Evolving Prostate Cancer Treatment & Research: What Patients Need to Know

Katherine Banwell:

Hello and welcome. I’m your host, Katherine Banwell. Today’s webinar is part of the Patient Empowerment Network’s Evolve series to help prostate cancer patients understand how the latest treatment developments may affect them. Today, we’re joined by a prostate cancer specialist who will share the updates in research, as well as key advice for patients and care partners. Before we meet our guests, though, let’s review a few important details.

The reminder email you received about this program contains a link to a program resource guide. If you haven’t already, click that link to access information to follow along during the webinar. At the end of this program, you’ll receive another link to a program survey. Please take a moment to provide feedback about your experience today in order to help us plan future webinars. And finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you.

Let’s meet our guest today. Joining us is Dr. Daniel Sentana. Dr. Sentana, welcome. Would you please introduce yourself?

Dr. Daniel Sentana:

You got it. Thank you, Katherine, for having me. I am a medical oncologist at Dana-Farber Cancer Institute here in Boston, and I treat genitourinary cancers, including prostate cancer as one of the things I specialize in.

Katherine Banwell:

Thank you so much for joining us today. Before we get into the evolving research, let’s learn more about you. What led you to become a prostate cancer researcher?

Dr. Daniel Sentana: 

Oh, that’s a good question. So, I would say it all comes down to the patients and the mentors. So, I went into medicine because I like having longstanding relationships with patients. And for the most part, patients that have prostate cancer are patients that live with their disease and are survivors for many years. So, that was a very important aspect.

And then, I was very lucky to work with people that specialized in GU cancer, specifically prostate cancer. And I want to name check two people. One is David Einstein, who’s an oncologist at Beth Israel Deaconess, and the other person is Dr. Alicia Morgans, who is a survivorship expert and also works here at Dana-Farber. So, those people that do amazing research and care for patients with prostate cancer, and the ability to care for people for so long, those were the things that got me into this field.

Katherine Banwell: 

That’s great to know. Thank you. So, before treatment is decided on, Dr. Sentana, it’s important to know the specifics about a patient’s diagnosis. First, what are the types of prostate cancer?

Dr. Daniel Sentana: 

Yes, so I think two questions in that. So, the first one is, does someone have localized, or the cancer is still in the prostate, or does someone have metastatic, meaning the cancer is outside of the prostate and spread to other places? Because that plays a lot into how we think of it, both in the treatment options that we have, but also in the outlook of that patient and what life is going to look like with this diagnosis.

The other part is prostate cancer, generally speaking, we think of a type of cancer called adenocarcinoma, which means is a cancer of glands. And the prostate is a gland, it helps secrete fluid that helps with semen normally. So, most of the prostate cancer, and when people say they have prostate cancer, that’s mostly what they have. They have prostate adenocarcinoma.

There are some small percentages of people that have different types of prostate cancer that arise from different cells within the prostate. One that is getting a lot of attention recently is something called neuroendocrine prostate cancer. But I would say for the most part, that’s a small group and we treat it very differently. Most people who come to us in clinic, they have – over 90 to 95 percent, they have traditional prostate adenocarcinoma.

Katherine Banwell: 

What testing should be done following a diagnosis?

Dr. Daniel Sentana: 

Yes, diagnosis of prostate cancer is actually something that is difficult on its own, and that’s because while we’ve had a screening test for a long time, it’s not the most predictive of it. And what I mean by that is we’ve relied historically on two things to diagnose prostate cancer. First thing was digital rectal examinations, and that’s something that a physician would do or a healthcare provider would do in a clinic, but at the end of the day, it relies on an individual picking up something on an exam. And we know that not all prostate cancer grows where you can feel it with your finger.

The other part of this is we’ve had now for many decades the prostate-specific antigen or PSA test, which is very, very revolutionary, and still today very important in prostate cancer. But again, people can have high PSAs and not have prostate cancer, and people can have low PSAs and get diagnosed with prostate cancer. So, many times both an abnormal digital rectal exam or an abnormal PSA is not enough to say you have prostate cancer.

Nowadays, we rely on two additional pieces of information which are very important. The first one is imaging. So, we’re lucky in most places to be able to access very sophisticated and very advanced techniques in imaging. I would say the most important one for localized disease is having access to MRI because that can give us a whole vision of the gland, and if there are any suspicious lesions, that could be prostate cancer.

For people that have more advanced disease, as we will talk about, I’m sure, there’s newer technologies like PET scans, which are specifically looking at prostate cancer, wherever it may be in the body. And so, imaging is very important in diagnosis.

