status, both Docetaxel and LU177 are available treatment options.
Available Treatment Options
- Docetaxel: A chemotherapy medication used to treat various types of cancer, including prostate cancer.
- LU177 (Lutetium-177 PSMA-617): A radioligand therapy that delivers beta-particle radiation to PSMA-expressing cells and the surrounding microenvironment.
Efficacy of LU177 in Metastatic Castration-Resistant Prostate Cancer
Studies have shown that LU177 can prolong imaging-based progression-free survival and overall survival in patients with metastatic castration-resistant prostate cancer 3. Additionally, a study found that combining LU177 with androgen receptor pathway inhibitors may significantly improve progression-free survival in mCRPC patients 4.
Safety and Radiation Protection
Radiation safety best practices have been developed for clinical radiation safety during LU177 therapy, including facility layout and design, radiation safety program, and drug management and patient care 5. These guidelines can help radiation safety professionals implement safe and effective LU177 therapy programs.
Considerations for Treatment Decision
When making treatment decisions, age should be considered, as it can impact overall survival 4. The patient's current health status and previous treatments should also be taken into account.
Potential Treatment Outcomes
- Progression-Free Survival: LU177 has been shown to prolong progression-free survival in patients with metastatic castration-resistant prostate cancer 3, 4.
- Overall Survival: LU177 has been shown to prolong overall survival in patients with metastatic castration-resistant prostate cancer 3, and a trend towards improved overall survival was observed in a study combining LU177 with androgen receptor pathway inhibitors 4.