A patient with high-burden mHSPC: should we intensify treatment?

Man, 72 years old, presents with increasing lower back pain and weight loss over 3 months.

Assessment summary:

• Medical history:
  • 3 years ago: radical prostatectomy for T2N0M0 PCa, ISUP grade group 4 (Gleason score 4+5)
  • 2 years ago: early prostate bed salvage RT without ADT for biochemical recurrence (PSA: 0.36 ng/ml)

He was lost to follow-up as he had moved across the country, and presents again today:

• Comorbidities: hypertension (well controlled), no diabetes, no cardiovascular events
• BPI-SF pain score: 6/10, requiring regular NSAIDs
• ECOG PS: 1
• PSA: 210 ng/ml
• CT and bone scan:
  • Multiple enlarged pelvic and para‑aortic lymph nodes, no liver lesions, no other visceral disease
  • Numerous bone lesions throughout spine, pelvis, ribs, and proximal femora; report estimates >20 discrete bone metastases
• No germline or somatic mutations detected