And obviously, the gold standard to this day is you need a biopsy. And most of the time, for people that have prostate cancer inside the prostate, so localized disease, that is going to be a prostate biopsy. I would say historically, this was done going after 12 quadrants in the prostate, still done these days. However, with the addition of newer imaging techniques, we now have the ability to make what I call targeted biopsies. So, you use the images that you have, usually MRI, this is a suspicious place, I’m going to especially make sure I biopsy that spot. And so, biopsy of the prostate is essential.

If someone we think has advanced prostate cancer, so cancer that has spread from the prostate, then the biopsy usually for us is more helpful if you go after the place where the cancer you think has spread. So, yes, I would say while we may start with an abnormal PSA or an abnormal exam finding, really you need a combination of imaging and biopsying to nail the diagnosis.

Katherine Banwell: 

What about biomarker testing, does that have a role in prostate cancer care?

Dr. Daniel Sentana: 

Yes. So, in different ways. As I said, in a way, PSA is about the most reliable and most longitudinally valid biomarker we have.

So, while it’s not a great test for diagnosing prostate cancer, once you have prostate cancer, it is actually a very good biomarker for how your disease is doing, at least at in the beginning stages when the cancer is still responsive and driven by androgen signaling. There are other biomarkers out there that are gaining importance, I would say. So, there are both what we call predictive biomarkers and prognostic biomarkers. So, let me explain a little bit though.

So, predictive means is that we have a therapy that, based on this test finding, we know it could benefit you more than people that do not have this marker. So, I would say, generally speaking, those are things that are like mutations that we find in cancer or some other things that are intrinsic to your disease.

The second thing, prognostic, means based on these findings, we know that in general, people with these findings are more likely to do better or worse than others. And so, for example, we have some newer tests that are looking at many genes in a patient’s prostate cancer sample that gives us a sense of like, beyond the usual imaging and biopsy, can we better predict who’s going to do worse, who has a more aggressive cancer than other people?

So, I would say those are some of the things that are emerging. For the most part, science advances slowly. So, we find something and then you have to prove that it’s actually helpful in changing the way we manage prostate cancer, but certainly this is a very important field across oncology, but certainly in prostate cancer.

Katherine Banwell: 

How is prostate cancer staged, and how does it impact care options?

Dr. Daniel Sentana: 

Yeah, that’s a great question and actually one that many of my patients ask me. So, I would say that any cancer is traditionally staged based on size of a tumor and where it has spread to. Prostate cancer is a little differently. So, staging is still important, but what we’ve discovered over time is that there is a continuum of risk. And so, what I mean by that is that not necessarily because you have stage I or stage II, you should be managed like this. There’s more to it. And some of the things that add into it is, what was your PSA number when you started? What were the imaging findings or the digital rectal, what did you find there? And oftentimes, the thing that’s most critical is, how aggressive was the cancer under the microscope after you did a biopsy?

So, while there is the traditional staging of stage I, stage II, stage III, and stage IV, or metastatic, in reality, as I said at the beginning, we think of it as localized. And within that, what is the risk of the cancer spreading over time? And then a whole different bucket is people who, from the beginning or later on, have metastasis or cancer spread.

Katherine Banwell: 

Why is an accurate diagnosis so important?

Dr. Daniel Sentana: 

For many reasons. I think principle is for patients to know what to expect, and when you’re hit with the word cancer, it’s really hard to process anything else that’s going on. But not all cancers created equally, fortunately, and this is especially true in prostate cancer, where we know that there are disease stages where you certainly have cancer and it’s important to think about it, but it is not going to harm you anytime soon. While other situations, you need treatment very, very imminently. And so, it’s important to know exactly where you’re at in that stage because as a patient, as someone living with cancer, you want to know, how worried should I be about this? How is this going to impact my day-to-day?

From our end, obviously, not only that, but also it helps us know how much treatment you really need, and how do we intensify treatment with a combination of approaches, or can we just do something as simple as monitoring and re-biopsying? So, that’s why really understanding for a patient to know where they are in that scale of needing to monitor versus something that needs immediate treatment is really important.

Katherine Banwell: 

You mentioned about patients asking some questions. Are there specific questions that patients should be asking about their diagnosis and test results?

Dr. Daniel Sentana: 

Yes. So, I think first, I want every patient to understand, why did this happen? And many times, we actually don’t have an answer for prostate cancer, but there is a subset of people that have risk factors that are from the environment and others that are inherited, meaning that their family or their parents potentially pass them on. So, I think it’s important for anyone who gets cancer to try to understand as much as possible, why did this happen? Even though, as I said, we don’t always find the right answer there.

