Philip Kantoff, MD: Consideration of Chemotherapy

CASE 2: Metastatic Castration-Resistant Prostate Cancer

Jerry K. is a 66-year-old Cuban American from San Diego, California, who works as a freelance IT consultant and systems analyst in the hospitality industry.

In January of 2009, he underwent a prostate biopsy after his PSA increased from 1.0 ng/mL (1/06) to 1.2 ng/mL (2/07) to 29.1 ng/mL (12/08).

Adenocarcinoma (Gleason score 4+4 = 8) detected in 7 of 10 cores; stage T1c

Prior medical history is notable for arthroscopic rotator cuff repair in 2006 with infectious complication requiring hospitalization

Patient is asymptomatic with good performance status (ECOG 0); taking no medications and liver function tests are within normal limits

Initial therapy included androgen deprivation therapy (ADT) with bicalutamide and an LHRH agonist along with 78 Gy of radiation

After 14 months of ADT, PSA decreased to a nadir of 0.20 ng/mL

Patient experiences periodic hot flashes

While on ADT, PSA increases to 1.0 ng/dL

Serum testosterone levels are castrate (20 ng/dL)

Bicalutamide is withdrawn; LHRH therapy is continued

After 26 months of ADT, the patient’s PSA increased to 5.0 ng/mL with a PSA doubling time of 4 months; patient complains of fatigue, periodic hot flashes, and intermittent lower back pain

Bone scan reveals several nodules in the L5 vertebra

Patient receives immunotherapy with sipuleucel-T for minimally symptomatic metastatic castrate-resistant prostate cancer

Denosumab initiated for skeletal metastases

At current visit (3.5 months after sipuleucel-T), patient presents with worsening back pain and radiographic evidence of progression.