Scribe BC - Radiation Oncology Prostate Cancer Consult

DIAGNOSIS Mr. John Smith has been diagnosed with locally advanced prostate cancer, Gleason score 4+4=8, ISUP grade group 4. His most recent PSA was 18.5 ng/mL. PRIOR TREATMENT * **Radiation Therapy:** 74 Gy in 37 fractions to the prostate and seminal vesicles, completed on 12/05/2023. * **Systemic Therapy:** ADT (Lupron) initiated on 01/06/2023, ongoing. Abiraterone/dexamethasone initiated on 01/01/2024, 250mg daily, cycles completed: 10, next administration due: 01/01/2025. * **Local Therapy:** None. PLAN SUMMARY The plan is to continue ADT and abiraterone/dexamethasone. The patient will be monitored with regular PSA tests and imaging as needed. Further treatment options will be considered if there is evidence of disease progression. John Smith, a 68-year-old male, seen today for a follow-up consultation. His wife, Mary Smith, is also present at the visit. INITIAL PRESENTATION Mr. Smith was initially diagnosed with prostate cancer in January 2023 after an elevated PSA and a positive biopsy. He was referred to our clinic by Dr. Emily Carter. His initial PSA was 22.0 ng/mL. Biopsy results showed Gleason score 4+4=8. He underwent staging investigations, including a bone scan and CT scan, which showed no evidence of metastasis. RESPONSE TO INITIAL THERAPY Following radiation therapy and ADT, Mr. Smith's PSA decreased to a nadir of 0.1 ng/mL. He has been on ADT since June 2023 and abiraterone/dexamethasone since January 2024. There have been no significant medication changes or interactions identified. PSA HISTORY: * 18.5 ng/mL (11/01/2024) * 0.1 ng/mL (01/01/2024) * 22.0 ng/mL (01/01/2023) SYMPTOMS Mr. Smith reports occasional mild fatigue but no significant pain. He denies any urinary symptoms, and his IPSS score is 2. He reports no issues with sexual function. He denies any hypogonadal symptoms. His bowel habits are normal. His energy levels are good, and his appetite is normal. He has maintained a stable weight. His performance status is ECOG 0. INVESTIGATIONS * CT scan of the abdomen and pelvis (01/01/2023): No evidence of metastasis. * Bone scan (01/01/2023): No evidence of metastasis. * TRUS prostate biopsy (01/01/2023): Prostate volume 45cc, adenocarcinoma, Gleason score 4+4=8, Grade Group 4, involving 8/12 cores, with no evidence of extraprostatic extension or lymphovascular invasion. * PET scan (01/01/2024): No evidence of metastasis, SUV max 2.5. PAST MEDICAL HISTORY * Hypertension * Hyperlipidemia PAST SURGICAL HISTORY * Appendectomy (1985) CURRENT MEDICATIONS * Lupron 22.5 mg injection every 3 months * Abiraterone 250mg daily * Prednisone 5mg daily * Lisinopril 10mg daily * Atorvastatin 20mg daily ALLERGIES Mr. Smith reports no known drug allergies. SOCIAL HISTORY Mr. Smith lives with his wife in a single-family home. He is retired. He does not smoke, and he drinks alcohol occasionally. He denies recreational drug use. FAMILY HISTORY His father was diagnosed with prostate cancer at age 75. PHYSICAL EXAMINATION Height: 178 cm Weight: 85 kg Vitals: BP 130/80 mmHg, HR 72 bpm, SpO2 98%, Temp 37.0°C Mr. Smith appears well-nourished and in no acute distress. He ambulates independently. There is no tenderness to palpation in the abdomen or pelvis. DRE results: The prostate is enlarged, firm, with a palpable nodule in the right lobe. No other abnormalities are noted. ASSESSMENT AND PLAN Mr. Smith is a 68-year-old male with a history of locally advanced prostate cancer, currently on ADT and abiraterone/dexamethasone. The differential diagnoses include biochemical recurrence, local recurrence, and metastatic disease. We discussed the importance of continued ADT and abiraterone/dexamethasone. We also discussed the risks and benefits of adding abiraterone plus prednisone. Abiraterone is a selective, irreversible inhibitor of CYP17, which results in more effective androgen depletion than ADT alone. It is combined with prednisone to reduce side-effects of mineralocorticoid excess. Two RCTs from STAMPEDE platform showed metastasis-free survival (MFS) and overall survival (OS) benefits in the overall population with combined ADT (for 3 years) and additional abiraterone (for 2 years) in patients with high-risk disease in addition to prostate and whole pelvic RT. 6 year MFS improved from 69% to 82%, and 6 year OS from 77% to 86%. The European Association of Urology and NCCN recommend the addition of 2 years of abiraterone to very high risk cN0M0 patients with ≥ 2 high-risk factors (cT3-4, Gleason ≥8 or PSA ≥ 40 ng/ml), and to cN1M0 patients. I outlined the potential adverse effects of abiraterone plus prednisone that include but are not limited to: cardiac angina (<3%), arrhythmia (7%), cardiac failure (2%), diarrhea (20%), dyspepsia (10%), peripheral edema (25%), fatigue, increased liver enzymes (30-40%), hyperlipidemia (55%), hypokalemia (19%), arthralgia (27%), myopathy (36%), cough, rash (8%), hot flush, hypertension (10-20%). Prednisone 5 mg daily is prescribed to reduce the incidence of mineralocorticoid adverse effects related to abiraterone. We also reviewed the side effects of steroid therapy. Mr. Smith has decided to continue with his current treatment plan of ADT and abiraterone/dexamethasone. He understands the importance of regular follow-up and PSA monitoring. The next step is to schedule a follow-up appointment in three months. He was provided with contact information for any questions or concerns. AI CONSENT The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.