Prostate Cancer Treatment: An Overview of Today’s Options

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 Lledo:

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 Lledo:

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:

I’m wondering what key questions patients should ask their health care team about their treatment options?

Dr. Daniel Sentana Lledo:

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 Lledo:

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?