Treatment Considerations for Patients With High-Risk, High-Burden Prostate Cancer


An expert on prostate cancer discusses treatment considerations for patients with high-risk prostate cancer who have high disease burden and other comorbidities.

Case #2: A 78-Year-Old Man with Metastatic Prostate Cancer

Initial Presentation

  • A 78-year-old cap screening naive man presents with right hip pain and fatigue

Clinical workup

  • Abnormal DRE; PSA 140 ng/mL; Hgb 9.9 g/dL
  • Biopsy revealed diffuse Grade Group 4 and 5 prostate adenocarcinoma
  • Imaging with CT and 99Tc bone scan revealed multiple metastatic bone lesions in the right hip and pelvis in the pelvis, liver lesions c/w mets, and a few scattered LN


  • Patient is diagnosed with de novo metastatic prostate cancer (de novo M1CSPC)
  • Germline and somatic genetic testing are negative

This is a synopsis of a Case-Based Peer Perspectives series featuring Paul M. Yonover, MD, FACS, of Uropartners/SolarisHealth Partners.

Dr. Paul Yonover summarized key considerations in a patient with de novo metastatic castrate-sensitive prostate cancer (mCSPC) who has high risk, high tumor burden disease based on the extent of nodal, osseous and visceral metastases. He stated that a multidisciplinary approach with medical oncology is imperative to optimize systemic therapy in this scenario.

He would recommend docetaxel chemotherapy if tolerable, with escalation by adding an oral agent like darolutamide or abiraterone with prednisone based on data from studies like PEACE-1 and STAMPEDE showing improved outcomes with chemo-hormonal therapy triplets. Radiotherapy to the primary prostate tumor has shown benefit in oligometastatic, low volume mCSPC but is omitted in high burden cases like this where it is unlikely to impact outcomes. However, stereotactic body radiotherapy remains an option for selective control of symptomatic metastatic lesions. The key distinctions from low burden mCSPC are the need for intensified systemic therapy and limited role of local therapies in the setting of extensive metastatic disease.

*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.

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