Tag Archive for: prostate cancer treatment
How to Play an Active Role in Your Prostate Cancer Treatment and Care Decisions
How to Play an Active Role in Your Prostate Cancer Treatment and Care Decisions from Patient Empowerment Network on Vimeo.
What steps can you take to engage in your prostate cancer treatment and care decisions? Dr. Atish Choudhury discusses current and emerging prostate cancer therapies, reviews key treatment decision-making factors, and shares advice for self-advocacy.
Dr. Atish Choudhury is the Co-Director of the Prostate Cancer Center at Dana-Farber/Brigham & Women’s Cancer Center.
Learn more about Dr. Choudhury here.
See More from Engage Prostate Cancer
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Transcript:
Katherine:
Hello, and welcome. I’m Katherine Banwell, your host for today’s webinar. Today, we’re going to explore the goals of advanced prostate cancer treatment and discuss tools for playing an active role in your care decisions.
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. Joining us today is Dr. Atish Choudhury. Dr. Choudhury, welcome. Would you please introduce yourself?
Dr. Choudhury:
Hello. Thank you so much for the invitation. So, I’m a medical oncologist at Dana-Farber Cancer Institute, and I’m the codirector of the prostate cancer center at the Dana-Farber/Brigham and Women’s Cancer Center. And I serve as the chair of the Lank Center for Translational Research as well, and ’t’s my pleasure to be here.
Katherine:
Thank you so much for taking the time out of your schedule to join us. Today, we’re talking about advanced prostate cancer.
What exactly does “advanced” mean in terms of this cancer?
Dr. Choudhury:
Yeah. So, it’s actually a pretty broad term, and it can mean different things in different contexts. But generally, what it means is that it’s cancer that has extended outside of the confines of the boundaries of the prostate itself – either locally where it is into the surrounding fat around the prostate capsule or to local lymph nodes, where it could also spread to other parts of the body – like lymph nodes, bone, and other organs.
So, it can really mean different things depending on the context.
Katherine:
Before we get into the types of treatment available, let’s start by understanding the goals of treatment. What are the goals of advanced stage prostate cancer?
Dr. Choudhury:
So, in general, the goal of treating any cancer is to a live a long, happy, healthy life with limited quality of life troubles from the cancer itself or its treatments. And so, for localized prostate cancer, that generally means treating with curative intent – that we give radiation or surgery, potentially in combination with hormonal treatments so that the cancer is taken care of and people can be cured and not need further treatments moving forward at all.
And there are situations, even in fairly advanced cases, where that’s a reasonable and accomplishable goal. And there are other situations that we might not be able to cure the cancer completely, but the treatments can be quite effective at keeping it under control and keep people with a very good quality of life so that prostate cancer is not a day-to-day burden for them and that they can survive with cancer for years, and years, and years.
Katherine:
It sounds like these goals would be determined with members of your healthcare team. So, who is typically on a patient’s prostate cancer healthcare team?
Dr. Choudhury:
Yeah. So, generally, the consultations here at Dana-Farber are multidisciplinary, with a medical oncologist, a radiation oncologist, and a urologic oncologist – so, a surgeon.
And so, if a patient is a good candidate for treatment to the prostate itself, then certainly, the surgeon and the radiation oncologist will talk about those treatments. And if the treatment is primarily with medications, then the medical oncologist will generally sort of take the lead. But there is often a role for local treatment to the prostate itself, even in cancer that’s spread beyond the prostate. So, that’s why the multidisciplinary consultation is so important.
Katherine:
Right. What do you feel is the patient’s role as a team member?
Dr. Choudhury:
Absolutely. So, I think it is very important for the patient to make sure that they come into these multidisciplinary meetings with questions around “What is my stage?” “What are the choices?” “What do I expect with treatment? Without treatment? With the various treatment options?” And basically, to take in the advice that they’re getting from the different members of the multidisciplinary team, and really think about how that’s impactful for them and their goals for themselves and what they really hope for the short term and for the long term.
I think what gets tricky is that there’s really very not-great sources of information that’s out there online and in YouTube videos and things like that, and I think it does play an important role for the patient to really understand what are the real high-quality sources of information – they tend to come from academic medical centers like ours. And certainly, we do encourage second opinions at other high-quality, high-volume centers so that the patients understand that the recommendations that are being made are generally made based on the based data and with people with a lot of experience at treating their kind of cancer.
Katherine:
What about caregivers? How do they fit into the team?
Dr. Choudhury:
Caregivers are critical because patients are not always the most expressive at, really, what their wants, and needs, and desires are. And especially when they’re on treatment, sometimes they’re not so expressive around the things that are bothering them on a day-to-day basis.
So, the caregivers are really important for communication with us to be kind of another set of eyes and ears in terms of kind of reporting what the patient’s symptoms are or what their goals or desires are that maybe they themselves don’t feel comfortable expressing. But they also play an important role in helping us with, kind of, lifestyle recommendations to the patient. Because certainly, much of the process of doing well with prostate cancer treatments is kind of lifestyle modifications – makes sure you’re eating healthy, exercising regularly – and the caregivers can play a very important role in making sure that patients stick to that kind of regimen as well.
Katherine:
I would think one of the issues for a patient too is that just having a cancer can be overwhelming and can make it difficult for them to even remember all the questions and concerns that they have.
Dr. Choudhury:
Yeah, that’s absolutely critical, and the caregivers play a very important role. So, often, people who are not partnered, for example, will just bring a friend to these appointments just to be that second set of eyes and ears.
Katherine:
Dr. Choudhury, we received this question from an audience member prior to the program: What is palliative care?
Dr. Choudhury:
So, palliative care is really a branch of medicine that helps with symptom management. And so, that symptom management doesn’t necessarily have to be end-of-life sort of symptoms relating to death and dying. It can be just along the way to help with managing the symptoms related to cancer and its treatment, but also to be kind of another medical provider to help with communication of goals of care – what’s really bothersome, what’s really important – so that we kind of incorporate those wishes and desires into the management decisions that we make.
So, a patient does not have to be at end-of-life to engage with palliative care. Certainly, even earlier engagement with palliative care can be helpful to maximize quality of life along the treatment journey. But as symptoms become more bothersome, certainly, our palliative care colleagues can be incredibly helpful – not just in helping manage pain, but also nausea, also depression and psychological side effects. So, they’re a really critical part of our treatment team.
Katherine:
Yeah. I think we have a pretty good understanding and the goals of treatment. So, let’s walk through the types of therapy that are used today to treat prostate cancer.
If you would start with surgery?
Dr. Choudhury:
Sure. So, surgery is a radical prostatectomy, and they take out the prostate – they take out neighboring structures called seminal vesicles, they take out the surrounding fat, and they’ll usually take out some neighboring lymph nodes as well. And there are advantages of surgery in that when the prostate is out, the pathologist can examine the whole prostate front to back, side to side, as well as those neighboring structures to really understand the stage of the cancer – “Where is it?” – and also, the grade – “Is it a high-grade cancer, a low-grade cancer, somewhere in the middle?”
