Christopher J. Kane, MD, FACS, provides an overview of current best practices in detecting and treating high-risk localized and oligometastatic prostate cancer. In this presentation, he reviews:
The diagnostic value of PSMA PET versus nodal dissection
The overall survival rates of patients treated with ADT plus XRT versus ADT alone
The risks of long-term ADT
Christopher J. Kane, MD, FACS, discusses active surveillance (AS) for intermediate-risk prostate cancer, sharing National Comprehensive Cancer Network (NCCN) Guidelines and defining favorable intermediate-risk disease. Dr. Kane shares the entry criteria for AS and then data from large randomized trials on treated vs. untreated patients that show more patients with intermediate-risk prostate cancer will die on AS as compared with radical prostatectomy, looking at data over a 20-year time horizon.
He then shares similar results from Prostate Intervention Versus Observation Trial (PIVOT) and ProtecT as well as data indicating that 50 percent of intermediate-risk patients on AS will end up with treatment within five years. Dr. Kane emphasizes that while the point of AS is to avoid overtreatment, for many intermediate-risk patients who begin with AS, treatment does occur but it occurs too late and they do not have the optimal outcomes that earlier treatment would allow.
Dr. Kane turns to progression and treatment rates for AS patients and points out that prostate-specific antigen (PSA) density is a key predictor of treatment. He shares his take-home points, including that favorable intermediate-risk prostate cancer patients are candidates for AS with comparable outcomes to low-risk disease on limited studies with short follow up. However, these patients are more likely to undergo treatment, even without reclassification/progression. He advises practitioners to consider other important clinical and pathologic factors such as percent pattern four, presence of cribiform patterns, and PSA density and the number of cores.
In conclusion, he asserts that in younger, favorable intermediate-risk patients, AS is not a sound management strategy in the hopes of avoiding treatment.
This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Active Surveillance for Intermediate-Risk Disease–Pro.”
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Christopher J. Kane, MD, FACS, provides a comprehensive overview of genetic testing in prostate cancer. He emphasizes the importance of distinguishing somatic mutations from germline mutations, and explains the concept of high-penetrance genomic syndromes.
Dr. Kane highlights that genetic testing can be done on various tissues, with cheek swabs and blood tests being the most common methods. He identifies common genetic changes, such as BRCA2, and mentions testing companies like Invitae, Color, and Foundation.
The discussion also covers the significance of single nucleotide polymorphisms (SNP) in non-coding regions of DNA and their role in inherited mutations. Dr. Kane discusses the criteria for testing, including personal or family history suggestive of an inherited syndrome, test validity, and its impact on patient care.
He underscores the relevance of genomic testing for advanced prostate cancer patients, as actionable therapeutics are available for those with DNA repair gene abnormalities. Dr. Kane refers to the Pritchard article, which revealed a higher frequency of genomic syndromes in men with metastatic prostate cancer than previously estimated. Dr. Kane concludes by acknowledging the limitations of family history and the superiority of SNP testing as a predictor of prostate cancer risk.
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Christopher J. Kane, MD, FACS, discusses data regarding the management of the primary in locally advanced and oligometastatic prostate cancer. He reviews a study on the diagnostic accuracy of Gallium Ga 68 PSMA-11 injections used with a PET scan (68Ga-PSMA-11 PET) for pelvic nodal metastasis detection prior to radical prostatectomy (RP) and pelvic lymph node dissection. He explains that 68Ga-PSMA-11 PET is critical in the assessment of men with clinically localized high-risk prostate cancer and that many patients with negative PSMA scans and high-risk clinical features will have positive lymph nodes (N1) discoverable by 68Ga-PSMA-11 PET.
Dr. Kane cites updated National Comprehensive Cancer Network (NCCN) Guidelines that include a recommendation not to omit a node dissection based on PSMA PET results. He reviews findings from both the SPCG-7/SFUO-3 trial and the National Cancer Data Base (NCDB) retrospective review, emphasizing the value of treating the prostate in N1 disease. Data from the VA Informatics and Computing Infrastructure (VINCI) database shows that androgen deprivation therapy (ADT) with radiotherapy was associated with improved prostate cancer-specific mortality (PCSM) among patients with prostate-specific antigen (PSA) levels <26 ng/mL and with improved all-cause mortality (ACM) among those same patients. Dr. Kane points to a similar analysis of VINCI data on patients who had undergone RP that found, compared with non-definitive therapy, RP was associated with significantly better PCSM and ACM. Compared to radiotherapy, RP was not associated with a significant difference in PCSM or ACM. Dr. Kane cites data showing a significant metastasis-free survival advantage among patients with a first postoperative PSA <0.2 ng/mL, a finding that has since been replicated. Finally, Dr. Kane emphasizes the value of treating the primary with T3 in high-risk disease, with T3 and N1 in prostate cancer patients, and with radiotherapy in low metastatic burden M1 disease. He explains the threshold of metastatic burden effect is not well known and there is a clinical trial underway exploring RP and radiotherapy in the M1 population with the current standard of care, and he reiterates that pathological N1 patients benefit from salvage IMRT/ADT.
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Christopher J. Kane, MD, FACS, delivers an insightful presentation on the topic of surgery versus brachytherapy for intermediate and high-risk prostate cancer. He begins by highlighting the importance of accurately defining high-risk disease and its implications for treatment outcomes.
While various definitions exist, Dr. Kane focuses primarily on high-risk disease characterized by a PSA over 20, Gleason sum of eight, and clinical stage T2C. Dr. Kane presents his viewpoint that surgery is the optimal treatment for well-selected patients with high-risk prostate cancer. He supports this assertion by discussing several key advantages of surgery over radiation therapy.
He emphasizes the benefits of improved pathologic staging and risk assessment that surgery offers. Additionally, he notes the effectiveness of adjuvant and early salvage therapy in curing many adverse pathologic patients. Moreover, surgery provides better local control and reduces the likelihood of ureteral obstructions and urinary procedures at progression.
Dr. Kane then presents comparative risk-adjusted mortality data from various studies. These analyses demonstrate that surgery significantly reduces cause-specific mortality compared to all forms of radiation therapy. The magnitude of the differences increases with disease risk, further underscoring the value of surgery for patients with higher risk disease.
This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Surgery vs. Brachytherapy for Intermediate and High-Risk Prostate Cancer–Radiation.
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