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5yr

58-Year-Old Male Experiences Increase in PSA After Treatment

Joe is 58 and missed his annual DRE and PSA screening. At his next exam, his primary care physician detected a palatable prostate nodule. His PSA level measured 16 ng/mL.

The needle biopsy reveals several clusters of cells suggestive of adenocarcinoma, with a Gleason score of 8-to-9.

Given the aggressive nature of his diagnosis, Joe chose a radical prostatectomy. The pathology report confirms adenocarcinoma that reaches beyond the prostate but has not invaded the seminal vesicles.

Staging scans confirm that the tumor is a T3a. Joe agrees to a course of radiation afterward.

At his 3-month follow-up, his PSA has increased to 20 ng/mL. A bone scan reveals multiple bone lesions in his ribs and pelvis.

What is the best treatment option for Joe?

  • 5yr
    1. Genetic testing for BRCA and HRD
    2. He unfortunately has stage IV disease, given multiple bone lesions, his young age and PS, would recommend upfront docetaxel plus ADT. If he prefers no chemotherapy, can consider Abiraterone
    3. Denosumab to reduce the risk of skeletal related events
  • 5yr
    How would you advise this patient about treatment and prognosis? What would you tell him?
  • 5yr
    ADT + either Docetaxel or AR inhibitor (Xtandi/Abiraterone). Add Denosumab.
  • 5yr
    Definitely check for BRCA and HRD. He could start with ADT and Taxotere or Androgen receptor inhibition therapies. Although he is young and has good PS, I generally reserve upfront Taxotere for high burden disease. There is data from recent ASCO about combining ADT + Taxotere and Abiratarone as well.
  • 5yr
    You’ve missed the boat here… he had metastastic disease at diagnosis which would have been detected if he had undergone PSMA-PET scanning prior to surgery. It would also have told you if the primary site was PSMA +ve. Standard of care for M2 disease is ADT + taxanes.
  • 5yr
    Would offer genetic testing to look for genetic mutations,if negative,would start ADT with Xtandi and also consider taxotere for highly aggressive disease.
    Would check pdl -1Status as well . If posivitive genetic mismatch would suggest a parp inhibitor.

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