Charles Ryan, MD: Follow-Up Recommendations During and After Treatment

What type of follow-up is needed for this patient during treatment and afterward?

This is a patient who I would probably see every three weeks while he’s getting chemotherapy. I would give him 6 cycles of chemotherapy, so we would be seeing each other quite a bit right at the outset of treatment. Following the completion of chemotherapy, we would reassess the situation. I would hope that his PSA would be down, his performance status would be good. If there are soft tissue elements, I may consider repeating a CT scan after the completion of chemotherapy. I don’t always repeat a bone scan because, in many cases, they can be quite confusing because of issues around bone scan flare and things like that. Once this patient has completed chemotherapy, provided that he is symptomatically well and his PSA is down and things look good, I might only see him every three months for a period of time.

One of the questions that comes up in a situation like this is local therapy. This is a person who presented to his physician at 61 years-old with a primary tumor that was very symptomatic. He was having lower urinary tract symptoms and even some hematuria. This is the type of patient who may benefit, in a palliative sense, from receiving local therapy, which might reduce his risk, for example, of pain or further hematuria. It might reduce his risk of further progression in the prostate which could lead to urinary retention or even kidney failure. For those situations, I think a discussion around local therapy is reasonable.

CASE: Metastatic Prostate Cancer (Part 2)

Mathew J is a 61 year old African American male who presented to his primary care physician with lower urinary tract symptoms, including sporadic hematuria. He complains of abdominal pain and low back pain starting four months ago and increasing in frequency. Prior medical history includes non-insulin dependent diabetes mellitus, well-controlled on metformin since 2006. The patient was referred to urology for further evaluation. ng/ml.

During his most recent follow-up exam, the patient complained of intermittent back pain and increasing fatigue.

• Digital rectum exam revealed nodular prostate /L
• Serum PSA level; 129 ng/ml
• Alkaline phosphatase, 258
• TRUS/prostate biopsy: 53 gram prostate, 12/12 cores (+), Gleason 4 + 5
• CT indicates blastic lesions to lumbar spine and pelvis
• Bone Scan positive for T/L spine, pelvis, right femur, scapula
• ECOG performance status, 1