Kenneth J. Pienta, MD: Chemo Ineligible CRPC

Kenneth J. Pienta, MD, Director of Urologic Research, The Donald S. Coffey Professor of Urology, Professor of Oncology, Professor of Pharmacology and Molecular Sciences, The Johns Hopkins Hospital, explains that if the patient was ineligible to receive chemotherapy for some reason, or if he had failed chemotherapy, enzalutamide is a reasonable next-line treatment following abiraterone.

If the patient has multiple sites of bone disease that are symptomatic, radium-223 is an option, Pienta notes. Generally, radium-223 is given as 6 doses, 1 month apart as the standard therapy. After this, the patient could receive abiraterone. If the patient had multiple sites of pain in the pelvis, radium-223 may be ideal, especially if he was ineligible for Taxotere or cabazitaxel or if enzalutamide was not working.

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