Advanced Prostate CA Flashcards
Can you start treatment without tissue diagnosis?
Yes you can - but you do need to plan for a biopsy at some point, whether it is primary or metastatic lesion (important as some treatment is dependent on path)
What is an important aspect of treatment for advanced prostate CA?
Patient’s QoL
must treat there urinary symptoms, pain, sexual fx (if that is there priority), and side effects
What are prognostic fxs for clinical recurrence and potential mets?
rad prostate: GG 4/5, PSADT < 1 year
EBRT: GG 4/5, PSADT < 18 months
What imaging should be done for biochemical recurrence?
Preferentially PSMA PET scan if available. It has greater sensitivity. If conventional scans are negative, again recommendation is PSMA PET scan.
Biochemical recurrence - but no radiographic evidence of metastases. What are your options?
Clinical trial or observation is preferred.
Can start ADT, especially if patient has rapid rise in PSA (or other poor prognostic fps) - but should be considered intermittent instead of steady tx.
Why intermittent therapy?
Better side effect profiles:
better hot flashes, sexual activity, and urinary symptoms
Suggestion of intermittent therapy is 8 month cycle (and stopped as long as no suggestion of clinical disease progression. Restart ADT was PSA 10 - this was one trial)
What is difference between low and high volume disease?
High volume = greater or equal to 4 bone mets, w/ at least one bone met outside spine/pelvis OR a visceral met
What is important in patient with metastatic disease?
Are they symptomatic
What should you follow after starting ADT in patient that is with metastatic hormone sensitive prostate CA?
PSA
regardless of PSA - should still do cross sectional imaging from time to time
What other testing should all MHSPC patients undergo?
Germline testing - implications for clinical trials
What is treatment regimen for MHSPC patients?
continuous ADT (lupron vs orgovyx) + [abiraterone (CYP17A inhibitor) + prednisone or apalatumide (AR inhibitor) or enzalutamide) OR docetaxel (MT inhibitor)
treatment choice should be based on pt - also if short term treatment (chemo) vs daily pill
Side effects of prior mentioned medications
docetaxel - febrile neutropenia, GI, lethargy
abiraterone - liver toxicity, HTN, hypokalemia (also be careful in patients that will be effected by steroids)
aplautamide - rash
enzalutamide - fatigue
the -ides have more increase in seizures
What is special about de novo MHSPC patients?
if never any local treatment, then recommendation is
ADT + docetaxel + abiraterone/predinsone OR darulotomide
What must you monitor in patients with nmCRPC?
PSADT (less than 10 months has been shown to be high risk)
When does radiation play a role in MHSPC patients?
For low volume disease, w/ ADT.
Must be primary radiation
STAMPEDE Trial
How often imaging for nmCRPC?
Every 6-12 months, PSMA or conventional
What is augmented treatment for nmCRPC?
ADT + apalutamide, enzalutamide, or darulotamide for HIGH risk patients (PSADT less than 10 months)
Otherwise can consider just observation
What info must you have for mCRPC?
PSA, testosterone, alk phos
locations of disease
current symptoms
Performance status
How often for imaging in mCRPC?
annually
Again - what should you order for all patients with mCRPC?
germline testing!
These patients are eligible for PARP inhibitors (if they have already done the other txs)
Newly diagnosed mCRPC, tx?
ADT + abiraterone/predisone OR docetaxel OR enzalutamide
mRCPC who is minimally symptomatic?
sipulcel T
cannot be using opioids
no visceral mets or bulky mets
When is radium 223 used?
bone mets, symptomatic
no known visceral disease or bulky mets
what about progressive mCRPC who have already received docetaxel and ARI?
Lu-PSMA if there PSMA PET scan is positive
can also offer cabazitaxel
