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Expert Opinion / Cases · December 02, 2014

What to Do When the World is Your Oyster? The Newly Diagnosed mCRPC Patient

Written by
Zachary L Smith MD


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  • Jacques Planas

    I would start treatment with abiraterone and prednisone.

  • Richard Ealy

    Sipuleucel-T along with Zoladex and to include Zometa with his taking a calcium supplement . Second, check for any studies with Abiraterone acetate.

  • Zachary Smith

    Jacques Planas: What makes you choose abiraterone in this setting over enzalutamide? Richard Ealy: How do your patients respond to the lack of observable improvement with sipuleucel-T? Do they not desire a treatment that will biochemically and/or radiographically give evidence of response? Also, when would you initiate AA after having given sipuleucel-T?

  • Stu Hyatt

    I would switch to Firmagon and see if there was a response. If not, I would try estrogen patches.

  • Zachary Smith

    Stu Hyatt: Switching to Firmagon from Lupron seems reasonable, as there is an RCT-proven benefit in progression-free survival. Additionally, the PATCH trial had convincing data for estrogen patches in this situation. However, it hasn't seemed to have picked up in common practice. Do you have good experience with this?

  • Stu Hyatt

    Patient was on Firmagon for about seven or eight mths and then there was a slow rise. Switched to three weekly estrogen patches (0.1 mg). At start PSADT was about 2 mths and that has increased to 25 mths. Still very slow rise in PSA which could probably be reversed by using four patches a week. Patient is satisfied.

  • Robert Sherman

    As a survivor and leader of a PCa support group, we notice there seems to be no consensus even among oncologists(urologists are another story) using Abiraterone before or after Enzalutamide or when to start Sip-T, How about Radium 223 , now rather then later?

  • fabio arena

    I'll start chemotherapy

  • Zachary Smith

    @Robert Sherman: Radium-223 has been shown to increase overall survival and is a great drug. However, it is indicated in patients with symptomatic bone metastases and no evidence of visceral metastases (so it would not apply to the patient in the above vignette). It was shown last year to be beneficial in both the pre- and post-docetaxel phase, but the landmark trial which Radium-223 got its approval based on (ALSYMPCA), was designed before abiraterone and enzalutamide were available. So the question of it's sequence in relation to those two drugs is less well known. I understand your feelings about everyone in the medical community sometimes seeming to be on a different page, but it's an evidence-based world we live in, and thus, our hands are often tied on what we can appropriately/ethically do. Decisions based on our own clinical opinion must be weighed against the evidence that is widely available and accepted by peers in the community.

  • Jan 24, 2021

    Pending Moderator approval.

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