With regards to testing, I would say anytime your provider is recommending a test or a procedure, it’s very important for someone with prostate cancer to think, “Okay, why is this necessary? How is it going to advance my care?” And it might not be completely apparent. I would say that some tests are easier to explain than others, but I think at the very least you should ask your provider and hear about it because some tests are more crucial than others. And I do this, I have things that I need the first visit that I meet a patient, and others that I signpost that we’ll need this test later on, but I don’t need it right this moment to make a decision.

Katherine Banwell: 

The next step for many patients is to decide on a therapy approach with their healthcare team. Can you share an overview of the common treatment options for prostate cancer today?

Dr. Daniel Sentana: 

Yeah, absolutely. So, I would say, again, if we think about this model of prostate cancer still in the prostate and prostate cancer has gone out of the prostate, it’s the easier one in a way is the one that’s in the prostate because we have decades of experience with several types of therapy. The mainstay way that we cure prostate cancer is one of surgery or radiation, and those two options have decades of evidence behind them, and we know that for many men, that’s all they’ll ever need.

There are some nuances there. So, as I said, some people that have lower risk prostate cancer, they can go on monitoring, on what we call active surveillance. It does not mean you’ll never get cancer treatment, it just means that we think the toxicity of the treatments at this time point outweighs the benefits, and so many of those patients are going to be monitored.

And then, there’s a subset of patients that have prostate cancer still in their prostate, but is at such high risk of spreading that we recommend adding hormonal medications, something called androgen deprivation therapy to radiation. And so, I would say most patients are looking at a combination of surgery or radiation, but there are some nuances there.
People with advanced prostate cancer. Anyone that gets diagnosed with advanced prostate cancer – whether it was at the beginning, that’s how they were diagnosed, or they first had disease in the prostate, but later, unfortunately, it managed to grow and spread – the main way that up until recently we’ve been managing this is focusing on androgen or hormone signaling. And there are a number of medications including the androgen deprivation therapy, or ADT, that I mentioned, that again have many, many years of experience. We have newer, a little bit more selective treatments that inhibit testosterone uptake by the cancer cells, and so those are pill-based treatments that are very important.

And after that, there are many additional things that we can consider. So, things like chemotherapy. Things like radioactive compounds that are known as radioligand therapy. We have targeted therapies. We have immunotherapy. So, once you have advanced prostate cancer, that’s certainly the space where there’s the most drug development and most interest in finding new treatments that I hope one day will move up to patients with localized disease.

But localized disease hasn’t changed that much how we manage it throughout many decades, it’s more so metastatic disease that has the bigger amount of development of new therapeutics. But I foresee that as we get better drugs that treat and allow people with advanced cancer to live for many years, we’ll try to find a way to see if we can select the patients that have prostate cancer still in the prostate, but could benefit from those more, I would say, systemic therapies.

Katherine Banwell:

So, it sounds to me like there are a lot more options available now than there were maybe 10 years ago?

Dr. Daniel Sentana: 

Certainly. Yeah, 10 years ago, there were, especially for metastatic disease, there was a handful of chemotherapies and a handful of targeting pills. And every year we have big studies come in and conferences where investigators report their research, and it’s really exciting, it’s tremendous, and I think it can only benefit patients to have newer ways of tackling prostate cancer and allowing them to live longer.

Katherine Banwell: 

You mentioned a number of therapies like targeted therapy, and immunotherapy, radiation, et cetera. How do clinical trials fit into treatment options?

Dr. Daniel Sentana: 

Yeah, absolutely. So, the first thing I’ll say is that there are a lot of misconceptions about clinical trials, but pretty much every therapy that we use nowadays to treat prostate cancer at some point was in a clinical trial. So, that’s a framework on how cancer advances in medicine. So, what a clinical trial is, broadly speaking, is a study of an intervention to see if it changes or improves the way that we manage care.

And I always tell my patients, clinical trials come in two shapes. The ones that are using things that we know work in prostate cancer, but we’re using them in a different situation, in a different setting. So, for example, I was talking earlier about using some of our medications we use for advanced prostate cancer, maybe we use them for people where the cancer is still in the prostate. And the other type of clinical trials are the ones that I think a lot of people think about, which is the experimental or newer things that we’re learning how they work.

