CARE™ Video Series - Part 3

nmCRPC Case Discussion

Genitourinary

27 Jun 2022

Introduction

Welcome to the third, and final, installment of the CARE™ nmCRPC Case Series!

This series aims to provide guidance on navigating the evolving treatment landscape and some of the challenges that specialists face in routine practice.

[Ce programme est présenté dans la langue utilisée par les participants du Comité académique.]

Case Study: “Charles”

55-year-old presents with PSA rise after radiation to the prostate.
Past medical history includes hypertension, dyslipidemia and elevated BMI.

February 2015

  • Radiation to prostate (external beam)
  • cT3a
  • Gleason 4+4
  • Nadir PSA 0.32 ng/mL
  • CT and bone scan negative

Initial Referral: June 2018

  • PSA 6.5 ng/mL
  • CT and bone scan negative
  • Started on an LHRH analogue
  • Followed every 3-6 months

December 2018

  • PSA nadired at 0.9 ng/mL

April 2019

  • PSA 1.3 ng/mL
  • T < 0.7 nmol/L

February 2022

    • PSA 5.3 ng/mL
    • T < 0.7 nmol/L
  • Bone scan/CT negative for metastases
  • ECOG PS 0

May 2022

  • After two months of darolutamide:
    • PSA nadired at 0.01 ng/mL

Tolerating meds well, no new significant side effects

LHRH = Luteinizing hormone-releasing hormone
ECOG PS = Eastern Cooperative Oncology Group Performance Status
T = Testosterone

Highlights from Discussion

How often and what type of imaging do you use while patients are on ADT?
  • If PSA is stable, then I typically see them once a year without any further imaging.
  • Baseline imaging is done as soon as progression is first seen and then when castrate-resistant prostate cancer is demonstrated, I do another set of traditional imaging (bone scan, CT).
    • Chest CT is now done in addition to the pelvis.

 

Can we get by with just adding a first-generation anti-androgen agent or have you stopped that practice?
  • We have abandoned the use of what we used to call secondary hormonal maneuvers in the majority of patients.
    • There are at least two studies comparing the use of ARAT versus the use of first-generation anti-androgen therapy showing a dramatic difference and three randomized trials showing significant overall survival.
  • This strategy is only used in the very occasional patient who is old, fragile, cannot get access to these medications, and is very concerned about their PSA.

 

When do you calculate PSA doubling time?
  • It is calculated every time the patient is seen.
    • This is made easy with new electronic medical record systems (i.e. Accuro) but may be more daunting to those who do not have access to this.

 

How do you choose between the available options with your patients?
  • They’re all excellent therapies. It comes down to the side effect profile of the therapies as well as potential drug-drug interactions.
  • It is best to choose the one that affects the patient the least and will minimize the potential need for changes in therapy.

 

How frequently do you monitor PSA / imaging in your patients undergoing treatment for nmCRPC?
  • Initially, PSAs are done relatively frequently (at least every three months), and if everything’s stable it is reduced to every six months or so.
  • Close observation is important.
  • I would not order a PSMA PET scan in a patient like this because it would not change how they are managed.

 

Do you ever order PSMA-PET scans?
  • In today’s landscape, there is not much utility in doing PSMA PET because there is a risk of losing access to the drugs available in the nmCRPC setting.

 

What type of bone health-specific modifications /treatments do you recommend?
  • All patients are started on vitamin D and calcium when ADT is started.
  • A bone mineral density scan is always done at the beginning so subsequent follow-ups can be arranged if the patient is osteoporotic.
    • If so, bone health therapy (oral or injectables) should be started
  • Physical therapy should be recommended.
    • Talking about and teaching patients how to exercise is important and is something we strive to do better.

 

In patients who progress, would you consider starting with another ARAT or would you refer them to medical oncology?
  • It’s very reasonable to get help from our medical oncology colleagues to consider the other systemic therapies that would be available to the patient, whether it’s through a multi-specialty clinic or direct referral.
  • Typically, the earlier you can start patients on the next line of therapy the better.

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