And it really helps guide “What is the risk of developing recurrence afterwards, and are there further treatments that we should be giving after the surgery? For example, radiation to the prostate bed to decrease the risk of recurrences. Surgery does have its own set of potential side effects and complications, so it’s not appropriate for everyone, but in general, that’s the process.
Katherine:
What other treatment options? You mentioned radiation. What else is there?
Dr. Choudhury:
Yeah, so, radiation comes in two forms: there’s seed radiation, which is implantable little radioactive pellets that are implanted throughout the prostate. And then, there’s external radiation, and that can be given in several forms and over several schedules that it’s really important to discuss with the care team.
The other forms of treatment that people on this call might’ve heard about or read about are in a category called “focal treatments,” and these are basically ways to – and the term we use is a blade but zap – an area of the prostate using lasers, or high-intensity ultrasound, or with freezing an area of the prostate, or with something called “irreversible electroporation.”
These are basically all ways to, again, zap an area of the prostate either with heat or with cold with the intention of killing off cancer cells in an area. And the trouble is that none of these treatments have actually been demonstrated to improve outcomes related to prostate cancer compared to just surveillance alone. And it does complicate, sort of, the monitoring afterwards to see if something has come back.
But there might be very selected patients where there’s an area of cancer that’s seen on a scan – like an MRI – with no cancer seen outside of that area who might decide to pursue this possibility of focal treatment with the goal of maybe putting off the need for something like radiation or surgery. But that’s something that really should be discussed with a multidisciplinary team so that people really understand what they’re getting into in terms of risks and potential benefits.
So, those treatments are not really considered standard at this time.
Katherine:
What about hormonal therapy?
Dr. Choudhury:
Yeah, so, hormonal therapy plays a role in the treatment of prostate cancer, really depending on the stage and the other treatments that are being considered. So, for example, if a patient is going to surgery for a localized prostate cancer, in general, we wouldn’t use hormonal treatment either before or after the surgery unless they’re planned for radiation after the surgery.
However, for patients who have intermediate risk or higher localized prostate cancer and are getting radiation, then we will often recommend hormonal treatments, which are basically testosterone-lowering drugs, to make the radiation work as well as possible. And then, for patients who have advanced cancer beyond where surgery or radiation is going to be of help, then, hormonal treatments are important to treat the cancer wherever it is.
And that’s because prostate cancer cells, wherever they are in the body – wherever they’re in the prostate itself, or in lymph nodes, or bones, or other organs – depend on the testosterone in your body to supply a fuel – to support its growth and survival.
And so, lowering the level of testosterone in the body basically deprives the cancer cells of that fuel and starts a process of killing cancer cells even without any need for radiation, or chemotherapy, or things like that. However, hormonal treatments are not curative. They don’t kill all the cancer – they kill some and put the rest to sleep. And so, if you stop the hormonal treatment, the cancer will grow back, and that’s why it’s not a treatment on its own for localized prostate cancer.
And that’s also why, for prostate cancer that’s spread, we often add on additional medications to the testosterone-lowering drugs to be more effective at really killing the cancer wherever it is compared to the testosterone suppression alone.
Katherine:
Oh, I see. For advanced disease, what treatments are available for patients that are hormone-sensitive or -resistant?
Dr. Choudhury:
Yeah, so “hormone-sensitive” means that the cancer has advanced, but the patient hasn’t started on testosterone-lowering drugs yet. And so, as I had mentioned, testosterone lowering is really the backbone of treatment of these patients. And so, there are additional treatments that have been demonstrated previously to be effective after testosterone-lowering by itself stops working, and these include a chemotherapy drug called docetaxel. And in addition, there are more potent hormonal drugs called abiraterone, enzalutamide, apalutamide, and darolutamide.
And the role of these other drugs is to block hormonal signaling within the cancer cells from hormones other than testosterone. And so, by doing the more potent hormonal drug in conjunction with the testosterone lowering, that leads to a much deeper response – much more tumor shrinkage – and, it turns out, also prolonged survival in patients treated with those combination treatments – compared top people who are treated with testosterone lowering alone and then receive these drugs later.
So, there’s something about treating more aggressively at the beginning in this hormone-sensitive state that plays out in prolongation of survival. And not only prolonged survival, but improved quality of life due to delaying the symptoms of cancer grown and progression.
Katherine:
Right.
Dr. Choudhury:
When we then talk about castration resistant disease, certainly we use the same classes of drugs, but then, there’s a wider armamentarium of things that we use that include, again, other kinds of chemotherapy.
There are radiation drugs, and an approved drug Radium-223. And there’s another drug on the horizon called Lutetium PSMA. There are immune therapy drugs – something called Sipuleucel-T – and then, this is also a situation where we do genetic testing of the cancer to understand if there’re certain –what we call “therapeutic vulnerabilities.”
Other treatment options that are available based on the genetics of the cancer that might be helpful in some people? And specific options include a chemo-immune therapy called “Keytruda” in a small subset of patients with particular genetic changes involving genes involved in mismatched repair of DNA. And then, there’s another set of targeted treatments called “PARP inhibitors” for certain sets of patients who have alterations in genes involved in homologous recombination repair of DNA.
So, that’s all very complicated, and so that’s why it’s important to get treated with high-volume providers of prostate cancer patients so that they’re really aware and onboard with these various treatment options that are available.
Katherine:
Yeah. Where do clinical trials fit in?
Dr. Choudhury:
So, clinical trials can fit in anywhere along the treatment trajectory for prostate cancer. It’s not something that’s reserved for kind of late-stage disease. So, for example, for people with localized disease, there are different types of treatment strategies that might be available to maybe enhance the activity of the surgery or the radiation that’s planned. And so, we might consider a clinical trial even for localized prostate cancer.
And then, anywhere along the way, there are standard treatments that are available, and then, there are some experimental approaches that might be available. And the experimental approaches might be to add an additional drug to the standard or to actually – what we call “deescalate treatment” – give a little bit less of the medication and see if the outcomes are the same. And these are tests.
And so, the control arm, when there’s a randomized trial, is generally considered a standard of care. And then, the experimental arm is some alteration or deviation from that standard. But many of our trials are also single-arm trials where we’re testing some experimental regimen that all patients who participate in the trial will take part in, and it’s really important for the patient to ask, “What are the clinical trials available?” “What are the alternatives as far as standard treatments?” and “Are there other clinical trials other than the one that’s being discussed,” that might be appropriate for them?
Katherine:
Are there emerging approaches that patients should know about?
Dr. Choudhury:
Yeah. So, a lot of the emerging approaches are related to the genetics of the prostate cancer, as I just mentioned. And then, these different forms of radiation drugs – in addition to the ones that have already demonstrated survival advantage, there are other ones in the pipeline. And then, one thing that patients are very curious about is immune therapy approaches to prostate cancer.
