Management of Advanced Prostate Cancer in Urology: Update on Androgen Receptor Inhibitors - Episode 1

Incidence of Advanced Prostate Cancer

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Bobby Liaw, MD; Neal Shore, MD, FACS; and Vivek K. Narayan, MD, MS, discuss the incidence and prevalence of advanced prostate cancer, including mCSPC and nmCRPC.

Neal Shore, MD, FACS: Hi everyone, and welcome to this Viewpoints video series entitled, “Management of Advanced Prostate Cancer in Urology: An Update on Androgen Receptor Inhibitors.” Gosh, there’s been an enormous amount that’s happened in the last few years. I’m Neal Shore, I’m the medical director of the Carolina Urologic Research Center and the chief medical officer for urology and surgical oncology for GenesisCare US [United States]. I’m based in Myrtle Beach, South Carolina. We have a great faculty today, and what a privilege to have with us Dr Bobby Liaw, he is an assistant professor of medicine, hematology, and medical oncology at the Icahn School of Medicine at Mount Sinai Hospital in New York City. We also have Dr Vivek Narayan, an assistant professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia; and Dr Ashley Ross, he is associate professor of urology at Northwestern University Feinberg School of Medicine in Chicago.

We have a great faculty, a lot of research experience, a tremendous amount of educational and clinical experience. We’re going to weigh in today on all the different facets of where androgen receptor pathway inhibitors are taking us for our patients with advanced prostate cancer. Specifically, we want to discuss the urologist’s role in caring for patients with both metastatic castration-sensitive prostate cancer [mCSPC] as well as nonmetastatic castration-resistant prostate cancer [nmCRPC]. We’ll talk about markers, we’ll talk about diagnosis management of these ARs [androgen receptor inhibitors]. We’ll talk about imaging as well. And we’ll touch on the role for genomic profiling. We’re going to review our recent real-world evidence, the guidelines, some recent historic, in the last few years but also contemporaneous, clinical trials data, and what does it mean for you, what are some of the pearls and how do we see this? At the end of the day, the most important thing is how can it benefit patients when you’re sitting in your clinic, and you’re with your patient and/or their caregivers, how do you talk about strategies and education?

With that, let’s get started. We have several segments; we’re looking forward to an interactive discussion. Let’s start off with you, Bobby, briefly review what does it mean to you when we talk about advanced-stage prostate cancer. What’s happened merely in the last 10 years in terms of the number of patients you see who have both mCSPC and nmCRPC?

Bobby Liaw, MD: First of all, I’m very happy to be taking part in this panel. Thank you so much for inviting me. Prostate cancer is a very common diagnosis, the second most common malignancy in the United States, and unfortunately, is the second leading cause of cancer mortality among men in the United States. When we look at statistics, in the year 2021 we’re talking close to 250,000 new cases of prostate cancer, it represents about 13% of all new cancer diagnosis, and it translates to about 1 in 8 men being diagnosed with this disease in their lifetime. As it comes to prostate cancer incidence rates, we all know that in the late 1980s, early ’90s, with the introduction of PSA [prostate specific antigen] screening and increased utilization, there was this initial dramatic surge. But after that initial peak, incidence rates fell. But compared with the pre-PSA testing era, I’d say we’re looking at something like roughly twice what was recorded in the pre-PSA era, and this is due to the fact that we’re picking up more cases of probably more low-grade prostate cancers that would have otherwise been clinically silent.

Now, changes in PSA screening guidelines have certainly affected and caused some declines in the incidence in more recent years. The USPSTF [United States Preventive Services Task Force] famously came out with recommendations back in 2012 against PSA screening in the general male population. That position has since changed, it’s more a shared decision-making model now between men and primary care doctors, with incidence levels again starting to stabilize if not slightly increasing over the last few years. Something worth considering is how the pandemic is affecting things. Access to health care and preventive medicines has certainly been affected with the COVID-19 pandemic. I don’t know that I have all the numbers to back me up on this yet, but with lesser access to primary care, I’m sure we’re going to see trends of less prostate cancer diagnosis being made in this time. But the concern here is that we’re going to start to see more delayed diagnosis and a trend toward finding newly diagnosed disease at more advanced stages.

In terms of specifically thinking about metastatic castration-sensitive prostate cancer, nonmetastatic CRPC, we have perhaps more limited data to tell us exactly what the prevalence looks like. I’d say the incidence of newly diagnosed de novo metastatic disease varies widely across the globe. In Western countries, here in the United States, the figure usually runs somewhere in the 5% to 7% range. Incidence for nonmetastatic CRPC, is even less accurately established, but if you think about it this way, it’s a relatively small proportion of the total prostate cancer population. Depending on where you look, I’ve seen it reported anywhere from as low as 2% to as high as 8%. Another way that I look at it is approximately 10% to 20% of prostate cancer cases will be castrate-resistant, and roughly 10% to 15% of those cases will be in this nonmetastatic CRPC category. But again, it would be nice to have much more clear data on this, and as our imaging modalities change, it’ll also change how we characterize nonmetastatic versus metastatic.

Neal Shore, MD, FACS: You’ve raised some great points. The global epidemiology is fascinating. If you go into parts of East Asia, the Middle East, Africa, parts of Latin America, the incidence of metastatic prostate cancer at initial presentation for initial diagnosis is upward of 50% of the patient populations. I’m curious, Vivek, you might like to first comment and then have Ash. And of course, Bobby, you’re all in metropolitan urban environments. Are you seeing any demographic differences in the amount of mCSPC in the last few years given the changes in the USPSTF and even the American Academy of Family Physicians not routinely getting PSA? Are you seeing a difference in your patient populations by race and by socioeconomic strata as to how they’re presenting to your clinics? You go first, please, Vivek.

Vivek K. Narayan, MD, MS: It’s an important question, both in terms of changes in the rates of PSA screening but then as Bobby also indicated with the recent COVID-19 pandemic, how that may shift or at least result in potential delays and diagnosis of cancer like prostate cancer. Here in West Philadelphia, I don’t know that I have hard data at this point, but at least anecdotally in my clinical practice, I do get the sense that there has been an increase in late-stage presentations of prostate cancer showing up in the clinic. These are generally the men with de novo metastatic castration-sensitive disease. I do think that again, in an urban population here in West Philadelphia, we unfortunately do see a large proportion of our patients who do not have routine access to preventive health care and may not have had the discussion about PSA screening with their primary care providers or their urologist. There is a shift among those patients where we are seeing these later-stage presentations, unfortunately.

Neal Shore, MD, FACS: That’s a great point.

Transcript Edited for Clarity