case answers for prostate cancer of pharmacotherapy casebook

1. Prostate cancer
(Case answers)
Faculity of Clinical pharmacy
2018

6. ?
1a
Identify the patient primary drug
therapy problem

7. Additional drug therapy:
1-prostate cancer
2-uncontrolled HTN
• Unnecessary drug therapy
Fluoxetine

8. ?
1bwhat information(signs ,symptoms
,laboratory value ,and other information)
indicate the presence and extent of his
metastatic prostate cancer

9. • Painless haematuria
• Dysuria ,dribbling ,nocturia ,hesitancy ,incomplete voiding.
• Fatigue and sever pain in right shoulder
• Prostate is markedly large and asymmetric on the right

10. Our patient Normal range
Hgb 9.5 g/dL 13.5-17.5 g/dL
Hct 27.1% 40-54%
LDH 742 IU/L 105-333 IU/L
Alk phos 912 IU/L 44-147 IU/L
PSA 35.7 ng/mL = or <4
Bone scan
Skeletal metastases involving the skull and
right shoulder
Bladder neck biopsy
High grade carcinoma , Gleason score 8
Perineal prostate biopsy
Gleason score 9 , positive perineural
invasion

11. ?
2Considering this patient’s disease stage and
history, what are the goals of
pharmacotherapy

12. • In early-stage prostate cancer, the goal is to
minimize morbidity and mortality.
• Surgery and radiation therapy are curative but
also associated with significant morbidity and
mortality.
• In advanced prostate cancer, treatment
focuses on providing symptom relief and
maintaining quality of life

13. • Advanced disease
• – commonly presents with back pain and
stiffness due to
• bone metastases.
• – Lower extremity edema can occur as a result
of lymphatic obstruction.
• – Anemia and weight loss are nonspecific
signs of advanced disease.

15. •Our pt:
•Gleason score :-
•(bladder) is 8
•(perineal) is 9
•PSA is 35 ng/mL
•T4
•N2
•M1b

16. • Goals of Treatment
• In early-stage prostate cancer, the goal is to
minimize morbidity
• and mortality. Surgery and radiation therapy
are curative but also associated with significant
morbidity and mortality.
• In advanced prostate cancer, treatment
focuses on providing symptom relief and
maintaining quality of life

17. ?
3-aWhat nondrug therapy might be useful for
this patient

18. NONPHARMACOLOGIC THERAPY
1. Observation
2. Surgery and Radiation Therapy
3. Physical Modalities
4. Psychosocial Interventions
5. Psychological Interventions
a. Cognitive-Behavioral Interventions
b. Behavioral Interventions

19. Observation
• Prostate-Specific Antigen (PSA) and Digital
rectal examination (DRE) are performed every
6 months.
Surgery
• Orchiectomy is the preferred initial treatment
for patients with impending spinal cord
compression

20. Radiation Therapy
• Radical prostatectomy and radiation therapy
are potentially curative therapies but are
associated with complications like:
1- blood loss
2- incontinence
3- fistula formation
4- impotence

21. Physical Modalities
• rehabilitative treatment such as optimizing
range of motion, strength, endurance, and
neuromuscular control can reduce instability
and pain associated with disuse.
Psychosocial Interventions
Social well-being is also affected by cancer pain.
education about cancer, hypnosis and imagery
based methods, and training in coping skills.

22. Psychological Interventions
1- Cognitive-Behavioral Interventions
The content of these thoughts and their relation to
subsequent emotions is discussed with a therapist.
Maladaptive stemming from dysfunctional
automatic thoughts and beliefs, can be identified
and modified through therapeutic intervention
2- Behavioral Interventions
such as biofeedback and relaxation

23. ?
3-bWhat pharmacotherapeutics alternatives are
available for treatment of metastatic
hormone dependent- cancer

24. Drug classes Name of drug Mechanism of
action
Side effects
LHRH agonist Leuprolide
Goserelin
Triptorelin
Histrelin
given as a
monthly injection
under the skin
Prevent testicles
from receiving
messages sent by
body to make
testosterone
Flares that may lead to
bone pain
LHRH antagonist Degarelix
Taken by monthly
injection
The same
mechanism of
LHRH agonist but
they reduce
testosterone level
more quickly and
do not cause flare
Severe allergic reaction
Anti - androgens biclutamide,fluta
mide ,
nilutamide,
Enzalutamide
Taken as pills
Block
testosterone from
binding to
androgen
receptor
Impotence
Eractile dysfuntion

25. Drug classes Name of drug Mechanism of action Side effects
CYP17
inhibitors
Abiraterone
Taken as pills
every day
blocks an enzyme
called CYP17, which
helps stop these cells
from making
androgens.
Impotence
Eractile dysfuntion

26. ?
4-aWhat drug, dosage form, schedule, and
duration of therapy are best for this patient