Now, the standard kind of immune therapy drugs that are approved for lung cancer, and melanoma, and kidney cancers don’t tend to work particular well for prostate cancer. But there are many clinical trials trying to combine those kinds of drugs with other drugs or have newer approaches to immune therapies that patients with advanced cancer can certainly ask about.
Again, all of this is really experimental, and people need to understand that these sorts of approaches aren’t going to help everyone. But participating in a clinical trial allows our patients to contribute to knowledge that can be useful for other patients down the line.
Katherine:
Right. Now that we’ve delved into the types of treatment, let’s talk about what goes into deciding on an approach. What do you typically consider when determining the best treatment approach or option for a patient?
Dr. Choudhury:
So, the starting point and the ending point is the patient themselves. And so, “the patient” means “What is their age? What is their fitness level? What are their activities? What’s the overall life expectancy? What are there other medical issues?” And then, we consider the cancer – “What is the stage? What is the grade? Where has it spread to, if it’s spread?”
And then, we try to incorporate all of those pieces with data – with clinical trials that have already been reported – and we have a lot of data in prostate cancer from patients who’ve participated in clinical trials, often randomized to one approach versus another, that gives us a sense of “What are the approaches that really benefit patients in terms of increasing likelihood of cure or prolonging the survival?”
And so, once we incorporate all of those things, we can come up with some treatment suggestions, and then patient preference on those suggestions obviously plays a very important role. But sometimes, we start down a line, and the patient is having troublesome side effects or it’s not working as well as we’d really hoped, and it’s important to be adaptive and to change things if things are not going down a route that we’d really hoped. So, that’s an ongoing conversation. It’s not that you make a treatment plan at the first visit and that’s the plan that’s stuck with throughout the whole course of things.
It’s a conversation at every visit on how things are going in terms of how the patients are doing and how the cancer is responding. And then, again, try to manage side effects as well as we can and adjust things if we need to along the way – and maybe switch to something that’s potentially going to be better tolerated or more effective, depending on what we see.
Katherine:
Right. It sounds like there are many factors to weigh when making this decision. I’d like to address a list of common concerns about treatment that we’ve heard from the community. So, I’d love to get your take on these. “There’s nothing that can be done about advanced prostate cancer.” Is that true?
Dr. Choudhury:
So, that is very much untrue in that even patients with pretty advanced prostate cancer – even what we call “high-volume” kinds of prostate cancer – can live for years, and years, and years with appropriate treatments.
And the concern, oftentimes, is that the way that we get those years, and years, and years are with treatments that lower levels of testosterone, and I’m guessing that some of your questions coming up are related to concerns around side effects of treatment. But many of our patients tolerate those side effects pretty well and can live quite a good, and vigorous, and fulfilling life even with pretty advanced prostate cancer.
Katherine:
The next one: “Clinical trials are a last-resort treatment option.”
Dr. Choudhury:
Yeah, so, as I’d mentioned before, clinical trials can be appropriate anywhere along the treatment trajectory of prostate cancer, and they are often being compared against standards which are often pretty good, but can we make them better? And certainly, participating in clinical trials isn’t for everyone, but for a long of our patients who are interested in seeing if an experimental approach might be beneficial to them or contributing some knowledge to patients down the line really do find trial participation to be quite fulfilling.
Katherine:
All right. The next one is: “Prostate cancer isn’t genetic, so I don’t need to be tested.” Is that the case?
Dr. Choudhury:
No. So, it turns out that prostate cancer is actually one of our most heritable cancers. Somewhere between 40% and 50% of the predisposition to prostate cancer is actually genetic, or inherited based on family. So, the part that’s tricky and the part that is hard to maybe explain to patients is that a lot of that heritability is not encompassed in particular cancer genes in the way that many people are familiar with with breast and ovarian cancers, which are often linked to genes called “BRCA-1” and “BRCA-2.” So, a small subset of patients with prostate cancer do have alterations in that BRCA-2 gene, or BRCA-1, or ATM, or some other genes involved in breast and ovarian cancers.
And that does impact, potentially, their treatments down the line, and certainly is impactful for themselves, their siblings, their children as far as, potentially, screening recommendations for other cancers. But oftentimes, we’ll do one of these tests in patients who have a pretty extensive family history of prostate cancer, and they come out negative, and the patient is very confused because they clearly have a family history, but it’s because not all the risk of prostate cancer is actually encompassed in these gene tests that we run.
Katherine:
Ah, okay. The next concern is “I’ll lose all sexual function when I receive treatment.”
Dr. Choudhury:
So, it very much depends exactly what the treatment is, and what’s being offered, and what the recovery is like.
So, for example, for patients who go into a prostatectomy and have very good erectile function, it’s not inevitable that you’ll lose your sexual functioning after a prostatectomy. There is a process – we kind of refer to it as “penile rehab” – of using medications like a Viagra or Sialis to restore the blood flow. You could use certain things like vacuum pump devices to restore the blood flow, and again, it’s not inevitable that people are going to lose their sexual functioning after a prostatectomy.
Even with testosterone suppression, while it plays a role in libido and erectile function, it’s not inevitable that people lose their libido and erectile function completely, even on these drugs. But certainly, more often than not, people will lose their erectile function on testosterone-lowering medications.
And so, there are alternative ways to get erections – involving, again, use of vacuum pump devices or injections that people can give themselves into the penis. People can have penile implant surgery to be able to get erections that way. And so, it’s really dependent on what the situation is.
Again, none of those more mechanical interventions are really ideal, but particularly when people have a defined course of treatment – for example, a surgery or radiation with a brief course of hormones – people can recover erectile function even after those sorts of interventions. And if they can’t, then we do have other approaches that will allow people to still be able to be sexually intimate with their partner after all of the treatments are completed.
Katherine:
Dr. Choudhury, one more concern: “My symptoms and side effects can’t be managed.”
Dr. Choudhury:
Yeah. So, again, it’s very rare that we run into situations where there are side effects or symptoms that can’t be managed at all, in the sense that we have very effective medications against hot flashes, or moodiness, or pain, or –just fatigue. And certainly, lifestyle plays a big role in this. Also, a lot of the symptoms that people express are related to underlying depression and anxiety issues, and certainly, engaging with a mental health provider can be helpful in terms of managing those as well.
And then, there’s a lot of nonpharmacologic treatments – meaning nonmedication approaches that can provide people a lot of benefit in terms of their quality of life, and we have an integrative center called the Zakim Center for Integrative Medicine that helps with the relaxation techniques, and massage, and yoga, and acupuncture…
And people find different approaches to help manage these symptoms and side effects. And so, it’s very unusual where we run into a situation where the side effects are unbearable and unmanageable. Usually, we can manage them in some form of way that allow people to have, again, a good quality of life and a meaningful life, even on prostate cancer treatment.
