From the Guidelines
The next steps for this patient should include a comprehensive evaluation to confirm metastatic prostate cancer, which is strongly suggested by the clinical presentation and imaging findings, with a focus on prompt diagnosis and treatment to improve quality of life and potentially extend survival. A prostate-specific antigen (PSA) blood test should be ordered immediately, along with a prostate biopsy to confirm the diagnosis and determine the Gleason score, as recommended by the American Society of Clinical Oncology 1. Bone scan and possibly PET-CT would help assess the full extent of metastatic disease, considering the limitations of traditional imaging modalities such as CT scans and the potential benefits of newer technologies like MRI and PET/CT 1. Referral to both urology and oncology specialists should be expedited to ensure a multidisciplinary approach to management. For the dysphasia, a gastroenterology consultation with possible endoscopy is warranted to determine if this is related to metastatic disease or a separate issue. Pain management should be initiated if the patient is experiencing bone pain, typically with NSAIDs, acetaminophen, or opioids if necessary. Androgen deprivation therapy (ADT) would likely be the initial treatment approach, using medications such as leuprolide 7.5 mg monthly or goserelin 3.6 mg subcutaneously every 28 days, possibly combined with an anti-androgen like bicalutamide 50 mg daily, as recommended by the St Gallen Advanced Prostate Cancer Consensus Conference 1. Nutritional support and consultation with a dietitian are important to address the weight loss. Key considerations in the management of this patient include:
- Prompt diagnosis and treatment to improve quality of life and potentially extend survival
- Multidisciplinary approach to management, including urology, oncology, and gastroenterology specialists
- Comprehensive evaluation, including PSA blood test, prostate biopsy, bone scan, and possibly PET-CT
- Pain management and nutritional support to address symptoms and improve quality of life
- Androgen deprivation therapy (ADT) as the initial treatment approach, with consideration of combination therapy and newer treatment options.
From the FDA Drug Label
The use of GnRH agonists may cause a reduction in bone mineral density. In men, data suggest the use of a bisphosphonate in combination with a GnRH agonist may reduce bone mineral loss [see Adverse Reactions (6. 5)]. Patients should be informed that diabetes, or loss of glycemic control in patients with pre-existing diabetes, has been reported during treatment with GnRH agonists, including ZOLADEX. A small increased risk of developing myocardial infarction, sudden cardiac death and stroke has been reported in association with use of GnRH agonists in men.
The next steps for a patient presenting with dysphasia and unintended weight loss, with a computed tomography (CT) scan of the chest/abdomen/pelvis showing multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications, would be to:
- Initiate GnRH agonist therapy, such as goserelin, to reduce testosterone levels and slow disease progression 2.
- Monitor for potential side effects, including reduction in bone mineral density, diabetes, and cardiovascular disease.
- Consider combination therapy, such as a bisphosphonate, to reduce bone mineral loss.
- Closely monitor the patient's condition, including blood glucose and cardiovascular health, and adjust treatment as necessary.
From the Research
Next Steps for Patient with Dysphasia and Unintended Weight Loss
The patient's presentation with dysphasia and unintended weight loss, along with a CT scan showing multiple sclerotic foci consistent with osseous metastatic disease, multiple pulmonary nodules, mediastinal hilar lymphadenopathy, and an enlarged prostate gland with macrocalcifications, suggests a diagnosis of metastatic prostate cancer.
- The standard treatment for metastatic prostate cancer is androgen deprivation therapy (ADT) 3, 4, 5, which can be achieved through either surgical or medical means.
- The choice of ADT agent is crucial, with luteinizing hormone-releasing hormone agonists and antagonists being the most effective options 4, 5.
- Recent studies have shown that relugolix, a novel oral gonadotropin-releasing hormone antagonist, may offer improved cardiovascular safety and reduced risk of major adverse cardiovascular events compared to traditional LHRH agonists 6.
- For patients with low-volume metastatic hormone-sensitive prostate cancer, consensus statements suggest that androgen deprivation therapy alone may be considered undertreatment, and all patients should be evaluated for systemic treatment combinations 7.
- Local therapy, including metastasis-directed therapy, may be considered in selected cases, especially if prostate-specific membrane antigen positron emission tomography staging has been performed and when indolent disease occurs 7.
Treatment Options
- Androgen deprivation therapy (ADT) with either luteinizing hormone-releasing hormone agonists or antagonists 4, 5
- Relugolix, a novel oral gonadotropin-releasing hormone antagonist 6
- Systemic treatment combinations, including chemotherapy and new hormonal agents 3, 7
- Local therapy, including metastasis-directed therapy, in selected cases 7