This document presents a case scenario for choosing the best management strategy for a 73-year-old male patient with hormone-naïve metastatic prostate cancer. The patient has bone metastases, a PSA of 115 ng/ml, and biopsy-confirmed Grade 4 prostate adenocarcinoma. Treatment options discussed include ADT alone, ADT plus abiraterone, ADT plus docetaxel, and newer approvals like apalutamide and enzalutamide. Key trials comparing these options are summarized. Factors to consider in choosing a treatment include availability, tolerability, differential toxicity profiles, and efficacy based on the patient's individual risk profile. For this patient who has completed ADT plus doc

1. Case Scenario For Best Management
Choice In Hormone Naïve Prostate
Cancer
By
Ereny s.Poles Saad
MbBcH, MsC, MD, Assiut University, Egypt
MsC Advanced Oncology, Ulm University, DE
ESMO accredited 2019

2. • No conflict of interest to be declared

3. • Male patient 73 ys old known to be controlled DM
and HTN.
• Patient presented in July 2017 by generalized bone
pain which was associated with urinary
manifestations as dysuria and interrupted urinary
stream.
• Patient sought medical advice, on clinical
examination----- tenderness over lumbar verterbrae
and enlarged both prostate lobes on DRE.

4. • Trans rectal US ---------- Hypo-echoic mass in left
prostate lobe.
• Biopsy --------Prostatic adenocarcinoma ISUP
grade 4.
• PSA ------------115 ng/dl.
• Bone scan ------Multiple sclerotic bony lesions in
dorso-lumbar vertebrae, both iliac crests and sacroiliac
joints.

5. • Patient received local radiotherapy on tender areas
(3000cGy / 10 ttt)
• AND THEN…………
-Comorbidity
-Physical status
-Nutritional status
-Cognitive function
*Cumulative Illness Score Rating-
Geriatrics (CISR-G)
*Charlson Comorbidity Index
* Mini-COG
* Karnofsky /ECOG scores
* Weight loss in last 3 months

6. It is not a matter of age

7. Decision tree for health status
screening (men > 70 years)
Droz, J.P., et al. Management of Prostate Cancer in Elderly Patients: Recommendations of a
Task Force of the International Society of Geriatric Oncology. Eur Urol, 2017. 72: 521.

8. Management process
-Comorbidity
-Physical Status
-Nutritional
status
-Cognitive
Function
-Imaging
-Laboratory
-Evidence
based
treatment
strategy

9. Different Treatment Strategies
• Life expectancy *
• Treatment intent
Active management
vs watchful waiting
• Symptomatic
• Impending cord
compression
Immediate vs
deferred
• No role of bone support in
HSPCa
Bone support agents
http://appsso.eurostat.ec.europa.eu/nui/submitModifiedQuery.do
*Gait speed is a good single predictive measure .For men at age 75, ten-
year survival ranged from 19% < 0.4 m/s to 87%, for > 1.4 m/s
https://uroweb.org/guideline/prostate-cancer/#5_3

10. Options
Continuous vs
Intermittent
ADT
Alone
Abiraterone
Acetate
Docetaxel

11. 1# option : ADT alone
• Medical (LHRH antagonist) vs Surgical castration.
• Combined androgen blockade using anti-androgen.
• Donot offer anti-androgen as a monotherapy.

12. 2# option :ADT plus Abiraterone
Acetate

13. STAMPEDE [James] (1) LATITUDE [Fizazi] (2)
Treatment arms ADT ADT + AA + P ADT + placebo ADT + AA + P
N 957 960 597 602
Newly diagnosed
M+
50% 48% 100% 100%
Key inclusion
criteria
Patients scheduled for long-term
ADT
- Newly diagnosed M1 or N+
situations
Newly diagnosed M1 disease and 2 out
of the 3 risk factors: ISUP grade > 4
> 3 bone lesions
Visceral metastasis
3 year OS 83% (ADT + AA + P)
76% (ADT)
66% (ADT + AA + P)
49% (ADT + placebo)
HR (95% CI) 0.63 (0.52 - 0.76) 0.62 (0.51-0.76)
M1 only
n 1,002 1,199
3 year OS NA 66% (ADT + AA + P)
49% (ADT + placebo)
HR m OS (95% CI) 0.61 (0.49-0.75) 0.62 (0.51-0.76)
HR r PFS (95% CI) 0.29 (0.25-0.34) 0.49 (0.39-0.53)
1. James, N.D., et al. Abiraterone for Prostate Cancer Not Previously Treated with Hormone Therapy.
N Engl J Med, 2017. 377: 338.
2. Fizazi, K., et al. Abiraterone plus Prednisone in Metastatic, Castration-Sensitive Prostate Cancer.
N Engl J Med, 2017. 377: 352

