Setting Realistic Goals With Palliative Therapy in mCRPC

Evan Y. Yu, MD: Another thing that I didn’t previously discuss is goals of therapy with this patient. For every patient who I see with cancer, and especially those who have a life-threatening cancer—those with an incurable cancer like this patient—I certainly discuss goals of care.

I’m very forthright in counseling the patients on what the goals of our treatment are. If they’re somebody who can potentially be cured of the cancer, that’s always the goal if we can accomplish it safely and with good quality of life. However, if that’s just not possible, I let the patient know that. I talk to the patient about that. I always ask the patient if they want to know about prognosis. I don’t want to surprise anybody with numbers. Most patients do want to know their prognosis, but if they don’t, I respect that as well.

I generally do lay out what our goals are in advance, whether this is a curative therapy or whether this is a palliative therapy. But in prostate cancer, in particular, I emphasize that even palliative therapy can be used for many years.

I think it’s very important to give patients a prognosis, or some sort of a time frame they can think about and work with if they’re interested in that. The reason is so they can do good life planning, family planning as well. They can also feel reassured. We have many good treatments available. Generally, the course of the disease and the natural history of some other cancers are that they are more aggressive.

Our patients with prostate cancer can live for many years. It’s helpful for them to know that, and it’s helpful for them to know that there are many other treatment options that can be used down the road to help them accomplish their goals.

Transcript edited for clarity.

Case: A 66-Year-Old Man with Metastatic Castration-Resistant Prostate Cancer

Initial presentation

• A 66-year-old man presented with increasing difficulty walking and sleeping on his back due to lower back and hip discomfort
• PMH: hypertension, medically controlled; no known family history of cancer
• PE: DRE revealed a nodular prostate; otherwise unremarkable
  
  

Clinical workup

• Biopsy with TRUS showed adenocarcinoma of prostate
  • Stage T2N0M0
  • Grade group 4
  • Expected survival > 5 years
• Germline testing: MLH1, MSH2, MSH6, PMS2, BRCA1/2, ATM, PALB2 and CHEK2
• Chest/abdominal/pelvic CT scan showed no evidence distant metastases or lymph node involvement
• Bone scan was negative
• PSA 26 ng/mL
  
  

Treatment and Follow-Up

• EBRT for 8 weeks + neoadjuvant concurrent, and adjuvant ADT for 2 years
• At 6 months post-ADT follow-up; PSA 5.9 ng/mL
• At 12 months follow-up:
  • Patient reported continued back discomfort, difficulty walking and loss of appetite
  • PSA 16 ng/mL
  • Bone scan showed multiple lesions in the right femur and pelvis
  • Abiraterone + ADT was initiated for 1 year
• At subsequent follow-up:
  • Patient complained of increased bone pain in right femur
  • PSA 18.6 ng/mL
  • Abiraterone was ceased; ADT continued
  • Treatment with radium-223 dichloride was initiated; 6 infusions completed and well-tolerated at post-infusion follow-up