From the Research
For a 79-year-old male with high-volume metastatic castration-sensitive prostate cancer (mCSPC) expressing PSMA, the recommended treatment is androgen deprivation therapy (ADT) combined with either docetaxel chemotherapy or a novel hormonal agent such as abiraterone acetate, enzalutamide, or apalutamide, with consideration of PSMA-targeted radioligand therapy like 177Lu-PSMA-617 in later disease stages, as supported by recent studies 1, 2.
Given the patient's advanced age, a comprehensive geriatric assessment should be performed to evaluate fitness for chemotherapy. If deemed appropriate, docetaxel would be administered at 75 mg/m² every 3 weeks for 6 cycles. For abiraterone, the standard regimen is 1000 mg daily with prednisone 5 mg daily. Enzalutamide is given as 160 mg daily, while apalutamide is 240 mg daily. ADT typically involves a GnRH agonist (like leuprolide 22.5 mg every 3 months) or antagonist (like degarelix 240 mg initial dose, then 80 mg monthly).
The combination approach is recommended because it targets androgen signaling at multiple levels, significantly improving survival compared to ADT alone, with studies showing improvements in overall survival with these combination approaches 1. Additionally, the use of PSMA-targeted radioligand therapy such as 177Lu-PSMA-617 has shown promise in patients with PSMA-expressing tumors, particularly in later disease stages 3, 4, 2.
Treatment selection should balance efficacy with the patient's comorbidities, functional status, and preferences. The patient's current health status, with a PSA of 0.2 and high-volume metastatic disease, suggests the need for aggressive treatment to control the disease and improve quality of life.
Key considerations in treatment selection include:
- The patient's fitness for chemotherapy, as assessed by a comprehensive geriatric evaluation
- The potential benefits and risks of each treatment option, including docetaxel, novel hormonal agents, and PSMA-targeted radioligand therapy
- The patient's preferences and values, including quality of life and survival goals
- The potential for treatment intensification, including the use of "triplet systemic therapy" with ADT, an ARPI, and docetaxel, as supported by recent studies 1.