And we obviously have those studies because that’s how we discover, “Okay, is this treatment really going to work?” But certainly at any point in your cancer journey, you should be asking your doctors, “Is there a clinical trial for me?” And sometimes there is, sometimes there isn’t. I will say here at Dana-Farber, we’re lucky that we have a large number of studies at any given time, but this is a rotating menu and some studies are open, some are closed. There might be some pauses in getting patients on the study, but it certainly doesn’t hurt to ask.

And really, as I said, it’s a way to move science forward, and they’re not for everyone. There could be barriers from the patient, and there could be things from our end that we’re not sure it’s the right fit for you, but it doesn’t hurt to ask. And again, I think it greatly benefits the bigger prostate cancer survivorship community who get on these studies and advance the care that we’ve been providing.

Katherine Banwell: 

We’re going to look more in depth about clinical trials in just a few moments, but I wanted to continue talking about treatment options. And I’m wondering what key questions patients should ask their health care team about their treatment options?

Dr. Daniel Sentana: 

Yeah. So, I think any treatment, a patient should be asking, “Why did you select this or why do you think is a good idea?” And second, “How is it going to benefit me?” And those are the two things that should drive the conversation. So, knowing why your provider has selected or has thought of this option. And normally the answer is, “For your disease characteristics, or for your situation, your type of prostate cancer, we have big studies that have shown this is beneficial. So, this is why.” But I think especially for people that are living with cancer for many years, it’s important to think about, “How is this benefiting me?” And I just want to expand on that a little bit if I can.

So, even for patients where we cannot cure their prostate cancer because of the amazing therapies that we currently have available, many patients can live with prostate cancer for years. And that’s a big change from a decade or certainly longer than that. And so, there’s trade-offs in everything. So, if a patient’s going to be on a treatment for many years, then we certainly have to worry about the long-term side effects of being on therapy. And then, there are situations where we know we have a very effective treatment, that the moment you start, the cancer is going to be under control, but do you really need it at that time point?

There’s this situation which we didn’t talk about, but I think a prime spot for this is what is known as biochemical recurrence in prostate cancer. Which is a situation where people have had treatment to cure their prostate cancer, but unfortunately the cancer returned, it’s just we cannot find where it is. It’s only detectable via this PSA test. And that’s a very area of controversy and a lot of work is being put into it because you have a marker that you show the cancer is there, but you cannot see it. So, should you start the treatment now? Should you wait until the cancer is seen? And do you go through potential benefit of going on a treatment now instead of saving it for later? Because the moment you use something, then it’s less likely you can rely on it at a future time point.

So, I think that’s why patients need to think not only, “What is the provider’s perspective on why this treatment is the right one for me?” but also like, “What am I getting out of it? Is it going to be I’m living longer? Is it going to be I have less symptoms from my cancer? Is it going to be my cancer’s quiet for a longer time?” And just know that there’s, for many things, medicine is very gray, and there’s rarely a right answer or a wrong answer. It’s all about a conversation and what is the right thing for that particular patient.

Katherine Banwell: Right. 

Personalized medicine is mentioned a lot these days. Could you explain what it means and how it’s being used in prostate cancer?

Dr. Daniel Sentana: 

Yes. So, I would say what personalized medicine means is that we are essentially making a recommendation based on a number of things that are unique to you. So, the most important ones in cancer are usually cancer-specific things. So, looking at what are some of the markers that suggest how aggressive a cancer may be, or again, some of these findings that might tell us, “Okay, this treatment probably works better than another.”

But the other side of that, that we were just talking about, is what are the values and what are the things that are important to a patient? So, I might have a number of treatments, but this is a patient that has a trip that’s coming up, or has an event that they’re looking forward to and they want to preserve their health and not be committed to a certain schedule. So, when we think about personalized medicine, it’s both tailoring it to the cancer and the cancer characteristics of you, of the patient, but also, what are the things that matter to you, and what are the objectives of you, so that we make sure that we’re both getting the cancer tackled, but also allow you to live your life the fullest as much as possible despite this diagnosis?

Katherine Banwell: 

I’d like to return now to the subject of clinical trials. What type of question should patients be asking about participating in a trial?

Dr. Daniel Sentana: 

It’s a misconception, I think, that clinical trials only happen in places such as this, like very large academic centers. In fact, there are many times studies that are happening in smaller community sites. And so, you’re never wrong to ask your provider, “Do you have any clinical trials?” But certainly, what I think patients should be thinking about is, “What type of study do you think would benefit me? Is there something that you think is potentially better or different about the way you would treat me now if I was on this study?”

