8/7/2019 Prostate Cancer Case[1]

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Prostate Cancer Case

Chief complaint:

³ I am being evaluated for treatment with hormone therapy for my prostate cancer.´

HPI:

Otto Maddux is a 65 year old male who initially presented to his local physician because

increasing problems with urination. He stated that he was unable to sleep through the night

because he was getting out of bed about 5 times per night to try and empty his bladder. He felt

as if he was never able to completely empty his bladder. He underwent a complete

evaluation, and a nodule was found during DRE. A biopsy of the nodule showed

adenocarcinoma of the prostate confined to his prostate (Gleason score 8).

At that time he discussed a number of treatment options with his doctor and family , but his

family encouraged him to decline treatment at that time.

He has been followed by his oncologist for six months, and his PSA has been slowly increasing.

He also has new onset bone pain bone scan demonstrated multiple osteolytic lesions

consistent with prostate cancer metastatic to the bone.

PMH:

Hypertension

Hyperlipidemia

Depression

Insomnia

FH:

Father died at the age of 83 with prostate cancer. Mother (80 y/o) is currently living in an

apartment in the upstairs of their home with history of CAD, arthritis and mild dementia.

Daughter died at the age of 32 with breast cancer.

SH:

Otto is retired office manager, who sometimes works part time to do accounting for his son¶s

business. Otto is married for 42 years and currently lives with his wife and 2 grandchildren

(ages 15 and 18y/o). He has two sons, and lost his daughter 5 years ago to breast cancer. He

is now raising his grandchildren.

ROS

Otto reports that he has pain in his back that has increased over the last few weeks, and that he

is not able to sleep secondary to pain and frequent need to urinate. He is managing his pain

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with medications he obtains at the pharmacy, but they are not helping. Additionally, Otto has

lost weight secondary to decrease appetite.

Medications:

No medications at this time, as Otto does not like to take medications. He has been prescribed

medications for hypertension, hyperlipidemia and sleep ± but he does not consistently take.

Allergy: Oxycodone ± constipation (per patient report)

PE:

Gen ± The patient is a frail looking male that appears uncomfortable and worried.

VS ± BP 140/88, P 70, RR 18, T 36.9 C, Ht: 6¶1´, 79.5 kg, BSA 2.02 m2

Skin ± dry

HEENT ± PEERLA, EOMI, disks flat, TMs intact, no hemorrhages of exudates

Neck /LN ± supple, no nodes palpable

Chest ± clear, good breath sounds

CV ± normal rate and rhythm, no m/r/g

Abd ± soft, non-tender, bowel sounds present in all quadrants, no hepatosplenomegaly

Genit/Rect ± Normal male genitalia, enlarged prostate on rectal exam with multiple firm nodules

in the anterior lobe

MS/Ext ± pain noted in lower back and mild pain in lower extremities. Pulses 2+

Neuro ± A&O x 3, CN II-XII intact, sensory and motor levels intact, Babinski (-), DTRs 2+

Today¶s labs:

Cr 0.9 ng/dl

Glucose 183 mg/dL

Hgb 12.5 g/dL HCt 38%

AST 25 IU/L ALT 12 IU/L Alk Phos 1900 IU/L

PSA 58 ng/ml ( 30 ng/ml one month ago)

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Part I

The medical team is reviewing Mr. Maddux¶s history. The following are some issues that are

being discussed.

1. There is some discussion regarding the questions of why Mr. Maddux did not have

therapy at the time of initial diagnosis. List the potential treatment options for Mr.

Maddux at the time of INITIAL diagnosis.

2. Discuss the potential role of the following for the initial treatment of Mr. Maddux:

a. Surgery

b. Radiation therapy

c. Androgen deprivation therapy

d. Bisphosphonates

e. chemotherapy

The team is discussing the CURRENT treatment approach for Mr. Mattox. Provide the

following information to help coordinate the pharmacotherapy for Mr. Mattox:

1. Create a complete problem list for Mr. Maddux.

2. Identify the signs and symptoms of prostate cancer the Mr. Maddux is current

experiencing..

3. Outline a treatment plan for Mr. Maddux for each of the problems identified. (Note:

This includes cancer treatment and treatment related complications, management of 

cancer-related complications, and management of comorbidities.)

4. Outline the patient education you would provide for each of the following:

a. LHRH agonist (goserelin)

b. Antiandrogen therapy (biclutamide)c. Bisphosphonate therapy

d. Treatment of insomnia

Clinical Course:

Otto Maddux has done very well with his treatment for about 18 months, and has minimal

complications associated with therapy. Additionally, he has been sleeping better and feels more

energetic and happier. His wife reports that he is more interactive with the family. He has been

eating well until recently when he lost a tooth, and this area is sore and filled with puss. Today

he presents for follow-up appointment and his PSA has risen significantly since his last visit 6

months ago. He also has a follow-up appointment with his dentist this afternoon.

Questions:

1. Based on the progression finding of disease progression ± what are some treatment

options for Mr. Maddux.

2. Discuss the complication of bisphosphonate associated osteonecrosis of the jaw.