Kenneth J. Pienta, MD: Pre-Chemo Hormonal Therapy

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 he is very worried about the patient in the case study, since he has presented with symptomatic castration-resistant prostate cancer (CRPC), including bone pain in his spine.

Patients who complain of bone pain, especially in their spine, are at risk for cord compression. In this patient, Pienta feels that the only 2 options are to initiate palliative radiation to the spine and then to start a super-castration agent, such as abiraterone. In this setting, abiraterone makes an effective systemic agent of choice because it has a demonstrated survival benefit, and it also has a definitive palliative benefit.

Since the patient is complaining of bone pain, Pienta would get an MRI of the patient's back to check for impending cord compression. Based on these results, Pienta would choose to use palliative radiation therapy prior to initiating the abiraterone or, if there were no danger of cord compression, Pienta would jump straight to abiraterone.

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