27. Optimal Plan

28. Optimal Plan

29. Optimal Plan

30. Optimal Plan

31. Optimal Plan

32. Optimal Plan

33. Androgen Deprivation Therapy
Medical castration
GnRH antagonist
Intermittent
Degarelix

34. Optimal Plan

35. • Degarelix (LHRH antagonist)
initial dose: 2 injection of 120 mg
maintenance dose: 80 mg every 28 days
given subQ in the abdominal area.
Stop when PSA <= 4 ng/ml.
If the PSA value > 20 ng/ml or rise to the
original baseline, the ADT should be resumed.
• Single fraction EBRT at a dose of 8 Gy.
Optimal Plan

36. • According to NOF, the patient should start on
supplemental Calcium and vitamin D3 to
prevent osteoporosis.
Calcium carbonate 1200 mg daily
vitamin D3 1000 mg daily
Optimal Plan

37. ?
4-bWhat alternative would be appropriate if the
initial treatment cant be used

38. • Orchiectomy
• Docetaxel 75mg/m every 3weeks and
prednisone

39. ?
5How should the therapy you recommended
be monitored for efficacy and adverse effects

40. Monitoring for efficacy
 Check the Tumor size and Lymph node involvement by (DRE) every 3 months
 Check the Tumor marker response by (PSA)
PSA checked every 6 months in first 5 years then annually (but for metastatic PC
every 3 months)
Also check LDH and Testosterone baseline
1

41. Monitoring for Adverse effect
Cardiovascular
Hypertension + QT interval prolonged
(BP + ECG)
Especially this patient has history of CHF and fluoxetine use
Hematological
Anemia
(CBC)
Metabolic / Endocrine
↑Cholesterol
Hyperglycemia
(glucose)
This patient has hypercholesterolemia and DM
2

42. Monitoring for Adverse effect
Musculoskeletal
Musculoskeletal pain
Osteoporosis
(DXA scan)
Hepatobiliary
↑LFTs
Especially this patient using lasix
Renal
↑Creatinine
We can also grade the toxicity by using the current version of NCI-CTCAE
Common Terminology Criteria for Adverse Events
is severity scale for adverse effects that associated with cancer therapy
2

43. ?
6How should the therapy you recommended
be monitored for efficacy and adverse effects

44. Patient education
To enhance adherenceWhat is prostate cancer?
What treatments work?
How long you're likely to live (your life expectancy). This is based on
your age and
your health. If you are older or if you have other serious health
issues, your prostate
cancer may never cause problems in your lifetime and you may
decide to hold off on
treatment.
For many men, prostate cancer grows slowly. A wait-and-see
approach obviously can't cure your cancer. But by choosing expectant
management, you'll avoid all the side effects of other treatments.

45. Treatment
•Radiotherapy uses high-energy x-rays to kill cancer cells.
There are two main types of radiotherapy used for
prostate cancer. They are sometimes combined with
each other, or with other treatments.
•[Hormone therapy] The healthy cells in your prostate
gland need the hormone testosterone to grow. And so
do the cancer cells. So, treatment to reduce or block the
testosterone in your body may slow down the cancer.
•Hormone therapy isn't usually used on its own for lower-
risk prostate cancers, but your doctor may recommend
having it with radiotherapy if your cancer seems likely to
spread.

46. Degarelix
•This drug used to treat locally advanced or metastatic
prostate cancer and may slow or stop the growth of
cancer
•This drug is not addictive
•This medication given as an injection under the skin,
and usually every month
•If you do not feel well, tell your doctor
•DO NOT stop medication if you get any side effects
without first talking to your doctor or pharmacist
•Most side effects are mild and short-lived

47. Radiotherapy
•This type of radiotherapy uses a special machine to
carefully direct radiation into your tumor from outside of
your body. You will lie on a table during treatment and
you will need to stay very still. One session of treatment
usually lasts around 10 minutes.
•Side effects of radiotherapy include tiredness, bowel
problems (such as feeling as if you need to go to the toilet
urgently), and problems when urinating (such as having a
burning feeling or blood in your urine).
•These side effects usually go away after treatment ends.
•However, other problems can happen months or years
after radiotherapy, including trouble getting an erection.

48. ?
7What pharm therapeutics options are
available to the patient for his progressive
androgen independent metastatic cancer

49. • 1- COMBINED ANDROGEN BLOCKADE : The use of ant androgens with a gonadotropin-
releasing hormone (GnRH) agonist thus produces a combined androgen blockade
• 2- If testosterone levels are not suppressed (ie, >20 ng/dL [0.7 nmol/L]) after
initial LHRH agonist therapy, an antiandrogen or orchiectomy may be indicated
• 3- CHEMOTHERAPY (Docetaxel/ prednisone) and Cabazitaxel