Kenneth J. Pienta, MD: Managing Metastatic 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 for patients with metastatic castration-resistant prostate cancer, it is important to consider an MRI to be sure that he has no impending cord compression.

If cord compression is evident, the patient should be treated with palliative radiation therapy and then abiraterone. Once abiraterone fails, docetaxel is effective; once docetaxel fails, or if he is ineligible for docetaxel, treat him with enzalutamide. If the patient progresses on enzalutamide, we could treat him with radium-223.

If the patient is having a lot of bone pain after abiraterone, we could also consider single-site or palliative radiation therapy. We could also consider future chemotherapy with cabazitaxel or mitoxantrone, but then if he cannot tolerate chemotherapy, we still have abiraterone, enzalutamide, and radium- 223 to be able to give him, in addition to adjunctive therapy with denosumab or zoledronic acid.

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