What is the recommended treatment approach for a patient with prostate cancer, Gleason score 7, Stage 2, PSA level of 20, and possible lung and liver metastases?

Treatment Approach for Prostate Cancer with Possible Metastases

For a patient with Stage 2 prostate cancer (Gleason 7), PSA 20, and possible lung and liver metastases, the recommended treatment is androgen deprivation therapy (ADT) as the primary treatment, with consideration for adding docetaxel chemotherapy if the patient is fit enough to receive it. 1, 2

Disease Assessment and Staging

• The patient's presentation suggests metastatic disease based on CT findings showing possible lung and liver metastases, which would upstage the cancer from the initial Stage 2 classification 3
• PSA level of 20 ng/mL places the patient in the high-risk category, even without considering the metastatic findings 4
• Confirmation of metastases is essential, as treatment approach differs significantly between localized and metastatic disease 4
• Bone scan should be performed to evaluate for bone metastases, which are common in metastatic prostate cancer 3

Treatment Recommendations for Metastatic Disease

• Androgen deprivation therapy (ADT) is the standard first-line treatment for metastatic prostate cancer, administered either through surgical castration (bilateral orchiectomy) or medical castration using LHRH agonists 1, 2
• When starting treatment with an LHRH agonist, an antiandrogen should be given for 3-4 weeks initially to prevent testosterone flare 1, 2
• Continuous ADT is recommended over intermittent ADT for metastatic hormone-naïve prostate cancer 1, 5
• For patients fit enough for chemotherapy, adding docetaxel to ADT has shown survival benefits in metastatic hormone-sensitive prostate cancer 2, 6
• The recommended dose of docetaxel for metastatic prostate cancer is 75 mg/m² every 3 weeks as a 1-hour intravenous infusion, administered with prednisone 5 mg orally twice daily 6

Monitoring and Follow-up

• Regular monitoring should include clinical assessment, PSA measurement, and management of treatment side effects 2
• Initial imaging by bone scan and CT scan (or MRI) of the abdomen and pelvis is strongly recommended 2
• Men on long-term ADT should be monitored for side effects including osteoporosis (using bone densitometry) and metabolic syndrome 2
• Regular exercise should be recommended as it reduces fatigue and improves quality of life in men on ADT 1, 2

Treatment for Disease Progression

• If the disease progresses to castration-resistant prostate cancer (CRPC), additional treatment options include:
  • Abiraterone or enzalutamide for asymptomatic/mildly symptomatic patients 1, 2
  • Docetaxel chemotherapy for symptomatic patients with good performance status 1, 2
  • Radium-223 for patients with bone-predominant, symptomatic metastatic CRPC without visceral metastases 2

Important Considerations and Caveats

• PSA is not always a reliable indicator of disease activity in patients with undifferentiated (or anaplastic) metastatic prostate cancer with neuroendocrine features 2
• Docetaxel should be used with caution in patients with abnormal liver function, as it is associated with increased treatment-related mortality in these patients 6
• Supportive care for bone metastases may include external beam radiotherapy for palliation of painful bone metastases and denosumab or zoledronic acid to prevent skeletal-related events 2
• Combined androgen blockade (CAB), which adds an antiandrogen to medical castration, may provide a small survival benefit but with increased toxicity 1