Daniel P. Petrylak, MD: Managing Metastatic CRPC

Daniel P. Petrylak, MD, Professor of Medicine (Medical Oncology) and of Urology, Professor and Co-Director, Signal Transduction Research Program, Yale Cancer Center, suggests that a bone antiresorptive agent such as denosumab or zoledronic acid, should be considered for men with metastatic castration-resistant prostate cancer.

If the patient progresses on primary docetaxel, one could consider going on another hormonal agent. If he hasn’t received isotopes, radium-223 is also approved in that particular setting. You could also consider cabazitaxel if the patient fails primary chemotherapy.

CASE 2: Metastatic Castration Resistant Prostate Cancer (mCRPC)

Duane B. is a 61-year-old African-American man from Gainesville, Florida, who works as a truck driver for a medical supplies company.

In January 2011, the patient presented to his PCP; his PSA was found to be 25.2 ng/mL and his prostate was enlarged on digital rectal examination; patient was referred to an oncologist for further evaluation.

Subsequent biopsy, CT, and bone scan showed prostate adenocarcinoma T2cN0M0, Gleason 5 (2+3), and the patient was considered intermediate risk

Patient received radical prostate-bed radiotherapy and full androgen deprivation therapy with subcutaneous goserelin (10.8 mg quarterly) and oral bicalutamide (50 mg daily); after approximately 18 months, the patient’s PSA had dropped to undetectable levels and the bicalutamide was discontinued in July 2012

Patient’s prior medical history is unremarkable except for prior tobacco use (quit smoking in 2005) and obesity; the patient is currently following a weight loss and exercise regimen

In April 2014, the patient returns to his PCP complaining of fatigue and intermittent pain in his hip and back and inability to work

Patient’s PSA level had increased to 15.3 ng/mL; his testosterone level was 29 ng/dL; bone scan showed the presence of multiple lesions in the lumbar vertebrae (L2 and L4) and in the hip

Zoledronic acid (every 3 weeks) was initiated for prevention of skeletal-related events