What is the current clinical concern for an 83-year-old male with Gleason 7 prostate cancer and worsening LUTS after radiation and triptorelin therapy?

From the Guidelines

The current management plan for the 83-year-old male with Gleason 7 (4+3) prostate cancer is appropriate, continuing Flomax (tamsulosin) 0.4 mg at bedtime to help manage his LUTS, as recommended by the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms 1. The patient's symptoms of nocturia 3-5 times per night, occasional stress incontinence, and constipation are common side effects following radiation therapy for prostate cancer. The combination of radiation therapy with neoadjuvant hormonal therapy using Trelstar (triptorelin), a GnRH agonist, is a standard approach for this intermediate-to-high risk prostate cancer. Trelstar works by initially stimulating testosterone production but then causing downregulation of receptors, ultimately leading to testosterone suppression which helps control prostate cancer growth. Close monitoring of his urinary symptoms is warranted, with instructions to report any worsening. If his LUTS worsen significantly, additional interventions such as anticholinergics, beta-3 agonists, or urological referral for possible procedures might be considered, as suggested by the guidelines 1. PSA monitoring has been initiated with a sample collected today, which is in line with the recommendations for men with prostate cancer, as stated in the 2023 European Association of Urology guidelines 1. The patient's treatment plan should be regularly reviewed and adjusted as necessary to ensure optimal management of his LUTS and prostate cancer, following the principles outlined in the guidelines 1. Key considerations in the management of this patient's LUTS include:

• Offering lifestyle advice and self-care information prior to, or concurrent with, treatment, as recommended by the guidelines 1
• Using alpha-1 blockers, such as Flomax, to manage moderate-to-severe LUTS, as suggested by the guidelines 1
• Considering combination treatment with an alpha-1 blocker and a 5-ARI for men with moderate-to-severe LUTS and an increased risk of disease progression, as recommended by the guidelines 1

From the FDA Drug Label

5.2 Tumor Flare

Initially, triptorelin (TRELSTAR), like other GnRH agonists, causes a transient increase in serum testosterone levels [see Clinical Pharmacology (12.2) ]. As a result, worsening signs and symptoms of prostate cancer during the first weeks of treatment have been reported with GnRH agonists. Patients may experience worsening of symptoms or onset of new symptoms, including bone pain, neuropathy, hematuria, or urethral or bladder outlet obstruction Closely monitor patients with metastatic vertebral lesions and/or with urinary tract obstruction during the first few weeks of therapy.

The patient's symptoms of worsening LUTS, nocturia, stress incontinence, and constipation after radiation therapy and initiation of TRELSTAR 11.25 mg are not uncommon and may be related to the treatment or the underlying condition.

• The tumor flare phenomenon associated with GnRH agonists like TRELSTAR may cause a transient worsening of symptoms.
• It is essential to closely monitor the patient's symptoms and adjust treatment as necessary.
• The patient should continue to receive Flomax 0.4 mg at bedtime for LUTS management and report any further worsening of symptoms 2, 2.

From the Research

Patient's Condition and Treatment

• The patient is an 83-year-old male with Gleason 7 prostate cancer, who has undergone external beam radiation and is currently receiving neoadjuvant hormonal therapy with Trelstar 11.25 mg.
• The patient reports worsening of his lower urinary tract symptoms (LUTS) after radiation therapy, including nocturia, occasional stress incontinence, and constipation.
• The patient is instructed to continue Flomax 0.4 mg at bedtime for his LUTS.

Management of LUTS

• Studies have shown that tamsulosin, the active ingredient in Flomax, is effective in improving LUTS in patients with benign prostatic hyperplasia (BPH) 3, 4.
• Tamsulosin has been shown to increase maximum urine flow (Qmax) and reduce LUTS in patients with BPH, with a rapid onset of action and a low potential for hypotensive effects or interference with concomitant antihypertensive therapy 3, 4.
• In patients with advanced prostate cancer, tamsulosin has been shown to provide significant relief from LUTS when combined with androgen deprivation therapy (ADT) 5.

Radiation Therapy and LUTS

• Radiation therapy can cause worsening of LUTS in patients with prostate cancer, as seen in this patient's case.
• Prophylactic tamsulosin has been shown to reduce urinary morbidity after prostate brachytherapy, although it did not significantly affect urinary retention rates 6.

Monitoring and Follow-up

• The patient's LUTS will continue to be monitored, and he is instructed to report any further worsening of symptoms.
• The patient's PSA levels will be monitored, and adjustments to his treatment plan will be made as necessary.