Hormone-responsive prostate cancer with bone metastases: How should therapy be sequenced?
Discussant: Peter Mulders, MD, PhD

A 70-year-old farmer presents to his urologist with complaints of urinary urgency and frequency of 6 months duration and increasingly severe (VAS 7/10) pain of 3 months duration in several ribs, lumbar spine, and right hip. He denies sensory changes, weakness, bowel or bladder dysfunction.

• At DRE prostate is diffusely enlarged and nodular.
• Serum PSA is 350 ng/mL.
• Multiple core biopsies of both lobes confirm adenocarcinoma with a Gleason score of 7 (4 + 3)
• Bone scan: Multifocal areas of increased uptake including an intense uptake in ribs, thoracic and lumbar spine, pelvis, right femoral neck. X-rays confirmed mainly osteoblastic metastases with few osteolytic lesions in right hip.
• Laboratory: Alkaline phosphatase 3 x upper normal limits, creatinine, calcium, platelets, WBC normal, Hgb 11.5 g/dL
• Comorbid illness: Diabetes mellitus type II; 2 years on oral antidiabetic therapy (metformin)
• ECOG PS: 2