ACP American College of Physicians - Internal Medicine - Doctors for Adults

A 66-year-old man is evaluated because of an increasingly elevated serum prostate-specific antigen (PSA) level. The patient received a prostate cancer diagnosis 4 years ago and underwent definitive radiation therapy, following which his PSA level became undetectable. He is currently asymptomatic.

A bone scan now shows multiple metastatic lesions.

The most appropriate management of this patient is androgen deprivation therapy with leuprolide. This patient has metastatic prostate cancer involving the bones. Prostate cancer is a hormone-responsive tumor, and his disease will most likely respond to hormone deprivation therapy with surgical castration or gonadotropin hormone–releasing hormone (GnRH) agonists such as leuprolide. GnRH therapy causes impotence, hot flushes, gynecomastia, and loss of libido, as does orchiectomy. Patients may experience tumor-flare reactions with the use of GnRH agonists, which initially cause an increase in luteinizing and follicle-stimulating hormones. These hormones lead to a transient increase in testosterone, which can exacerbate prostate cancer symptoms. This reaction can be prevented by a brief course of concomitant antiandrogen therapy with agents such as bicalutamide, nilutamide, or flutamide.

Although docetaxel-based chemotherapy has been shown to improve survival, this agent is generally indicated only for patients with hormone-refractory cancer. Several studies have demonstrated an improvement in overall survival with docetaxel-based chemotherapy in this setting.

Hospice care is premature because multiple sequential medical interventions are likely to improve this patient's overall and progression-free survival. Observation is inappropriate because his disease is likely to progress without any intervention.

Samarium-153 is a radionuclide that is taken up by bone. It may be useful in treating prostate cancer with painful bone metastases but may cause bone marrow suppression and should be used only in patients whose cancer is no longer responsive to other therapies.

Key Point

• Androgen deprivation therapy with surgical castration or gonadotropin hormone–releasing hormone agonists is first-line therapy for asymptomatic patients with metastatic prostate cancer.