Overall Survival for High-Volume Metastatic Castration-Resistant Prostate Cancer
The likely overall survival for this 79-year-old patient with high-volume metastatic castration-resistant prostate cancer (mCRPC) is approximately 15.3 months after starting Lutetium-177 (Lu-177) therapy, based on the VISION trial data.
Current Disease Status and Treatment Plan
This patient presents with:
- High-volume metastatic prostate cancer that is castration-resistant
- Low PSA production
- PSMA expression (positive)
- Currently on Docetaxel, Apalutamide, and ADT
- Good overall health with no pain at age 79
- Insufficient circulating tumor DNA for genetic testing
- Plan to use Lu-177 when progressing past Docetaxel
Expected Survival Based on Evidence
Lu-177 PSMA Therapy Outcomes
- The VISION trial demonstrated that Lu-177-PSMA-617 plus standard of care significantly improved overall survival compared to standard of care alone (15.3 vs 11.3 months; HR 0.62; 95% CI 0.52-0.74; p<0.001) 1
- This represents a 4.0-month absolute survival gain with Lu-177-PSMA therapy in patients previously treated with androgen receptor pathway inhibition and taxane-based chemotherapy 1
Factors That May Influence Survival
- The patient's good overall health status is favorable for treatment tolerance
- PSMA expression is a positive predictor for response to Lu-177 therapy
- Low PSA production may indicate a more aggressive phenotype, potentially impacting survival
- Age (79) is not necessarily a limiting factor given the patient's good health status
Comparison with Alternative Treatments
For patients with mCRPC who have progressed after docetaxel:
- Cabazitaxel: Median OS of 13.6 months (CARD trial showed OS gain of 2.6 months; HR 0.64) 1
- Enzalutamide: Median OS of 18.4 months (AFFIRM trial showed OS gain of 4.8 months; HR 0.53-0.75) 1
- Abiraterone: Median OS of 15.8 months (COU-AA-301 trial showed OS gain of 4.6 months; HR 0.74) 1
Treatment Sequence Considerations
- The TheraP trial showed that Lu-177-PSMA-617 and cabazitaxel had similar overall survival outcomes in patients who progressed after docetaxel (RMST 19.1 vs 19.6 months) 2
- The ENZA-p trial showed that adding Lu-177-PSMA-617 to enzalutamide improved overall survival compared to enzalutamide alone (median 34 vs 26 months; HR 0.55) in first-line mCRPC treatment 3
Potential Complications and Monitoring
- Grade 3-4 adverse events are more common with Lu-177-PSMA-617 compared to standard of care (52.7% vs 38%) 1
- Therapy-related myeloid neoplasms have been reported in approximately 1.3% of patients treated with Lu-177-PSMA, particularly in those with extensive prior treatments 4
- Regular monitoring of complete blood counts is essential during and after Lu-177 therapy
Conclusion
Based on the VISION trial data, which is the most recent high-quality evidence for patients with similar characteristics, the expected overall survival for this patient after starting Lu-177 therapy is approximately 15.3 months. However, individual factors such as good performance status and treatment response may positively influence this outcome.