Katherine:
Thank you, that’s really helpful. I’d like to talk about the term “shared decision making.” What does that mean to you, exactly?
Dr. Choudhury:
So, shared decision-making really means that when the physician conveys information to a patient, that the patient really understands what’s being said, and what, really, the alternatives are – and the real risks and the benefits of the different alternatives. And so, if a patient goes to see a surgeon and they say, “Well, we should take this out,” and there’s never really discussion of what the risks and benefits of the alternatives are –and the alternatives could be just watching, or radiation, or even more intensive treatment, then that’s not really shared decision making.
But what I think is not exactly shared decision making is when the patient is getting information from really non-knowledgeable or non-reputable sources and then starts to come up with conclusions based on hearsay or people trying to sell them a product that really hasn’t been FDA approved or really tested. And so, those are situations where when the information is really not good, then we can run into troubles with communications. But there are a lot of really excellent sources for patient information that’s available, and the Prostate Cancer Foundation is a really good source, and a lot of the academic prostate cancer centers are really great sources of information.
And so, being educated and asking good questions is really the best way for a patient to feel comfortable that they’re not missing anything and that they’re, again, having all the information that they need to make a good choice for themselves.
Katherine:
Do you have any advice to help patients speak up if they’re feeling like they’re not being heard?
Dr. Choudhury:
Sure. So, I mean, there’s never any barrier to bringing up concerns with whoever that you’re seeing, and if you feel like whoever you’re talking to isn’t being receptive to those concerns, then certainly, second opinions are very useful. But if you see multiple doctors and they’re kind of telling you the same thing based on good evidence, then you probably have to take in what they’re saying, and process it, and see if it really does apply to your particular situation.
But any cancer doctor who really has your self-interest in mind will be very open to discussing the concerns that you have, so you should absolutely bring them up.
Katherine:
To close, Dr. Choudhury: What would you like to leave the audience with? Are you hopeful?
Dr. Choudhury:
Yes. I’m actually incredibly hopeful. There’s been such a transformation in our diagnosis and management of prostate cancer compared to when I first started as an independent attending back in 2012. In the last ten years, there’s been so many new treatments that’ve been approved in the last decade and a lot of newer technologies available for staging patients – really finding where their prostate cancer is.
And newer technologies for treating the cancer wherever it is and in a really smart way. And so, we can really individualize our treatments for the patient that’s in front of us being a bit more intensive for people with higher-volume or higher-risk cancers, and actually potentially being able to back off treatment, and actually stopping some of the testosterone-lowering drugs in patients who are responding exceptionally well to the medications and the local treatments that we’re giving them.
And then, also, I’m really hopeful about the newer treatments and newer technologies that are on the horizon. We have newer – what we call “molecularly targeted agents.” We have new approaches involving immune therapies that are being tested – newer radiation approaches. And I feel like all of this put together allows us to, again, satisfy the goal of maintaining patients’ good, healthy, meaningful quality of life moving forward.
Katherine:
Yeah. Dr. Choudhury, thank you so much for taking the time to join us today.
Dr. Choudhury:
Oh, you’re welcome. It’s so wonderful to have this opportunity.
Katherine:
And thank you to all of our partners. Please continue to send in your questions to Question@PowerfulPatients.org, and we’ll work to get them answered on 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.
What Is Precision Medicine for Prostate Cancer?
What Is Precision Medicine for Prostate Cancer? from Patient Empowerment Network on Vimeo.
Prostate cancer has the option of precision medicine in the treatment toolbox. Dr. Heather Cheng from Seattle Cancer Care Alliance defines precision medicine and explains how it is used to help provide optimal prostate cancer care.
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Transcript:
Sherea Cary:
So, what is precision medicine? And what…and what is precision medicine when we think about prostate cancer?
Dr. Heather Cheng:
Yes, it’s a great question and something I get really excited about. So, precision medicine, I guess in a nutshell would be finding out more about somebody’s personal prostate cancer and being more precise about our treatment decisions, meaning using that information to avoid overtreating or using drugs or treatment that don’t work and choosing treatments that we have a much higher level of confidence will be effective. Now, that’s the potential, sometimes we’re more successful than other time, but in prostate cancer, we have a few exciting examples that are, I think that are new, that I think just get me really excited because, for example, some cancer…some people, cancers have certain mutations or markers in them, that if they’re there, which is not in all people with prostate cancer, but if they’re there, then we have a different treatment tool box for those patients, so we have new extra, extra drugs or extra treatment opportunities, and that’s the sort of precision aspect or tailoring or we’re making the treatment it better for the patient and their cancer, and that’s really exciting, so it’s not one-size-fits-all, but kind of more tailored to the patient and their particular cancer.
Why Is Specialized Care Important in Prostate Cancer?
Why Is Specialized Care Important in Prostate Cancer? from Patient Empowerment Network on Vimeo.
Prostate cancer specialized care can be utilized in different ways. Dr. Heather Cheng from Seattle Cancer Care Alliance explains the various ways specialized care can be used to help provide the best care in prostate cancer diagnosis and treatment.
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Transcript:
Sherea Cary:
Can you speak to the importance of connecting to specialized care in prostate cancer?
Dr. Heather Cheng:
Yes, I think it is really important when people are thinking about a diagnosis of prostate cancer, which is a difficult thing under the best of circumstances, but it’s so important to get the best information, the most current information. And if you’re thinking about prostate cancer surgery, if you’re thinking about prostate cancer radiation, if you’re thinking about medical therapies, you want to make sure that you have the most up-to-date knowledge and you’re in the best hands, and sometimes that’s going to a cancer center or a center that does see a lot of patients like you, who have cared for a lot of patients who have been in a situation like yours and have a lot more experience and have knowledge about the most current treatments and have experience. And so I think it’s important when you’re getting a diagnosis to get that information, and to at least have knowledge about all of your options and get the best knowledge, and I think that’s where patient education and then also getting second opinions can be really helpful, and telemedicine is allowing that to be easier, but really getting all the information before you make a decision and feeling that you’re well-informed is really going to go a long way in improving your outcomes and getting kind of the best treatment that you deserve, right? Patients really deserve that.
Prostate Cancer Treatment Tools and Advancements
Prostate Cancer Treatment Tools and Advancements from Patient Empowerment Network on Vimeo.
What’s the latest in prostate cancer treatment tools and advancements? Dr. Heather Cheng from Seattle Cancer Care Alliance shares information about areas of prostate cancer research that have experienced recent advancements.
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Transcript:
Dr. Heather Cheng:
I think it’s a really exciting time. I think there are a lot of advancements throughout prostate cancer. I think one area of importance is early detection, but we also have newer imaging platforms, meaning the way, and we can discover where the prostate cancer is, is advancing through new types of PET scans that we didn’t previously have. And then my own kind of research which is near and dear to my heart is talking about genetics and what we have learned about the genetics of the risk of prostate cancer, but also how the genetics of the cancer itself, which sometimes is inherited, and sometimes isn’t can help us plan for better treatments for patients.
