A 65-year-old man was diagnosed with localized prostate cancer
Biopsy revealed adenocarcinoma of the prostate gland, Gleason score 7 [4+3]
PSA 15.7 ng/mL
Baseline staging: T3bN1M0 with right seminal vesicle and pelvic lymph node involvement

Initial Treatment

He undergoes radical prostatectomy with PLND
- PSA nadir of 0.4 ng/mL post-surgery
- Gleason 7 (4 + 3) confirmed
- Positive surgical margins
- Baseline staging confirmed – AJCC Stage IVA

February 2019

Follow-Up Notes

Serum PSA, 38 ng/mL; ALP, 289 IU/L
PSMA PET CT:
- Metastatic retroperitoneal LNs outside resection field
- Abdominal nodes
- Bone mets in ribs and thoracic spine
Genetic testing: BRCA2 mutation-positive

Additional Treatment

Abiraterone + prednisone initiated
Improved pain, PSA, and ALP

October 2019

Follow-Up Notes

Patient reported bone pain
Laboratory testing revealed rising PSA and ALP (serum PSA, 350 ng/mL; ALP, 2500 IU/L)
Imaging showed radiologic progression
ECOG PS 1
PSMA PET CT: increased uptake in retroperitoneal and abdominal LNs

mCRPC Treatment

Treated with docetaxel x4 cycles and denosumab
- Serum PSA, 38 ng/mL; ALP, 289 IU/L
- Reporting bone pain increased in back, now reporting pain in hip area
Bone scan and CT scan:
- Enlargement of retroperitoneal and abdominal LNs
- Additional bone mets noted in pelvic region

Transcript:

Daniel J. George, MD: PARP inhibitors have been around for a long time and one of the real advantages, even though this is a relatively new class of drugs to prostate cancer, [is that] we have a lot of experience in breast [and] ovarian cancer with these agents. The toxicity profile is well known and it’s a targeted therapy. The toxicity profile is largely limited to cells that are rapidly reproducing, and these typically tend to be cells in the bone marrow particularly; the red blood cell lineage but also to some extent, platelets, white cells, and the gut because it’s a rapidly turning over epithelial cell type. We can see effects in the GI [gastrointestinal] tract with diarrhea and some nausea associated with it. We do see patients who certainly have anemia, the most common [adverse] effect, but also, rarely, other cytopenias. These are the things that we’ll be monitoring for in our patients.

For me, the best way to manage those toxicities are with dose interruptions. Dose interruptions allow the drug to wash out relatively quickly, and that allows us to reset, particularly for diarrhea and GI [adverse] effects toxicities or hematologic toxicities; [it] can take several weeks for those to recover, but they do recover. It’s important to recognize that for mild levels, we can live with low levels of anemia and mild declines in hemoglobin and whatnot or manage diarrhea with Imodium and other agents or nausea with anti-nausea medicine. These are toxicities that, for the most part, we can work around when they’re low grade, but as they get a little bit higher grade, when we see weight loss, we see dehydration, and if we see anemia now with hemoglobin under 9 g/dL, these are the situations where I think a dose interruption could help.

Then depending on that recovery we can rechallenge, and re-challenging at the same dose is absolutely reasonable in these patients because some of that toxicity is with that initial exposure, and patients’ bodies acclimate, so they don’t always respond and develop the toxicity the same way twice. It’s important to recognize that, but as patients, as you see the recurrence of that toxicity again, begin to increase to say, grade 2 to grade 3 levels, that’s where I think a dose reduction is going to be helpful. And for me it’s always a dose interruption followed by a rechallenge or a dose reduction or both and recognize that when you have patients get repeated toxicities, even with a dose reduction, those are the patients that will discontinue therapy. Longer-term toxicities can happen, and are things that I think are important to keep an eye on, and we do look for blood dyscrasias even, myelodysplastic syndrome; they’re very rare in a metastatic castrate-resistant population. As we use these drugs earlier and study them earlier in other settings, that may not necessarily be the case, but at least to date from the studies we have, those episodes were not seen. Most if not all the toxicity concerns are in that early setting with using these drugs and being able to manage that. It’s important for people to recognize, not to panic, that a dose interruption is not a bad thing, and the majority of our patients we’re able to rechallenge.

Transcript edited for clarity.