International Prostate Cancer Update Archives

Patient Advocacy for Prostate Conditions: Advocate Perspective

Posted by Wendy L. Poage, MHA | Aug 2021

Wendy L. Poage, MHA, President of the Prostate Conditions Education Council (PCEC), discusses a survey done with primary care physicians (PCPs), explains what PCEC, a non-profit advocacy group, has been doing during the COVID-19 pandemic, and provides action items to urologists to help with advocacy work. Giving the caveat that the survey was just a pilot study with fewer than 100 PCPs, Ms. Poage explains that the data show that even though 90 percent of PSA screenings for prostate cancer are performed by PCPs, only 68 percent of PCPs say it is a valuable test, suggesting that there may be some gaps in who receives screening. Ms. Poage emphasizes PCEC’s commitment to PSA screening, explaining that PCEC teamed up with LabCorp to provide online screening forms and in-person discussions and screenings throughout the COVID-19 pandemic. They also worked with MDxHealth on managing prostate cancer patients during the pandemic. Ms. Poage explains that they worked on a telehealth collaboration tool so prostate cancer patients could still receive treatment. She notes as well that PCEC also focuses on education for veterans, genetic risk groups, people exposed to environmental hazards, people of lower socioeconomic status, marginalized racial groups, and rural populations. Ms. Poage concludes with a call to action, asking urologists to host educational events and reach out to their primary care partners.

Germline Genetics in Prostate Cancer

Posted by Brian T. Helfand, MD, PhD | Aug 2021

Brian T. Helfand, MD, PhD, Chief of the Division of Urology and the Ronald L. Chez Family and Richard Melman Family Endowed Chair at NorthShore University HealthSystem, Director of the Personalized Prostate Program, and Director of Clinical Research in the Program for Personalized Cancer Care, discusses germline genetic testing and its ability to support prostate cancer (PCa) diagnosis and prognosis when used effectively. He begins with the NCCN guidelines for PCa germline testing, detailing its recommended use for patients with: intermediate-risk, high-risk, regional or metastatic disease; intraductal histology; Ashkenazi Jewish ancestry; family history (FH) of high-risk germline mutations; and positive family history of cancer. Dr. Helfand then considers genetic assessments, stressing the importance of FH, rare pathogenic mutations (RPMs), and SNPs in reaching conclusions. He continues with an explanation of genetic risk score (GRS), a number calculated based on the cumulative variation across multiple SNPs which is then used to provide an estimate of disease risk, and shows data supporting the idea that GRS is more informative than FH. He looks at how to complete genetic testing with intention, suggesting screening with the goal of identifying men at risk of PCa and aggressive cancer, as well as identifying men who are likely to respond to specific chemotherapies. Dr. Helfand also reviews data from the UK biobank showing the associations FH, RPMs, and GRS have with PCa incidence and mortality. He also presents data on active surveillance showing that it should be used with caution if patients have any DNA damage repair genes. Dr. Helfand reviews data on DNA damage response and cancer therapy, showing that men with DNA double repair gene mutations are more responsive to PARP inhibitors and platinum-based chemo, while men with mismatch mutations are more responsive to immune checkpoint inhibitors. Dr. Helfand concludes by saying that genetic testing should be included in PCa decision-making more often and used to understand the future of PCa patients.

Can We Trust TRUS Biopsies?

Posted by Francisco G. La Rosa, MD | Aug 2021

Francisco G. La Rosa, MD, Associate Professor in the Department of Pathology at the University of Colorado Anschutz Medical Campus in Denver, evaluates the efficacy of transrectal ultrasonography (TRUS) biopsy and contrasts the technique with transperineal prostate mapping biopsy (TPMB). He describes the development of biopsy techniques, explains how to select a biopsy sample size, and demonstrates why the 360-degree view of the prostate offered by TPMB is advantageous. Dr. La Rosa underscores that sampling should be volume-dependent as the percentage of prostate cancer and high-grade prostatic intraepithelial neoplasia detected using a conventional 8-12 core biopsy declines as the volume of the prostate gland increases. He recommends a scaled approach, beginning with eight biopsy cores for glands up to 15cc and increasing up to 14-20 cores for glands over 50cc. Dr. La Rosa then contrasts TRUS with TPMB, remarking that the latter diagnoses prostate cancer in twice the number of patients and can detect or rule out more aggressive disease. Additionally, two-thirds of men with a previous negative TRUS biopsy were later diagnosed with prostate cancer after undergoing TPMB. Dr. La Rosa concludes that TPMB, which also has lower complication rates, is more reliable than TRUS biopsy.

