Kenneth J. Pienta, MD: Pre-Chemo mCRPC Treatment

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, discusses treating patients with castration-resistant prostate cancer (CRPC) in the pre-chemotherapy space.

At this point, Pienta explains, the only 2 FDA-approved drugs are abiraterone and sipuleucel-T. Pienta prefers sipuleucel-T when the patient has only mild symptoms and rapid progression is not a concern. As an adjunctive therapy, I can also use an anti-osteoclast therapy, like zoledronic acid.

Since there is no way to measure the short-term effect of sipuleucel-T, Pienta only uses the treatment when the patient can tolerate being off cytotoxic therapy for 3 months while they prepare for, receive the therapy, and then recover from the therapy.

CASE 1: Metastatic Castration-Resistant Prostate Cancer (mCRPC)

Robert C. is a 63-year-old physical education teacher and high school wrestling coach from Savannah, Georgia

In May 2007, patient presented to his PCP and received routine screening for prostate cancer.

Patient’s PSA level was 6.2 ng/mL

Digital rectal examination and subsequent CT scan revealed the presence of prostate adenocarcinoma T2bN0M0, Gleason 6 (2+4), classified as intermediate risk

Patient underwent radical prostatectomy and adjuvant radiotherapy in June 2007

Patient’s prior medical history is notable for abdominal aortic aneurysm surgery in 2002 and hypertension (well controlled on current therapy)

His liver function tests were unremarkable

In July 2010, after approximately 3 years, the patient returned to his PCP for a routine physical, and an increase in PSA to 9.7 ng/mL was detected; he was asymptomatic.

Bone scan in August 2010 was negative

Androgen deprivation therapy (ADT) was initiated in August 2010 with goserelin; the patient’s PSA subsequently decreased to 0.5 ng/mL

In September 2012, after approximately 2 years, the patient’s PSA began to rise to 2.0 ng/mL; testosterone level was 19 ng/dL

Oral bicalutamide was added to his ADT; he continued to be asymptomatic

In April 2013, the patient presented to his PCP complaining of lower back pain and moderate to severe fatigue; his PSA had increased to 3.7 ng/mL

Bone scan revealed the presence of diffuse bone lesions in the lumbar and sacral vertebral bodies