What is the appropriate prescription, including premedication, for a patient with prostate cancer and a BSA of 1.5 undergoing chemotherapy with Docetaxel?

Docetaxel Prescription for Prostate Cancer (BSA 1.5 m²)

For metastatic castration-resistant prostate cancer with BSA 1.5 m², administer docetaxel 112.5 mg (75 mg/m² × 1.5) intravenously over 1 hour every 3 weeks, with mandatory premedication of oral dexamethasone 8 mg at 12 hours, 3 hours, and 1 hour before infusion, plus continuous oral prednisone 5 mg twice daily. 1

Complete Prescription

Premedication Regimen (Prostate Cancer-Specific)

• Dexamethasone 8 mg orally:

  • 12 hours before docetaxel infusion
  • 3 hours before docetaxel infusion
  • 1 hour before docetaxel infusion 1, 2

• Prednisone 5 mg orally twice daily: Continue throughout treatment course 1, 2

Docetaxel Dosing

• Dose calculation: 75 mg/m² × 1.5 m² BSA = 112.5 mg total dose 1
• Administration: Intravenous infusion over 1 hour 1
• Schedule: Every 3 weeks (21-day cycle) 2, 1
• Duration: Up to 6 cycles for hormone-sensitive disease 2 or up to 10 cycles for castration-resistant disease if no progression 3

Clinical Context and Evidence

Standard Dosing Rationale

The 3-weekly schedule at 75 mg/m² represents the FDA-approved and guideline-recommended standard for metastatic prostate cancer, supported by pivotal trials demonstrating survival benefit 1, 2. This dosing achieved median overall survival improvements in both hormone-sensitive and castration-resistant settings 2.

Premedication Differences for Prostate Cancer

The prostate cancer premedication regimen differs from other indications because patients receive concurrent prednisone therapy. The reduced dexamethasone schedule (8 mg × 3 doses vs. 16 mg daily × 3 days for breast cancer) accounts for this baseline corticosteroid exposure while still preventing hypersensitivity reactions, which occur in 2% of adequately premedicated patients 2, 1.

Treatment Monitoring Requirements

Before Each Cycle

• Neutrophil count must be ≥1,500 cells/mm³ before administering next dose 1
• Check complete blood count, liver function tests 1
• Assess for peripheral neuropathy (discontinue if ≥grade 3) 1

Ongoing Surveillance

• PSA every 3-6 months 4
• Imaging every 6-12 months (note: 24.5% may have radiographic progression without PSA rise) 3
• Monitor testosterone, LDH, hemoglobin, alkaline phosphatase 4
• Maintain concurrent ADT throughout treatment 4

Dose Modifications for Toxicity

Reduce to 90 mg (60 mg/m²) if:

• Febrile neutropenia occurs 1
• Neutrophils <500 cells/mm³ for >1 week 1
• Moderate neurosensory symptoms develop 1
• Severe or cumulative cutaneous reactions 1

Discontinue if:

• Grade ≥3 peripheral neuropathy develops 1
• Patient continues to experience severe reactions at reduced dose 1

Alternative Dosing Considerations

Two-Weekly Schedule (50 mg/m² = 75 mg every 2 weeks)

While the standard remains 3-weekly dosing, a 2-weekly schedule may be considered for older, frailer patients with higher ECOG performance status or significant comorbidities 5, 6. This alternative showed:

• Longer time to treatment failure (5.6 vs 4.9 months, HR 1.3, p=0.014) 5
• Reduced grade 3-4 neutropenia (36% vs 53%) and febrile neutropenia (4% vs 14%) 5
• Fewer neutropenic infections (6% vs 24%, p=0.002) 5
• No toxic deaths compared to 5 deaths in 3-weekly group in one series 6

However, the 3-weekly schedule remains the evidence-based standard with the strongest survival data from pivotal trials 2, 1.

Critical Safety Considerations

Hypersensitivity Reactions

Without premedication, infusion reactions occur in 30% of patients; with proper dexamethasone premedication, severe reactions drop to 2% 2. Reactions typically occur within the first 10 minutes of infusion 2. If grade 3-4 reaction occurs despite premedication, stop treatment and provide aggressive symptomatic therapy; consider desensitization protocols for subsequent cycles 2.

Neutropenic Complications

Grade 3-4 neutropenia occurs in approximately 53% with 3-weekly dosing 5. Prophylactic G-CSF is not routinely recommended but should be considered in high-risk patients or after febrile neutropenia 2. Neutropenic infections represent a significant risk (24% in 3-weekly schedules) 5.

Fluid Retention

The corticosteroid premedication regimen specifically reduces the incidence and severity of docetaxel-associated fluid retention 1. Without premedication, this complication is significantly more common and severe 1.