Castration-resistant prostate cancer: adaptation or clonal selection? Insight from the EORTC 30891 trial

Management of patients with castration-resistant prostate cancer (CRPC): results of an Italian survey using the delphi method

PURPOSE

To assess the opinions of urologists, oncologists and radiation oncologists on the indication for androgen deprivation therapy (ADT) and the definition and management of castration-resistant prostate cancer (CRPC).

METHODS

In this study using the Delphi method, a list of 15 statements (66 items overall) addressing key issues in ADT and CRPC was sent to 255 participants (urologists, oncologists and radiation oncologists). Responses were rated on a 5-point Likert scale (1=strong disagreement; 5=strong agreement). Disagreement was defined as ≥66% responses with scores 1-2 and agreement as ≥66% responses with scores 3-5. No consensus was absence of agreement/disagreement.

RESULTS

Overall, there was agreement and disagreement in 50% and 15% of the items, respectively. In 71.2% of the items the panelists agreed with each other. The highest concordance rate was observed between urologists and oncologists (87.8%). There were no items with 3 different opinions between the specialists. All panelists agreed on the definition of CRPC. Urologists and oncologists agreed on the recommendation to continue ADT in CRPC. In both nonmetastatic and metastatic asymptomatic CRPC patients with biochemical progression, treatment should be based on PSA kinetics. The panelists agreed on the use of chemotherapy in symptomatic and asymptomatic metastatic CRPC patients but not in those with nonmetastatic CRPC. There was agreement on the timing of initiation of abiraterone and enzalutamide either before or after chemotherapy.

CONCLUSIONS

With few exceptions there was agreement among urologists, oncologists and radiation oncologists about the management of CRPC, although the indications were not always in line with international guidelines.

Solitary recurrence of castration-resistant prostate cancer with low or undetectable levels of prostate specific antigen salvaged with local ablative radiation therapy: A case report

Prostate cancer recurrences are usually first detected by increased levels of prostate specific antigen (PSA), and systemic therapy is often initiated if distant metastasis is confirmed. However, low or nearly undetectable levels of PSA in the modern era of ultrasensitive PSA assay may be difficult to interpret in patients with a history of prostate cancer. Deciding whether to initiate additional systemic therapy in limited indolent metastatic disease while balancing the quality of life of the patient and ensuring the oncologic control of the disease may be challenging. In the present study, the case of a biopsy-confirmed solitary spine recurrence of prostate cancer with nearly undetectable but persistent levels of PSA (0.05 ng/ml) is reported. Treatment of the recurrence with local ablative radiotherapy improved the pain experienced by the patient, and reduced his levels of PSA to undetectable limits (<0.05 ng/ml). Repeated imaging analysis, PSA assay and clinical assessment demonstrated durable control of the disease without the requirement for additional systemic treatments. The present case highlighted the importance of initiating appropriate work-up according to the clinical scenario. Local treatment for solitary or oligometastatic recurrence of prostate cancer may enhance the effectiveness of current therapeutic strategies and benefit certain patients.