How Is Genetic Information Used for Prostate Cancer Treatment?
How Is Genetic Information Used for Prostate Cancer Treatment? from Patient Empowerment Network on Vimeo.
Prostate cancer can impact patients differently depending on their risk group. Dr. Heather Cheng from Seattle Cancer Care Alliance explains how genetic information is used in prostate cancer treatment and other factors that can impact patient outcomes.
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Transcript:
Sherea Cary:
Can you speak to how you and your colleagues are using genetic information to help with the treatment and understanding prostate cancer for different risk groups?
Dr. Heather Cheng:
Yeah, thank you that…that’s something that I think is following the lines of this idea of precision oncology or tailoring. Tailoring people’s management, either if they don’t have cancer and we’re worried about the risk of cancer, we can use genetic markers that we can test from saliva or blood to help understand that person’s risk of prostate cancer better, and in some cases, there are some families where there are markers or genes that run in the families that might increase the risk of developing prostate cancer, but also sometimes the same genes are increased the risk of breast cancer and ovarian cancer, and if they’re present, then it’s important to think about knowing that, getting that information, because then there are strategies that we can use to find it earlier and to treat it more aggressively and hopefully have much better outcomes in a much better likelihood of curing prostate cancer. But then also the other related cancer, so for men, this is really important because we haven’t previously been thinking about it in the same way, but that’s one example of how genetics can affect the thinking about the risk of prostate cancer. We know that Black men have a higher risk of prostate cancer to begin with, and we were beginning to understand why that might be.
Some of it may be genetic, some of it may be access to healthcare and knowledge, which we’re trying to help disseminate the knowledge here, and then sometimes it’s care delivery, so we want to focus on all of those things, but genetics are part of that.
An Expert’s Review of Advanced Prostate Cancer Treatment and Research
An Expert’s Review of Advanced Prostate Cancer Treatment and Research from Patient Empowerment Network on Vimeo.
What’s the latest in advanced prostate cancer treatment and research? Expert Dr. Tomasz Beer shares recent updates, and discusses how developing therapies could impact the future of prostate cancer care.
Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.
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Transcript:
Katherine:
When it comes to prostate cancer research and emerging treatment options, what are you excited about specifically?
Dr. Beer:
Well, there is so much to talk about there. And I do want to say that the things that we’re excited about and that are promising, we want to present them in the proper light, meaning that they’re significant potential advances, but they’re not necessarily cures next year.
You know, we want to raise hopes and excitement at a proper level. So, I think right now, what we’re seeing is progress that is likely to yield drugs that will extend survival, will help us control the disease in a meaningful way. We’re not yet at a point where we can, for advanced prostate cancer, have a reasonable hope of cure in the near term. That doesn’t mean we’re not trying. We’re aiming high, absolutely.
But at the moment, the most exciting thing right in front of us, in my view, is lutetium 177-PSMA 617. That is a radioactive molecule attached to a binder that is specific to prostate-specific membrane antigen, PSMA, and essentially delivers this radioactive drug directly to prostate cancer cells by attaching to that target, the PSMA.
We recently completed and reported at ASCO and published in the New England Journal of Medicine the results of a Phase III trial, where we were able to show extension of life, extension of control of cancer, in a meaningful way, with this drug, and we’re eager to see the FDA’s review, and I think generally hopeful that the FDA will allow this drug on the market hopefully in the coming months. So, that’s a real tangible thing that is not just pie in the sky years away. I think it’s likely to be available sometime in less than a year, hopefully much less than a year. Speculating on those things is always a little risky, but –
Katherine:
Of course.
Dr. Beer:
– we all think that’s coming.
I think there are several other targeted drugs that may expand the portfolio of things that we can do in response to a mutational analysis. So, I mentioned microsatellite instability and DNA repair defects. There might be treatments for mutations in a pathway called AKT and others. And so, I think we’re going to see more very specific drugs that address segments of prostate cancer. And then a big area of activity that I’m very excited about is immunotherapy. And immunotherapy has been difficult in prostate cancer.
It has made more headway in melanoma and kidney cancer, and a number of other solid tumors, frankly, and we’re a little bit behind, and I think in part because natural prostate cancer doesn’t elicit quite as much of an immune response as some of the other tumor types; so, it’s not so easy.
But some of the newest technologies for synthetic antibodies are being designed that link the T cells from the immune system directly to prostate cancer cells and activate them, I think hold a lot of promise.
And ultimately, when it comes to cure, the immune system right now looks like the most promising strategy for actually eradicating cancer because once you activate the immune system, it can really do quite a job on cancer. Right now, for prostate cancer, that is still almost entirely in clinical trials and still for a minority of patients. So, this is not an answer for everybody, but once we get a hold of something that’s promising, I think the field’s going to work very hard to expand its utility and make it a reality for more and more patients.
Key Considerations When Making Prostate Cancer Treatment Decisions
Key Considerations When Making Prostate Cancer Treatment Decisions from Patient Empowerment Network on Vimeo.
What considerations are vital when making prostate cancer treatment decisions? Expert Dr. Tomasz Beer shares important factors that impact advanced prostate cancer care.
Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.
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Transcript:
Katherine:
What are the considerations when choosing treatment for advanced prostate cancer?
Dr. Beer:
Well, here, the considerations in advanced prostate cancer are first and foremost, what is the best treatment for this particular individual, right?
That’s what we want to do, and by the best treatment, I mean most effective with the fewest side effects, protecting their quality of life. But that’s an oversimplification. In reality, to arrive at what the best treatment is, we need to really understand quite a bit about the patient’s cancer. Sometimes it’s mutational status, as we discussed earlier, but also, the way it’s presenting, how aggressively it’s growing, is it involving the liver or lungs, or is it only in the bones, is it fast, is it slow.
And then the other thing that is extremely important is the patient’s health, other medical conditions. Some treatments are really more difficult to give when somebody has cardiovascular disease, or diabetes, or nerve damage, or other causes preexisting to the cancer treatment.
So, those kinds of things which we call comorbidities in the medical arena are really important in refining the risk-benefit ratio for each treatment. And finally, and critically, what prior treatments patients have received, that’s a major consideration. We obviously wouldn’t be using the same treatments again in many patients. There are exceptions to that, but for the most part, if a treatment’s failed once, it’s not likely to be of great benefit.
So, we integrate the cancer presentation, perhaps genomics in some situations, patient-specific health conditions, patient’s prior treatments, and then of course, patient’s values and personal priorities and what’s most important to them. And from all of that information, we take a look at the available portfolio and suggest one or two options, which we as physicians, based on our experience, expertise, and the knowledge of the literature, believe that fit most closely and are most likely to be successful.
