I would probably start this patient on enzalutamide. I would also administer an antiresorptive therapy such as denosumab or zoledronic acid for the bone metastases. Then I would see how the patient fares with time. And if the patient fares well and the pain improves, I would consider sipuleucel-T at that point.

If the patient were 80 years old, I would use the same exact approach.

For a 62- or 80-year-old patient receiving an LHRH agonist for PSA-only recurrent prostate cancer who develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later, I would administer enzalutamide or abiraterone without the addition of bone-targeted therapy.

If the 80-year-old patient had problems with fatigue, I would try to avoid abiraterone and administer enzalutamide. It’s always a concern with steroids.

For a 62-year-old patient who has been benefiting from an LHRH agonist for PSA-only recurrent prostate cancer but develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later, I would administer enzalutamide or abiraterone if he had a Gleason score of 6 or 7. If the patient had a Gleason score of 8, 9 or 10, I would prefer to administer chemotherapy.

If the patient were 80 years old without comorbidities, meaning that he has almost 10 additional years to live, his age would not influence my treatment decision. I would treat similarly.

Because the patient is castration resistant with extensive disease, an oral hormone-reactive agent such as abiraterone or enzalutamide would probably be used in the current times. In the past, chemotherapy would have been the recommended treatment. I don’t know if I would use radium-223 as an initial therapy for such a patient in this setting. I would want to save that in reserve.

If the patient were 80 years old, I would consider abiraterone or enzalutamide.

For this 62- or 80-year-old patient in this setting, I would administer docetaxel chemotherapy. I would also add denosumab as bone-targeted therapy.

I would administer abiraterone in addition to denosumab or zoledronic acid to a 62-year-old patient receiving an LHRH agonist for PSA-only recurrent prostate cancer who develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later. I will discuss the option to receive chemotherapy in the near future with this patient.

For an 80-year-old patient, I would treat similarly if the performance status were the same as that for the 62-year-old patient.

For a 62- or 80-year-old patient receiving an LHRH agonist for PSA-only recurrent prostate cancer who develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later, I would administer enzalutamide or abiraterone.

For both the 62- and 80-year old patients in these scenarios I would administer chemotherapy with docetaxel.

I would administer enzalutamide to a 62-year-old patient receiving an LHRH agonist for PSA-only recurrent prostate cancer who develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later.

If the patient were 80 years old, I would treat in a similar manner.

I would give a strong consideration to starting chemotherapy for a 62-year-old patient receiving an LHRH agonist for PSA-only recurrent prostate cancer who develops pain, recent weight loss and extensive bony and pulmonary metastases 2 years later. Given his age, the rapidity of disease progression, his symptomatology and visceral metastases, chemotherapy would be my option.

If the patient were 80 years old, assuming he had a good performance status, no significant comorbidities, I would consider chemotherapy. I may initially begin with a reduced dose. If the 80-year-old patient had any kind of performance status issue or concerns about tolerability, I would probably lean toward an oral antiandrogen.