Prostate Cancer Risk Assessment: Focus on Early PSA and Hereditary Risk

Posted by Gerald L. Andriole, Jr., MD | Aug 2021

Gerald L. Andriole, Jr., MD, Robert K. Royce Distinguished Professor and Chief of Urologic Surgery at Barnes-Jewish Hospital, the Siteman Cancer Center, and Washington University School of Medicine in St. Louis, Missouri, discusses two areas of prostate cancer risk assessment: age-adapted PSA and hereditary risk. Dr. Andriole begins with an early trial which showed that for men who have a PSA of <1 in their first screening, their 15-year chance of developing metastatic prostate cancer or dying is less than 1%. Their risk level drops down to <0.2% if their PSA value remains at <1 in a second screening. If screenings continue to show low PSA levels as the patient ages, one could conclude that a low-risk score should result in no further screening, but Dr. Andriole cautions against this approach. He then discusses the PROBASE study, a prospective study randomizing PSA testing in men starting at age 45 vs. the standard age of 50. The early arm of the study has 23,301 men and the goal is to look at the detection of Gleason grade group 2 or above cancer by the time a man reaches age 50. Dr. Andriole addresses the role of family history, noting that a positive family history increases the probability of developing prostate cancer, but not necessarily mortality. In contrast, a higher genetic risk score (GRS) is associated with a higher mortality rate. He then discusses using a Prompt score, which is more efficient when compared with a PSA screening alone. Dr. Andriole concludes that physicians should assess PSA early in life and may consider adding in 4K score. Ultimately, a combination of a number of factors, including family history, race and ethnicity, genetic risk score, and PSA, will be needed.

Current Status of PSMA Diagnostics

Posted by Jérémie Calais, MD, PhD | Aug 2021

Jeremie Calais, MD, MSc, Assistant Professor and Director of the Clinical Research Program in the Ahmanson Translational Theranostics Division of the Department of Molecular and Medical Pharmacology at UCLA, discusses PSMA diagnostics and compares imaging modalities to establish which modality is ideal for prostate cancer staging. He shares the FDA guidelines, stating that Ga 68 PSMA-11 is to be used for patients with prostate cancer (PCa) with suspected metastasis who are candidates for definitive therapy, and with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level. Dr. Calais summarizes two trials used to support FDA approval of the diagnostic agent, including one on biochemical recurrence localization showing an overall detection rate of 75%, and another on primary nodal N1 staging that shows a sensitivity of 40% and a specificity of 95% for Ga 68 PSMA-11. Dr. Calais also notes the weaknesses of PSMA-11, including PET/CT’s inability to detect microscopic cancer cells, the way bone trauma in the ribs can lead to false positives, the challenge of accurately reading faint uptake lymph nodes, and how urine can disrupt analysis of the prostate fossa. Dr. Calais then compares PSMA against fluciclovine, finding that PSMA has a 30% higher detection rate; and against conventional imaging, finding that PSMA has a 27% higher rate of accuracy, as well as higher sensitivity and specificity. He also compares PSMA and local staging with MRI, highlighting a study on intra-prostatic tumor detection that shows a negligible difference in detection rates, as well as two studies on PSMA PET for biopsy guidance that show PSMA PET’s effectiveness in detecting especially challenging cancer. Dr. Calais concludes that PSMA PET/CT should replace other imaging modalities for prostate cancer staging and should be used as a complement to MRI for intra-prostatic tumor detection and staging.