Using Your Voice to Partner in Your Prostate Cancer Treatment Decisions
Using Your Voice to Partner in Your Prostate Cancer Treatment Decisions from Patient Empowerment Network on Vimeo.
How can prostate cancer patients work to become partners in their care? Expert Dr. Tomasz Beer discusses “shared decision-making” in prostate cancer care and offers his perspective about the patient role in treatment decisions.
Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.
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Transcript:
Katherine:
The term “shared decision” is being used lately when talking about patient care. What does this term mean for you?
Dr. Beer:
Well, you know, at some level in my view, at least in the United States, virtually all medical decisions are shared decisions. We have a culture of advising our patients about their options, perhaps recommending a course of action, if it’s clearly preferable in our judgment to other options, but really involving patients in those decisions and taking serious consideration of the patient’s personal preferences and values.
And oftentimes in cancer care, especially when we’re dealing with noncurative treatments, treatments that are designed to keep the cancer at bay, perhaps shrink it, prevent or reduce cancer-related symptoms, protect quality of life, we really need to understand each individual patient’s willingness to undergo treatments, take on treatment-related risks, and their personal priorities. Is it their goal to live as long as possible and accept more risks? Is it their goal to focus on the quality of life today and avoid risks to the extent possible and only take them on when they’re absolutely necessary?
These are the kinds of discussions that we have with patients every time we consider a treatment change. So, to me, shared decision-making is really what we do with every patient and almost every visit. In some cases, it’s particularly important because there are areas in medicine where there’s really equipoise, and we don’t have a very clear recommendation one way or another.
Prostate cancer screening is an example for that. We all would dearly love to believe that early detection of prostate cancer is helpful, but early detection of prostate cancer comes with its own harms, the risk of overdetection, overdiagnosis, overtreatment, all because we pick up not just the aggressive cancers but also very slow-moving cancers that are not life-threatening. And so, folks undergoing cancer screening really need to know upfront what they’re getting into and make a decision about their view of the balance between the risks and the benefits. That’s a classic example of shared decision-making.
Katherine:
What is the role of the patient in making treatment decisions?
Dr. Beer:
Well, I think that the role of the patient is absolutely critical. I mean, they’re the ones receiving the therapy, and there are many things that we look for from our patients. To me, the most important is a clear understanding of their options and the reality within which we operate, having a set of hopes that are forward-looking, hopeful, and optimistic but also grounded in reality, so that good decisions can be made based on reasonable expectations. No. 2, a clear and honest articulation of the priorities, and that can be difficult.
You know, sometimes it’s hard to balance priorities. We obviously want to live as long as possible with a good quality of life. But what if the choice is better quality of life with a shorter lifespan or a longer lifespan but more side effects? And that’s really hard to sort out for some folks. And in my experience as a physician in the trenches, I can also tell you that sometimes the goals of the patients and the goals of their loving spouses and families are a little different.
And trying to help us – as physicians, our primary responsibility is to address the patient’s goals, but we all know that what we really want for our patients is a consensus of all the people they love that are important to them so that everyone can be supportive and on the same team. Those differences can be really stressful.
So, another thing that I look for in my patients and try to help with is building a family and friend support network that’s aligned, that’s on the same team, really. And then really strong communication with the physician or the provider about how things are going, letting us know about side effects honestly, and many people do that, but some people are afraid to share side effects for fear that their treatment might be taken away. And that honest, straightforward communication is really important for the best decision-making. And then, you know, of course, knowledge about the treatments and understanding of what we’re talking about is helpful, but actually, to me, it’s not the most important thing.
Having read the detailed papers on docetaxel chemotherapy while helpful, is not as important as having a really clear understanding of one’s values and priorities and a candid assessment of one’s quality of life and the ability to share that with a physician. I can cover the technical medical stuff, but what I can’t do is guess what’s important to my patients.
Why Should You Ask Your Doctor About Prostate Cancer Genetic Testing?
Why Should You Ask Your Doctor About Prostate Cancer Genetic Testing? from Patient Empowerment Network on Vimeo.
Why is it genetic testing important when it comes to prostate cancer care? Learn how test results could reveal more about YOUR prostate cancer and may indicate that one treatment may be more effective than another.
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Transcript:
Why should you ask your doctor about genetic testing?
The test results may predict how your prostate cancer will behave and could indicate that one type of treatment may be more effective than another type.
Genetic testing identifies specific gene mutations, proteins, chromosomal abnormalities, and/or other molecular changes that are unique to YOU and YOUR prostate cancer.
There are two main types of genetic tests used in prostate cancer:
- Germline or hereditary genetic testing, which is conducted via blood or saliva and identifies inherited gene mutations in the body. Germline mutations are present from birth and can be shared among family members and passed on to subsequent generations. Results can identify whether you could be at risk for another type of cancer or if your family members may need genetic counseling and testing to guide their own cancer risk.
- The second is somatic or tumor genetic testing, which is performed through testing tumor tissue or by testing cancer cells/DNA extracted from blood to identify gene mutations that are unique to the cancer itself. It is also commonly referred to as genomic testing, biomarker testing, or molecular profiling. Somatic mutations are NOT inherited and are NOT passed on to subsequent generations or shared among family members.
- Depending on your history, your doctor may order one–or both–of these types of tests.
So why do the test results matter?
Both germline and somatic mutation testing can identify the presence of certain genetic mutations that may help to guide your treatment plan, and germline testing specifically can inform cancer risk for you and, potentially, family members.
- In some cases, mutations can indicate that a newer approach, such as targeted therapy or immunotherapy, may work better for you.
- Results of these tests may also help you to find a clinical trial that may be appropriate for your particular cancer.
- And, genetic testing results could also show that your cancer has a mutation or marker that may prevent a certain therapy from being effective, sparing you from getting a treatment that won’t work well for you.
How can make sure you have had essential biomarker testing?
- First, always speak up and ask questions. Remember, you have a voice in YOUR prostate cancer care.
- Ask your doctor if you have had or will receive genetic testing, including germline and somatic testing, and how the results may impact your care and treatment plan.
- Ask whether your family members should meet with a genetic counselor or undergo testing to help gauge their risk of developing prostate cancer.
- And, finally, bring a friend or a loved one to your appointments to help you process and recall information.
To learn more about your prostate cancer and to access tools for self-advocacy, visit powerfulpatients.org/prostatecancer.
Expert Perspective on the Future of Prostate Cancer Treatment and Research
Expert Perspective on the Future of Prostate Cancer Treatment and Research from Patient Empowerment Network on Vimeo.
How has prostate cancer treatment and research changed over time? Expert Dr. Maha Hussain shares her perspective about treatment and research progress, the role of the patient, and how to advocate for more research progress in the future.
Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.
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Transcript:
Katherine:
Dr. Hussain, how do you feel about the future or prostate cancer research, and what would you like patients to know?
