71 yr old male with de novo castrate sensitive metastatic prostate cancer with diffuse adenopathy [bx proven] and bone marrow involvement [s/p BM Biopsy]. He is status post orchiectomy. I have requested NGS and genetic testing. I plan to start an oral anti-androgen agent. In such situations is there a specific agent you prefer that would be less myelosuppressive?
Any of the novel hormonal agents (abiraterone, enzalutamide, apalutamide) would be acceptable in this situation. None of them are particularly myelosuppressive, and it is most likely that any baseline cytopenia that the patient has is related to the marrow-infiltrative prostate cancer. So treating the patient with hormonal therapy is likely to lead improvements in baseline cytopenias. In many cases, orchiectomy or ADT alone would be able to improve the cytopenias, assuming they are due to prostate cancer marrow involvement. The novel hormonal agent can be added within the first couple months of therapy, if you have concerns about toxicities. If this patient has high-volume metastatic disease (defined as visceral metastases and/or ≥ 4 bone metastases with ≥ 1 beyond the vertebral column/pelvis) and is a candidate for chemotherapy, I would also consider triplet therapy with orchiectomy + abiraterone or darolutamide + docetaxel. Obviously the chemotherapy would be myelosuppressive; there is no urgency to adding the chemotherapy. I would start with ADT + either abiraterone/prednisone or darolutamide. If doing well after ~3 months, consider adding docetaxel chemotherapy.
