Stephen J. Freedland, MD

Videos

A review of the currently available genomic testing options for patients with clinically localized prostate cancer and the NCCN and AUA/ASTRO recommendations based on risk group.

Available Genomic Tests for Clinically Localized Prostate Cancer

Stephen J. Freedland, MD, details which patient populations he orders genomic testing for, and how the tests can address clinical challenges in prostate cancer treatment.

Addressing Clinical Challenges of Prostate Cancer Management with the Use of Genomic Testing

 One big issue we have in prostate cancer is matching the aggressiveness of the treatments with the aggressiveness of the tumor. There are 2 places we fall down in doing that. One is we overtreat low-risk disease. That’s a major issue. That was 1 of the main reasons the US Preventive Services Task Force said don’t screen with PSA [prostate-specific antigen] to detect cancer because with urologists and other providers—mainly the blame was with us—the minute they see cancer, they’re going to rush you to the operating room and rip out your prostate and create all these quality-of-life decrements: leaking of urine, problems with erections, risks of surgery in and of itself. You’re not going to live a single day longer or better for having all that done. There’s a lot of truth to that.

As a field, as a community, we’ve learned how to do active surveillance, and there are now data. The majority of men with low-risk disease are going on active surveillance protocols. That’s crucial, and we’ve done a yeoman’s job in terms of that. There’s more work to do. In particular, we need to expand our definition of “low risk.” I use quotes because I’m not talking NCCN [National Comprehensive Cancer Network Guidelines], which are clear in defining low risk. I’m using the term in the concept that this person is at low risk of metastases. We can extend that to at least 7 tumors that have a lethal biology—not all. There are plenty within that group that can be safely observed. That’s the next frontier, and genomic tests and other biomarkers hopefully can get us there.

Likewise, we see patients walk in the door with bad disease, and we’re like, “I don’t want to do too much. Let’s do a bit of surgery and see how it goes. We’ll do your radiation and add some hormones, but we’re not going to do it too long.” The data are still accumulating, but STAMPEDE was telling in terms of adding abiraterone to radiation patients. There are studies ongoing that are testing that and related drugs. For those who are high risk, we need to do super-aggressive local therapies but also combine it with appropriate systemic therapies, aggressive systemic therapies, and combination systemic therapies for a period of time. Not lifetime systemic therapy, but systemic therapy for probably a year. We don’t know. [It could be] more than a couple of months but less than a couple of years. I pick a year.

We do aggressive therapy and then stop and see. Did we create that long-term tumor control? If we did, then we stopped therapy to preserve the quality of life. It’s a constant battle between quality of life and quantity of life. That’s the struggle we face in prostate cancer. At the end of the day, by matching the aggressiveness of the disease with the aggressiveness of the tumor, we can maximize quality and quantity of life.

An expert urologist explains the potential for overtreatment of low-risk prostate cancer and undertreatment of high-risk prostate cancer and the potential consequences for patients.

The Potential for Overtreatment or Undertreatment of Prostate Cancer

How do we make decisions in high-risk patients? Surgery vs radiation, external brachytherapy, hormone therapy. For me, it’s the proverbial fork in the road. Do you want surgery or do you want radiation? That drives the decision-making after that. There’s no easy way to make that decision. Certain patients agonize over the decision. Rightfully so; it’s a tough 1. There are no easy answers. Other patients say, “You’re the doctor. You tell me.” We try to explain that the best data we have are from 1 randomized trial from at least 12 years ago, which showed no difference in survival. There weren’t a lot of high-risk patients in that trial, so we don’t know for sure if they’re equivalent, but the best data suggest there are.

There are nuances, quality-of-life differences. What further treatments you can have, I try not to push people 1 way or another. I find it helpful to give them numbers and data. Specifically, I say that the majority of 50-year-olds will choose surgery. The majority of 70-year-olds will choose radiation. In your 60s, it’s split. Age is not the be-all and end-all. It should be physiological age, not chronological age. Putting all of that into the mix becomes challenging in the real world, in the trenches. If you’re talking to patients, and they have diabetes and this and that, give them that framework. I find comfort knowing that the majority of people in my place have chosen X. Therefore, I feel like I should choose X, or it gives me comfort because I was leaning toward X to begin with.

Certain people have the mindset of wanting the tumor out. Get that thing out of my body now. Great, we’ll take you to surgery. Other people don’t want to be cut. I don’t want to undergo anesthesia. I don’t want to risk the issues with incontinence. I don’t want surgery. Great, we’ll do radiation. You try to be abstract, keeping your own biases and emotions out of it, but we’re there to help guide the patients and work together on shared decision-making.

If they choose the path of radiation, we have a phenomenal radiation oncologist at our institution [to help with] the decisions about androgen deprivation therapy [ADT]. Yes or no? Duration of ADT, external beam vs brachytherapy vs combination. That’s all their decision-making. I wouldn’t be happy if they told me how to do the surgery. I’m not going to tell them how to do the radiation. We respect each other in that sense, but we’re often the first person seeing the patients, helping them decide. If the patient is gung ho—“I want surgery, I want this out”—that’s fine. We do the surgery. But if they show any hesitancy, then I need to think about this. I tell them to meet with the radiation oncologist because you’re going to hear a more thorough discussion from them. They’re going to give you a different perspective from what I can, so make sure you meet with them. I’m trying to push people to meet with both sides. One appropriate. I don’t think everyone needs to, but anyone who’s open to radiation should be hearing that from the radiation oncologist themselves.

A focused discussion on the challenges that urologists commonly face during the treatment decision-making process, and which factors typically inform treatment selection for clinically localized prostate cancer.

Stephen J. Freedland, MD

Articles

Available Genomic Tests for Clinically Localized Prostate Cancer

Addressing Clinical Challenges of Prostate Cancer Management with the Use of Genomic Testing

The Potential for Overtreatment or Undertreatment of Prostate Cancer

Clinical Challenges Surrounding Treatment Decision-Making in Clinically Localized Prostate Cancer