Dr. Hussain:
First, let me say that I would love for the patients to know that they are a partner, a most critical partner in the process.
That we need to continue the research and investment in research. It is research that will end up curing cancer. Wishful thinking will not do it. And patient volunteering, which I think is remarkable across all cancers. The business I’m in, the way that drug discovery and evolution often happen because patients volunteered. And without testing these new treatments and combinations, we will not be able to get better results.
And I will tell you that, when I started my training, the median survival for patients with resistant prostate cancer was on the magnitude of about nine months. Now it is three years-plus. Now, you could argue, well, that’s not huge. But that is a huge change because, again, we’re picking up the cancers much earlier. And the patients who had, as I mentioned, metastatic disease, again, the longevity then at the time I was in training, but even afterwards, was give and take in the three years. And now we’re talking six-plus years.
And so, there’s been tremendous progress. And really partnership with the patients and their families and supportive others is very critical, and investment in research. So, yes, advocate constantly for more investment in research.
How Does Genetic Testing Impact Prostate Cancer Care?
How Does Genetic Testing Impact Prostate Cancer Care? from Patient Empowerment Network on Vimeo.
Genetic testing has taken on a vital role in prostate cancer care. Expert Dr. Maha Hussain provides insight about genetics and biomarker testing, how results are used in determining treatment options, and key questions to ask to ensure the best care.
Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.
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Transcript:
Katherine:
Many patients are confused about the role of genetics and biomarker testing in prostate cancer care.
For people who haven’t heard of some of these terms before, let’s go into the definitions. So, what is genomic or biomarker testing, first of all?
Dr. Hussain:
So, I think there’s one thing. Maybe I can explain because the wording can be confusing. So, there is the genetics, and there is the genomics. The genetics would be what we inherit from our families. So, this would be present in our body. The genomics testing would be to look for what the structure of the genes of the cancer itself, cancer cells itself. Now, that doesn’t mean that this was inherited. It’s just that this is a renegade, and it evolved. And that is what is going to show up.
The reason these two are important, both of them have implications potentially for treatment or perhaps clinical trials. And again, with the PARP inhibitors, the BRCA-like genes will have implications for treatment sort of for resistance cancers.
With regard to the genetics, the implications are for, again, inheritance of family and potential risk for blood relatives. Now, there are panels that are FDA-approved for the purpose of genetic testing. And the requirement or the indications right now, anybody who presents with metastatic disease or an aggressive disease and diagnosis, the recommendation is to proceed with the genetic testing, certainly counseling and testing, because there are some people who prefer not to be tested. And that’s something else.
What I tell my patients is this, even if the testing is done and it was negative for inherited genes that might put the patient family at potential higher risk, the fact that a person has prostate cancer by default puts potential, adds risks to family, to blood relatives.
And the risks aren’t just for the males with regard to prostate cancer, but certainly breast cancer, ovarian cancer, pancreatic cancer potentially, and things of that sort. So, this is where I think a patient needs to be discussing with their doctors. And certainly, there are many centers that have genetics counselor, and so that’s where I generally refer my patients to. I counsel them myself, and then refer them also for more discussions with genetics counselor.
Katherine:
What exactly are genetic mutations? And how do they impact a treatment path?
Dr. Hussain:
Well, I think, again, it’s the changes that happens in specific genes that may promote the aggressiveness of a cancer. And so, the BRCA gene is one of the oldest genes that have been identified in breast cancer. And essentially, the body regulates itself.
And when cancer cells come up and they sort of – the body no longer sustains that regulation, the genetic regulation in those cancer cells. Those cancer cells will behave the way they want to. That means that they’re going to grow faster. That means they could be resistant to treatment and things like that. And so, that’s what we check for, these alterations. And there are certain medications that would allow – and again, in prostate cancer, it’s not a lot. It’s just, as I said, right now the only things that are proven is the PARP inhibitors. This is essentially to kind of gang over the cancer cell, preventing from allowing it to repair itself so it can continue to grow.
Katherine:
Some patients may not know if they’ve received these important tests. So, for patients that aren’t all that sure, what key questions should they be asking their physician or their specialist?
Dr. Hussain:
So, I would say when it comes to the genetics testing, I believe a patient has to consent.
Because again, we live in the U.S., and this is a private matter for the patient. So, this generally has to be the case. Otherwise, depending on the institution, sometimes some tests will require for the overall testing for looking for any genetic alterations, general tumor alternation. Different centers have different things. But the patient should ask and say to their doctor, “Have my cancer genes been tested? Have my genes been tested? And if they have, what are the results?” Because we generally share with the patients once it’s been done.
The other things I should point out, some of the good things that have happened recently. Up until recently, when it comes to the tumor genomic testing, tissue was required. Nowadays, the FDA has approved blood tests that several companies now run that can actually collect blood sample and basically test it for circulating tumor cell genes there.
Now, no testing is 100 percent perfect. But in situations like patients with prostate cancer who may not have recent tissue or adequate tissue for testing, certainly doing the blood test to verify if there is anything reflective of the genes of the cancer, and that may allow for potential actionable-type treatments. Again, up until now, this is more going to apply for potential clinical trials or resistant metastatic disease.
Treatment Options for Advanced Prostate Cancer
Treatment Options for Advanced Prostate Cancer from Patient Empowerment Network on Vimeo.
What are treatment options for advanced prostate cancer? Expert Dr. Maha Hussain provides a breakdown of hormone therapy and explains how targeted therapy is used in prostate cancer care.
Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.
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Transcript:
Katherine:
Now that we understand how test results can help inform a patient’s cancer and how it may behave. Let’s discuss how they can affect treatment options for men with advanced disease. First, let’s do a brief review of the treatment types currently available. There’s hormone therapy, right. What else?
Dr. Hussain:
Perhaps, it’s simpler if we focus on advanced disease, specifically metastatic disease.
So, if that’s the deal, then the backbone of treatment is hormone treatment. And it really is. We call it hormone, but technically it’s an anti-hormone. What we’re trying to do is shut down the hormonal pathway that stimulate the testes, which is the factory that makes testosterone. So, we are looking at shutting down testosterone production from the testes in order to starve the cancer.
Now, the male hormone is produced predominantly – somewhere about 95 percent of it is made by the testes, and then there are about 5 percent-ish that comes from other sources. These are, again, male hormones like the adrenal gland and so on. And there was a while ago some research – I want to say from the MD Anderson crowd, but this is two years ago – that suggested also that the tumor may start to make sort of in-house production of male hormone to support itself.
Now, having said that, again, testes continue to be the source of the majority of the male hormone. And so, historically, the first data that showed benefit was actually by surgically removing the testes, which is what we call orchiectomy or bilateral orchiectomy. And then medications began hitting the market and were evaluated in the late ’80s and then 1990s, beginning with Lupron – which by the way, in the ’80s, it was an injection that the patient had to give themselves every day, which is remarkable.