And I have some patients that come from long distance to consider a clinical trial, but certainly I think if a patient has an expectation or a number of questions that they’re hoping to address, that will let us know. So, are you looking for a special type of therapy? Or are you looking for a certain approach to treating your cancer? If we know that information ahead of time or you bring it up on that first visit, then I don’t have to tell you about perhaps some things that are just not applicable or you would not be interested in.

But certainly, as I started saying, no matter where you’re getting your cancer care, you’re never wrong to ask, “How about a clinical trial?” Because again, in the long run, this is how science advances and how we come up with better treatments for men with prostate cancer.

Katherine Banwell: 

Could you walk us through the common misconceptions that patients may have about participating in a trial?

Dr. Daniel Sentana: 

Yes. Well, there are certainly many of them, but I think probably one that, for historical reasons, one that normally comes up is this idea of being either like a guinea pig or going on placebo. So, just to say that obviously, when you go on a clinical study, we don’t know your outcome, but the same is true for any of the established treatments we use. So, we have just more information on the established options than a clinical trial, but for better or worse, when someone is getting care, we cannot predict the future.

And so, the other thing I want to say is that for the most part, clinical trials nowadays, especially in oncology, do not involve placebo. And that’s because we have learned over time that it’s not ethical to withdraw care for patients that could get otherwise very good treatment. And so, while there are some studies that still use placebo, I would say these are generally when you’re kind of running out of options, those can be a good reason to use it because we don’t know if this new therapy is going to help you.

The vast majority of studies that patients go on, they are offered – so, either they all get the study drug, or at certainly the alternative, which is the best standard of care. And in prostate cancer, that could be one of the hormonal agents, it could be chemotherapy, it could be a type of surgery, a type of radiation.

So, just because you go on a trial does not mean you’re not going to get appropriate care. It means that you could get potentially better care, but we don’t know. At the very least, most studies make sure you get the standard, and if there’s that option to go on the study arm that has the newer option, the newer approach, then potentially you can do better. But that’s the purpose of the study, we’re learning if they help or not.

Katherine Banwell: 

Exactly. If someone is worried or anxious about participating in a clinical trial, what would you say to them?

Dr. Daniel Sentana: 

Yes, and I think it’s very natural for anyone with cancer to worry about their outlook and what this treatment is going to do, but certainly on a clinical trial, where the level of uncertainty increases. I think what I can say to them is that every treatment that we have these days, at some point, was in a clinical trial, and certainly there are medications or a procedure that didn’t end up being used, and we acknowledge that all the time. When a study is presented or when we discuss the findings of a big study, everyone always says, “We thank patients and their families for taking the step and being courageous at going on a trial.”

So, I would say the uncertainty is part of medicine and part of oncology. Clinical trials are a promise and are a hopeful way to perhaps improve the care that we get. So, it’s very understandable to be anxious or to be concerned about some things. But if you want to not only perhaps improve your options, but also contribute to other patients down the line to know that this is an effective way to treat your cancer, then certainly that altruistic behavior and that leap of faith can only benefit others and potentially even you right now.

Katherine Banwell: 

Before we close the program, Dr. Sentana, I’d like to get your thoughts on the future of prostate cancer care. Are you hopeful?

Dr. Daniel Sentana: 

Oh, certainly, yes. There’s a lot to look into that. As I said, I think even in the last decade alone, or even five years, the number of ways that prostate cancer care has become more complicated is a challenge, but it’s a challenge that I think the oncology community welcomes. Because up until now, there wasn’t a lot of progress and I will say also a lot of attention in prostate cancer because it’s a cancer that affects men, and men normally don’t like to talk about their health in general, but definitely not something that affects their genitourinary care.

But I’m hopeful because I think there’s a lot of attention these days on getting screened and on identifying the cancer earlier. And certainly, the number of research and opportunities that are coming into improving the way we care for patients is tremendous. And certainly, we’re lucky to be at a center where there’s a good amount of work being done in that sense. But any patient that is being cared for, for prostate cancer, knows that you are part of a larger community, and that we’re all in this together, and the future can only look up.

Katherine Banwell: 

Yeah. Well, that’s a very promising outlook to leave our audience with, Dr. Sentana. Thank you so much for joining us today.

Dr. Daniel Sentana: 

Absolutely. Well, thank you so much, Katherine, for having me. It’s been a real pleasure.

Katherine Banwell: 

And thank you to all of our collaborators. If you’d like to watch this webinar again, there will be a replay available soon. You’ll receive an email when it’s ready. And don’t forget to take the survey immediately following this webinar. It will help us as we plan future programs. To learn more about prostate cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for being with us today.