Today he presents to the clinic with bone pain and a serum PSA of 67 ngmL 67 mcglX

Why was bicalutamide discontinued on 10/2/07? How would you characterize the patient's disease? What treatment is an option for him?

What long-term complications would you expect from his chronic androgen suppression?

The combination of estramustine (280 mg three times a day, days 1-5) and do-cetaxel 60 mg/m on day 2 every 3 weeks also improves survival in hormone-refractory metastatic prostate cancer.50 Estramustine causes a decrease in testosterone and a corresponding increase in estrogen; therefore, the adverse effects of estramustine include an increase in thromboembolic events, gynecomastia, and decreased libido

(Table 92-9). Estramustine is an oral capsule and should be refrigerated. Calcium inhibits the absorption of estramustine. While both the docetaxel/prednisone and the docetaxel/estramustine regimens are effective in hormone-refractory prostate cancer, most clinicians prefer the docetaxel/prednisone regimen because of the cardiovascular adverse effects associated with estramustine and the improved survival seen with do-

cetaxel/prednisone. In addition, androgen ablation is usually continued when chemo-

therapy is initiated.

Patient Care and Monitoring

1. Obtain complete past medical history, family history, and social history.

2. Obtain complete list of any concomitant prescription and over-the-counter medications, be sure to include herbal, vitamin, and mineral supplements.

3. Verify completion of prostate-cancer workup and staging.

4. Using information obtained, identify appropriate treatment options.

5. Discuss the benefits and risks of appropriate treatment options with health care team and patient.

6. If drug therapy is selected, review patient medical history for drug-drug, drug-herbal interactions.

7. Initiate therapy, if patient was asymptomatic, monitor PSA and circulating an-drogens for castration level of testosterone. If patient was symptomatic, monitor symptoms for improvement or worsening.

8. Monitor for any new symptoms and adverse events from therapy.

The regimen of mitoxantrone plus prednisone has been shown to be effective in reducing pain from bone metastasis and was a standard therapy prior to the development of docetaxel and prednisone. The effectiveness of mitoxantrone after failure of docetaxel-based therapy has not been scientifically evaluated. Many clinicians will treat patients with radiation therapy for palliation of symptoms after failure of

docetaxel-based chemotherapy. outcome evaluation

Monitoring of prostate cancer depends on the stage of the cancer. When definitive, curative therapy is attempted, objective parameters to assess tumor response include assessment of the primary tumor size, evaluation of involved lymph nodes, and the re sponse of tumor markers such as PSA to the treatment. Following definitive therapy, the PSA level is checked every 6 months for the first 5 years, then annually. Local recurrence in the absence of a rising PSA may occur, so the DRE is also performed. In the metastatic setting, clinical benefit responses can be documented by evaluating performance status changes, weight changes, quality of life, and analgesic requirements, in addition to the PSA or DRE at 3-month intervals.

Abbreviations Introduced in This Chapter

ASCO American Society of Clinical Oncology AUA American Urological Association BPH Benign prostatic hyperplasia

CAB

Combined androgen blockade

CI

Confidence interval

DES

Diethylstilbestrol

DHT

[ >1 hyd ro t estoste ron e

DRE

E^igitai rectal examination

ESH

Foil icfe-s timulati ng hormone

GnRH

Gon adotropi n-reJeasing h0rm0nc

IGF-1

Insulin-like growth factor-1

IM

intramuscular

LH

l uteinizing hormone

T.HRH

Luteinizing hormone-releasing hdrtnone

NCI

National Cancer Institute

PCPT

Prostate Cancer Prevention Trial

PSA

EJrostate-specific antigen

SELECT

Selenium and Vitamin E Cancer Prevention

Trial

TRUS

Transrectal ultrasound

VACURG

Veterans Administration Cooperative Urologic

Research Group

' Self-assessment questions and answers are available at ht-tp://www. mhpharmacotherapy. com/pp.html.

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