But even then, there is a personal preference by patients to go and take injections as opposed to go through surgery with orchiectomy. But still, I would say for some patients it may be an option until it ought to be discussed as an option. Then what we know is this, is because of the potential other sources for the male hormone, the concept of what we call combined androgen depravation was being evaluated.
And again, this goes back to the ’80s when the first drug was flutamide and then bicalutamide, and there are other drugs that became. And they kind of added a sprinkle, I call it, to survival. But it wasn’t dramatic, huge differences in survival. And so, generally, while we used it, everybody believed in using it. Moving forward, the drugs like abiraterone, enzalutamide, apalutamide are the three hormonal drugs that have demonstrated conclusively really an advantage in terms of prolonging life when added to the Lupron.
So, what I tell my patients is that, when it comes to hormone treatment there is really no way around it. You can delay it. Some people are exploring for some patients who don’t have a lot of cancer, maybe a couple of areas, maybe just do targeted radiation and then leave the person alone to buy them some treatment-free time.
And, to me, this is where the discussion that has to happen with the patient. What is the objective? Is the objective to kind of be ahead of the game and maximally treat the cancer with the hope of prolonging life? Or is the objective to delay treatment? And I would tell you that, with these types of conversation, nine out of 10 or 9.5 out of 10 men opt for moving aggressively up front with management. So, that’s that.
Now, the one thing I should point out, one of the trials that also was a landmark trial in this disease was the study CHAARTED, which was an intergroup clinical trial at the time it was designed, led by ECOG, and the PI was Dr. Chris Sweeney. I was part of the team that worked on the design also of the study.
And that was a trial that looked at adding docetaxel to hormone therapy, versus hormone therapy alone, to try to see if it adds something. Historically, all the chemotherapies prior to that that were added to hormone treatment for patients with newly diagnosed metastatic disease had not delivered. And docetaxel did.
However, one thing I should point out, based on that trial – and I don’t want to go into too much details for the sake of time – the patients that seemed to be benefiting were the patients that had more aggressive, more disease in their system. And so, liver metastases, lung metastases spread in the bone at different areas, not like few isolated areas in the spine or the pelvis, but much more than that.
And so, for the patients who have what we call high-volume prostate cancer based on scans – and I’m happy to explain what that means if it’s needed – these are the patients that I would offer either the docetaxel plus hormone treatment, which is the injection, or the injection plus the hormonal pills that I mentioned earlier.
Katherine:
What about targeted therapy? How is that used?
Dr. Hussain:
Okay. So, let’s begin with the molecularly targeted therapy. So, as we speak right now, for patients who have newly diagnosed metastatic disease that we call hormone-sensitive, molecularly targeted therapy is not standard of care. So, I would encourage patients who may qualify for clinical trial to be involved in those. The flipside is – we can talk about it – is that molecularly targeted therapies, specifically with PARP inhibitors have pretty much entered in the space of prostate cancer with a couple of drugs that were FDA-approved.
The other way of targeted treatment, which would be what we refer to targeted radiation, this would be a different story. This is not systemic treatment. This is a local treatment. And what is done is basically if patients do not have a lot of cancer in their body based on scans, and only certain areas, and they are starting systemic therapy, they can certainly consult with a radiation oncologist to target radiation to areas that are visible on scan. So, if somebody has a couple of, let’s say, pelvic bone lesions, maybe a lymph node, and they are already starting systemic therapy, they can consult with a radiation oncologist focal radiation. And so, that would be the general scheme.
Understanding Prostate Cancer Staging and Progression
Understanding Prostate Cancer Staging and Progression from Patient Empowerment Network on Vimeo.
What are the stages of prostate cancer? Expert Dr. Maha Hussain provides an overview of prostate cancer stages and progression – and explains scans that detect disease to aid in optimal care.
Dr. Maha Hussain is the Deputy Director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Learn more about this expert here.
See More From INSIST! Prostate Cancer
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Expert Perspective on the Future of Prostate Cancer Treatment and Research |
Transcript:
Katherine:
Dr. Hussain, we’re going to spend most of this conversation talking about advanced prostate cancer. But before we move on, would you give us a brief overview of the stages of prostate cancer?
Dr. Hussain:
Absolutely. So, with any cancer, we count sort of like four stages. But I would say in prostate cancer the biggest thing is when the cancer is newly diagnosed, which could be confined to the prostate or locally advanced, meaning the cancer has gotten outside the capsule of the prostate but still within that pelvic region.
There is the group of patients who have pelvic lymph nodes at time of diagnosis. And of course, that is the patients who have systemic disease, which would be technically stage four. Now, the systemic disease implies any abnormality that is found on scans that is beyond the public region. So, that could be lymph nodes in the back of the belly. That could be thoracic lymph nodes. That could be neck nodes. That could be lung lesions, of course, or bone, or liver.
Now, the most common area where the cancer goes to is really – when we talk about metastatic disease – is the bone. And then lymph is another area where the cancer goes to. Prostate cancer that is confined to the prostate is curable in the vast majority of patients. There is a category of men who undergo surgery or radiation, and then their PSA begins to go up afterwards.
And this is what we call biochemical relapse. And this is a situation where we know that, in all likelihood obviously, especially of the patients who have had their prostate out, that the cancer has spread. With the current imagine, a good chunk of times, we do not find anything because we’re able to pick up PSA that goes from undetectable to 0.2 to 0.3, but there’s not enough cancer to show up on the scans. We’re hoping, obviously, the better scans, the PET Axumin scan, the PSMA scans are going to help us to identify sites of metastases.
But this is a group of men where if there is no cancer visible and the only thing we’re dealing with is PSA that’s going up, if they’ve had surgery, then
there’s room for what we call salvage therapy with radiation and hormonal treatment. The case is a bit different if there’s only just the prostate – if radiation was given previously. And of course, we talked about metastatic disease.
Katherine:
Once someone has been diagnosed, what tests are used to help understand the aggressiveness of their disease and their overall prognosis?
Dr. Hussain:
Well, I think there is different basic things, as in, what was the extent of the cancer? How did it look under the microscope? And what is the PSA levels? So, these are the general things. There are different sort of genomic panels that the urologist will use to kind of decipher and other things to kind of help with figuring out aggressiveness and things like that. What I would say is this, is a patient who is diagnosed and has a cancer, and at a minimum has what we consider a Gleason 7 prostate cancer – so, that’s the scoring system that is done with the original Gleason score, or the new patterns where it’s talking about intermediate risk to high risk – to me, this is a cancer that needs to be treated.
And again, that’s all to do with if a person has other comorbidities, they have some other terminal condition that’s a separate story. But talking generically, that would be when we would recommend. And these are the patients that are generally not seen by the medical oncologist. They’re seen by the urologist, and then they can refer them to radiation oncology also for consultation.
