Dr. Garraway on the evolving world of early prostate cancer detection and treatment

Although active surveillance isn’t a viable option for all men with prostate cancer, it is the preferred option among many patients and doctors because it preserves the quality and quantity of life. The question becomes whether clinicians can expand the range of men who can receive this type of management.

Isla Garraway, MD, PhD, recently participated in a discussion at the 2021 Society of Urologic Oncology, that focused on several approaches to early detection and treatment of prostate cancer, one being active surveillance. More specifically, the discussion involved whether patients with intermediate-risk prostate cancer should be able to undergo active surveillance. Garraway is an associate professor and director of research in the department of urology, and a member of the Jonsson Comprehensive Cancer Center and Broad Center for Regenerative Medicine at the UCLA School of Medicine in Los Angeles, California.

You served as session chair for, “Prostate Cancer I: Early Prostate Cancer Diagnosis and Treatment,” at the SUO annual meeting. Could you provide a brief overview of this session and discuss some of its highlights?

It was a really great session, and it featured a really diverse array of speakers from multiple specialties, all of whom manage patients with early-stage or localized prostate cancer. So, I think if we were to label a theme about the session this morning, it would be related to management of intermediate-risk prostate cancer; in particular, selecting the best patients who, as we think about expanding those who we can place on active surveillance, we're thinking about, including some intermediate-risk prostate cancer patients. So, it's about selecting those patients, and what we should be considering when we're doing that.

In addition, we also heard a really great talk about radiation treatment for localized prostate cancer, and a really fun debate considering where we should be fitting in [and] if we should be fitting in focal therapy for prostate cancer at this time. Finally, as far as detecting prostate cancer and prostate cancer screening, we talked about polygenic risk scores and how this is a new molecular tool that can predict the absolute lifetime risk of developing prostate cancer.

What are some of the current challenges involved with early prostate cancer diagnosis and treatment?

In terms of diagnosis, we still have the challenge related to [prostate-specific antigen] screening and how we can conduct screening in a way that we're detecting patients with prostate cancer [who] will need to be treated in order to preserve quality or quantity of life, as opposed to [engaging] in practices that will result in overdetection of indolent cancers. So, because that's a challenge, I think we need to really focus on new tools, like the polygenic risk scores. In addition, in terms of treatment, we have the challenge of expand[ing] active surveillance as an option for many of our patients to really preserve the quality of life. Therefore, we need to be aware of selection criteria. So, that was something that we also touched on in terms of figuring out favorable intermediate-risk patients who potentially could benefit from active surveillance, vs those who are more suitable for a definitive treatment right away. It's really important to look at the pathology we learned before considering these patients for active surveillance. Finally, I think the indication for focal therapy is still an open question. We really need more longer-term outcome data, as well as data from randomized, controlled clinical trials, to really understand where focal therapy fits in our scheme of treating patients with localized disease.

What are some recent innovations that have changed the early prostate cancer space?

Again, those polygenic risk scores and using molecular tools to help us perform smarter screening for patients with prostate cancer will help augment PSA screening and other tools to really figure out when we should initiate prostate cancer screening in men and how frequently that screening should occur. There was also really great evidence supporting new hypofractionation approaches, and that's a radiation treatment for localized prostate cancer, and in particular, intermediate-risk prostate cancer. So, hypofractionation is a way of delivering higher levels of radiation in a shorter period of time, and that's really great for patients because it allows them to complete their treatments earlier. Then again, it was also really interesting to hear about focal therapy and those ongoing studies.

Are there any notable trials that physicians should keep an eye on regarding the early detection and treatment of prostate cancer?

In this session, we didn't focus on trials so much. But in a previous session, there were some new trials to investigate in terms of the diagnosis of prostate cancer and the techniques we're using to diagnose prostate cancer. There's been a push to consider using a transperineal biopsy approach when we're detecting prostate cancer, instead of our more standard transrectal approach. The reason for that is to try to reduce infectious complications, as well as the need for broad spectrum antibiotic treatments. When we use so many antibiotics, it potentially increases our chances of developing antibiotic-resistant organisms. So, as a result, the idea has been to move more towards transperineal biopsy approaches that do not require such in-depth antibiotic treatments prior to the diagnostic biopsy. There are a couple of trials opening that are looking at both the cancer detection rates as well as the side effects of incorporating transparent needle biopsies vs transrectal biopsies.