14. 3 # option : ADT plus Docetaxel

15. STAMPEDE James(1) GETUG Gravis (2) CHAARTED
Sweeney (3)
Treatment
arms
ADT ADT + Docetaxel +
P
ADT ADT +
Docetaxel
ADT ADT +
Docetaxel
N 1,184 592 193 192 393 397
Newly diagnosed
M+
58% 59% 75% 67% 73% 73%
Key inclusion
criteria
Patients scheduled for long-term
ADT
- newly diagnosed M1 or N+
situations
Metastatic disease
Karnofsky
score > 70%
Metastatic disease
ECOG PS 0, 1 or 2
Primary objective OS OS OS
HR (95% CI) 0.78 (0.66-0.93) 1.01 (0.75-1.36) 0.61 (0.47-0.80)
M1 only
N 1,086
HR (95% CI) 0.76 (0.62-
0.92)
1. James, N.D., et al. Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone
therapy in prostate cancer (STAMPEDE) Lancet, 2016. 387: 1163.
2. Gravis, G., et al. Androgen-deprivation therapy alone or with docetaxel in non-castrate metastatic
prostate cancer (GETUG-AFU 15). Lancet Oncol, 2013.14: 149.
3. Sweeney, C.J., et al. Chemohormonal Therapy in Metastatic Hormone-Sensitive Prostate Cancer.
N Engl J Med, 2015. 373: 737

16. 4# Recent approvals

17. 4# Recent approvals

20. So how to choose
•Avaliability
• Tolerability
• Differential
toxicity
profile
• Efficacy
Best Choice
Patient
For

21. • Efficacy
Best Choice
Patient
For
So how to choose

23. *A key limitation is that the comparison was opportunistic and not
designed in the usual way, hence power is limited to detect any
realistic differences.
*The unequal allocation ratio reflects the planned design of the
comparisons.
*The allocated treatment being given was not masked for practical
reasons. This, of course, allowed for relapse therapies to be given at
the investigator’s discretion.

27. So how to choose
• Differential
toxicity
profile
• Efficacy
Best Choice
Patient
For

29. We have to remember

30. So how to choose
•Avaliability
• Tolerability
• Differential
toxicity
profile
• Efficacy
Best Choice
Patient
For

31. So back to our case
Definition of high- and low volume or
risk in CHAARTED/ LATITUDE
CHAARTED
(volume)
* > 4 Bone metastasis
including > 1 outside
vertebral column or spine
OR
*Visceral metastasis
N
o
t
h
i
g
h
LATITUDE
(risk)
> 2 high risk features of
1-> 3 Bone metastasis
2-Visceral metastasis
3-> ISUP grade 4
N
o
t
Gravis, G., et al. Burden of Metastatic Castrate Naive Prostate Cancer Patients, to Identify Men More Likely to Benefit from Early Docetaxel:
Further Analyses of CHAARTED and GETUG-AFU15 Studies. Eur Urol, 2018. 73: 847.
73 ys man DM, HTN hormone naïve M1 Prostate cancer,
ISUP G4, PSA< 100 ng/dl

32. The question is to be
• Use Docetaxel + ADT upfront to avoid extra
metabolic side effects of AA ??????
• Upfront use of new anti-androgen (API/
ENZA)+ADT to avoid hematological toxicity but
in absence of solid data on options beyond
progression.

33. • The patient received ADT + 18 weeks
Docetaxel ended February 2018.
• On follow-up the PSA showed steady decline
up to undetermined level by the 3rd month of
treatment.
• On March 2018 patient was admitted for 3
days at the ER for DKA and on discharge he
was referred for consultation about
continuation of ADT.

34. Back to our options
Continuous
Vs
Intermittent
ADT
Abiraterone Acetate
Docetaxel
Aplutamide
Enzalutamide

35. Continuous vsIntermittent
• Androgen deprivation therapy should be stopped only if all of
the following criteria have been met:
* Well-informed and compliant patient.
* No clinical progression.
*Clear PSA response, empirically defined as a PSA <
4ng/dL in metastatic disease.
• Strict follow-up is mandatory which should include a clinical
examination every three to six months.
• PSA should always be measured by the same laboratory.
https://uroweb.org/guideline/prostate-cancer/#5_3

36. • Treatment should be resumed in case of:
1- Progresses clinically.
2- has a PSA rising above a pre-determined
(empirically set) threshold: 10-20 ng/mL
Continuous vsIntermittent
https://uroweb.org/guideline/prostate-cancer/#5_3