Introduction:
This was a 66 year old male who visited me in my clinic in early 2018. He had recently undergone a routine health check. A persistent lower back-ache, present since a year, gradually increasing in intensity and restricting his movements had prompted him to undergo an evaluation.
History:
Unfortunately, the tests had returned an unfavourable result. His PSA level was elevated at 150ng/ml. An Xray of his lumbo-sacral spine had shown a fractured vertebra and his sonography showed an enlarged prostate which looked suspicious for a malignancy.
Besides the back pain, he also reported urinary complaints of nocturia, increased frequency, urgency, and hesitancy.
Investigations:
I asked him to urgently undergo a PSMA PET-CT Scan. The scan showed an increase in uptake in the prostate gland, the draining lymph nodes, along with the presence of multiple lymph nodes in the abdomen. There was extensive involvement of all the vertebrae, the pelvis, and the bones of the upper and lower limbs. A biopsy of one of the lymph nodes seen on the scan confirmed the diagnosis. It showed an Adenocarcinoma of the Prostate of a high grade. Since the bones and lymph nodes were involved, it was a stage 4 cancer.
Concerns:
The patient was extremely anxious and scared at this point. The stage 4 diagnosis had convinced him that his days were numbered. I counselled him that he was not about to die. There were multiple treatment options available. His cancer could not be cured but it could definitely be controlled. He would eventually be pain free and would be able to lead a normal life.
Treatment Offered:
With the patients consent I commenced his treatment. With targeted therapy options available, the patient did not require chemotherapy upfront. I started him on injection Leuprolide, given as an intramuscular injection every 3 months. It would block the testosterone production by the testis, inducing a medical castration and thereby neutralizing its stimulatory effect on the cancer cells. Along with this I gave him tablet Bicalutamide for 10 days to block any transient testosterone flare. Injection Denosumab was given for the bony metastases, and I also added an anti-androgen, tablet Abiraterone Acetate with tablet Prednisolone, a low dose steroid.
Along with the main therapy, supportive care was added with tab Ecosprin, Calcium and Vitamin D supplements.
Response:
The patient responded extremely well to the treatment. His symptoms resolved within 3 months of beginning treatment, which included the severe back pain he was earlier experiencing.
His PSA, which I monitored monthly, normalised within 2 months of treatment initiation.
A PSMA PET-CT Scan at 3 months showed a clear scan with no active disease.
The patient had had a complete response to the treatment I had started.
Accordingly, the treatment was continued and remains ongoing till date.
The patient has returned to his daily routine, he is pain free, eating well and leading a normal life.
He undergoes regular PSA level checks and PSMA Scans, so that any loss of treatment response and cancer recurrence can be picked up immediately.