A 72-year-old man from Delhi with a history of hypertension and type 2 diabetes presents with bone pain in the lumbar spine and pelvis for 3 months. PSA is 145 ng/mL. Bone scan shows multiple hot spots in the spine, pelvis, and ribs. Pelvic MRI confirms a large prostate mass with invasion into the seminal vesicles and regional lymph node metastases. What is the most appropriate initial treatment?

Explanation

## Clinical Assessment **Key Point:** This patient has metastatic prostate cancer (cT4, PSA 145, bone metastases) — this is very high-risk/metastatic disease (M1b). Curative local therapy is not indicated. **High-Yield:** Metastatic prostate cancer (any T, any N, M1) is incurable with surgery or radiation alone. The cornerstone of initial treatment is systemic androgen deprivation therapy (ADT), which provides rapid symptom relief and extends survival [cite:Harrison 21e Ch 97]. ## Why ADT Is Correct In this patient: - Bone metastases (M1b) indicate systemic disease beyond surgical cure - Very high PSA (145 ng/mL) reflects high tumor burden - Seminal vesicle invasion and lymph node metastases confirm advanced local disease - ADT (LHRH agonist [leuprolide, goserelin] or LHRH antagonist [degarelix] ± first-generation antiandrogen [bicalutamide]) is the standard initial systemic therapy - ADT rapidly lowers testosterone, causing tumor regression and symptom relief (bone pain, LUTS) - Median overall survival with ADT in metastatic disease is 2–5 years; newer agents (abiraterone, enzalutamide) can be added for castration-resistant disease **Clinical Pearl:** The goal in metastatic prostate cancer is to achieve castrate levels of testosterone (<50 ng/dL) as quickly as possible. LHRH agonists take 1–2 weeks to work; adding a short course of antiandrogen prevents the initial testosterone flare. LHRH antagonists work immediately without flare. **Mnemonic:** **STAMP** — Systemic Therapy, Androgen deprivation, Metastatic Prostate cancer ## Why Other Options Are Incorrect | Option | Reason for Rejection | |--------|---------------------| | Radical prostatectomy + adjuvant therapy | Surgery is contraindicated in metastatic disease; it does not improve survival and exposes the patient to operative morbidity. Systemic therapy is the priority. | | Palliative radiation only | While radiation may relieve bone pain, it does not address systemic disease. ADT must be initiated to control the cancer and prevent further metastatic progression. | | Docetaxel monotherapy | Chemotherapy is reserved for castration-resistant prostate cancer (CRPC) after ADT failure, not as first-line therapy in hormone-sensitive metastatic disease. | **Warning:** Do not confuse metastatic prostate cancer with localized disease. Surgery is never curative in M1 disease. ADT is the foundation of all subsequent systemic therapies.