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After completing this case study, the reader should be able to:

  • Describe typical symptoms associated with prostate cancer at initial diagnosis and at disease progression.

  • Describe the standard initial treatment options for androgen-dependent metastatic prostate cancer.

  • Recommend a pharmacotherapeutic plan for patients with castration-resistant metastatic prostate cancer.

  • Counsel patients regarding the toxicities associated with the pharmacologic agents used in prostate cancer treatment.


Chief Complaint

“I have blood in my urine, I’m using the bathroom all the time, and my shoulder is really hurting.”


Paul Williams is a 73-year-old African-American man who usually has yearly physicals and PSA checks by his local physician. The levels have always been in the range of 4–6 ng/mL. He did not go in for his yearly physical last year, and he now presents with painless gross hematuria, shoulder pain, and a PSA level of 35.7 ng/mL. He has had increased urinary symptoms for the past 5 months.


  • Hypercholesterolemia

  • CHF

  • Diverticulitis

  • Severe GERD

  • Depression


Father, lung cancer diagnosed age 71, died age 73; mother, breast cancer, died at age 93. He has a paternal aunt and paternal grandmother who both were diagnosed with unspecified malignancies.


Retired highway maintenance employee. Christian by faith, Protestant by denomination. He has an associate degree. He drinks on average one six-pack of beer per day. He smoked 10 cigarettes a day for 21 years; stopped smoking at age 42. He is married with two children. He is an only child.


  • Valsartan 160 mg PO daily

  • Carvedilol 3.125 mg PO twice daily

  • Aspirin 81 mg PO daily

  • Furosemide 40 mg PO daily

  • Potassium chloride 10 mEq PO daily

  • Allopurinol 300 mg PO daily

  • Tamsulosin 0.4 mg, two capsules PO daily

  • Fluoxetine 20 mg PO daily

  • Atorvastatin 40 mg PO at bedtime

  • Ibuprofen 400 mg PO four times daily PRN pain

  • Esomeprazole 40 mg PO BID




He reports significant fatigue and severe pain in right shoulder. No fever, chills, or sweats. No epistaxis or dysphagia. Reports no chest pain, shortness of breath, dyspnea, or cough. No nausea, vomiting, diarrhea, or constipation. He reports dysuria × 5 months with dribbling, nocturia eight times per night, hesitancy, and incomplete voiding. He has recurring hematuria. He denies memory loss, diplopia, or neuropathy; he has had no falls recently. He reports a 15- to 20-year history of tinnitus.

Physical Examination


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