I have never administered chemotherapy, abiraterone, enzalutamide or sipuleucel-T to a patient with PSA-only relapse outside of a clinical trial.

It’s possible that sipuleucel-T may be ideal earlier in the disease setting. Data suggest a greater survival benefit for patients with lower baseline PSA values. If you extrapolate that, the greatest survival benefit might be in nonmetastatic disease, but we need data from a randomized trial before it can be used in that setting.

I have not administered chemotherapy, the endocrine agents enzalutamide and abiraterone or sipuleucel-T to a patient with PSA-only relapse.

No, I have not administered chemotherapy or the other agents mentioned to a patient with PSA-only relapse.

I have not administered chemotherapy, abiraterone, enzalutamide or sipuleucel-T to a patient with PSA-only relapse.

Yes, I have administered chemotherapy to a handful of patients with PSA-only relapse who insisted on receiving treatment. I figured that if they were going to insist on receiving therapy, they could either receive it from me or someone else. I knew I would take good care of them and who knows what would happen if they went elsewhere. Generally, it’s not something I would do outside of a clinical trial.

No, I have not administered enzalutamide or abiraterone to a patient with PSA-only relapse.

I have administered sipuleucel-T once to a patient with PSA-only relapse who was paying himself for the associated costs. I think it’s a good idea, but it’s just not something that’s financially feasible for most patients.

Yes, I have administered chemotherapy to a patient with PSA-only relapse. For example, I used it for a particularly young patient with a rapid PSADT.

I have administered enzalutamide or abiraterone to younger patients with PSA-only relapse, but it is generally rare.

I have administered sipuleucel-T to patients with PSA-only relapse at their request. These patients were willing to pay for sipuleucel-T treatment. Generally, I rarely administer sipuleucel-T in this setting.

No, I have not administered chemotherapy to a patient with PSA-only relapse. I don’t think there’s any evidence to support that.

I have not administered enzalutamide or abiraterone to a patient with PSA-only relapse, but patients ask about it. We will get there eventually. Some clinical trials are evaluating enzalutamide in that setting. If you consider the biological mechanism of action of enzalutamide, it might make sense to block the androgen axis sooner, rather than later.

I have not used enzalutamide in that setting in part because enzalutamide, which I believe is a little easier to administer, had not been approved in the prechemotherapy space. Since this has happened, I believe the use of enzalutamide will spread into the PSA-only relapse setting.

This is an absolutely perfect situation for the use of sipuleucel-T. That’s probably the best clinical scenario to use it in, recognizing that you must tell the patients that it will not affect their PSA levels.

Generally, I will not administer chemotherapy to a patient with PSA-only relapse.

For a patient with PSA-only disease progression on ADT without metastatic disease, I would administer ketoconazole and hydrocortisone because that combination has activity. I would try antiandrogens, but there’s no evidence for administering chemotherapy in this situation.

However, if the patient had a doubling time less than 3 months, I would consider either hormonal therapy or even chemotherapy because you know the patient will soon develop progressive disease. In that situation hormonal therapy or even chemotherapy is totally reasonable.

The first patient for whom I used chemotherapy in this setting was a young patient who had a radical prostatectomy with positive lymph node surgery. He went on immediate ADT, but his PSA level began to rise at a rapid rate. He had no metastatic disease that was detectable. I believe he was somewhere around 30 when I started him on docetaxel. He was dead within 2 years. I have not treated many patients in that fashion.

No, I have not administered enzalutamide or abiraterone to a patient with PSA-only relapse. Outside of a clinical trial, it is difficult to obtain enzalutamide and abiraterone in this setting. If a patient were willing to pay for these agents, I would probably use abiraterone because data are available in the PSA-only setting. Enzalutamide is a peculiar drug. Some of my patients have developed bad fatigue on it. For some elderly patients, I start at half dose to mitigate the fatigue-associated effects. In this situation, I slowly dose escalate so that they are more able to tolerate it.

I have not administered sipuleucel-T to a patient with PSA-only relapse.

No, I have never administered chemotherapy, enzalutamide, abiraterone or sipuleucel-T to a patient with PSA-only relapse.

No, I have not administered any of these agents to a patient with PSA-only relapse.