Overview of the Classification and Management of Prostate Cancer


Expert urologist Michael S. Leapman, MD, MHS, provides comprehensive insight to the classification of prostate cancer and current treatment modalities available to patients.

Michael S. Leapman, MD, MHS:
Most patients with prostate cancer present to me because they’ve been screened with a PSA [prostate-specific antigen] blood test, and they are referred because their PSA is elevated. We’ll typically do a further work-up, usually involving an MRI of the prostate and a prostate biopsy. Most patients who I diagnosed are generally diagnosed with localized prostate cancer, a cancer that’s confined to their prostate gland without any evidence of distant spread.

It’s very important to classify risk based on multiple parameters. For my patients and for all patients, these include a patient’s age, their PSA level, clinical stage, MRI appearance, and Gleason score of the cancer. We also look at the number of prostate cores involved with cancer, and the percentage of cancer in those biopsy cores as well.

We assign patients with localized cancer to NCCN [National Comprehensive Cancer Network] risk classification groups: very low risk, low risk, intermediate, favorable intermediate, unfavorable intermediate, high, and very high, based on combinations of those parameters.

What’s striking about prostate cancer is it’s such a varied and heterogeneous disease, and so the treatment options depend on a patient’s risk stratification, a patient’s age, preference, and other comorbidities. We really are trying to balance multiple considerations when coming up with a treatment or management plan for a patient. To begin with, for patients with very low or low-risk prostate cancer, in general observation with active surveillance, or watchful waiting, is the preferred initial approach. Through this approach, we carefully monitor the disease for changes in aggressiveness that might indicate a need for treatment. For our patients undergoing active surveillance, they will generally be followed with regular PSA monitoring, periodic biopsies, and prostate MRIs to restage their prostate. For patients with intermediate or high-risk prostate cancer, we consider definitive treatment options including radical prostatectomy, radiation therapy, as well as focal or ablative treatments.

For radical prostatectomy, I perform all my surgeries robotically, as do most people in the United States. These are done through a minimally invasive approach in which ports are placed in the abdomen, and the prostate is surgically removed, separated from the bladder, from the urethra, and a new connection is made between the bladder and the urethra after the prostate has been removed. In addition, for many patients, we perform a pelvic lymph node dissection at the time, removing the regional lymph nodes that may be involved with cancer. For patients receiving radiation therapy, that can be delivered with or without androgen deprivation therapy [ADT], which is a form of testosterone-lowering medication.

External beam radiation can be delivered through multiple approaches and various numbers of treatment courses or fractions of treatment. For high-risk patients and unfavorable intermediate-risk patients, this is usually combined with a course of androgen deprivation therapy or testosterone-lowering medications. For high-risk patients, they are typically receiving a minimum of 18 months of androgen deprivation therapy in conjunction with their external beam radiation, whereas for unfavorable intermediate-risk prostate cancer patients, somewhere between 4 to 6 months of ADT is given.

An additional option is ablation treatment. This is a treatment in which energy is used to destroy either the entire prostate or a portion of the prostate where we believe the cancer to be located. These include irreversible electroporation, focal cryotherapy, high-intensity focused ultrasound, as well as transurethral ultrasound ablation.

After definitive treatment, we follow our patients very closely with PSA monitoring. The earliest sign of recurrence is usually picked up through an elevation in PSA levels. When their PSA levels after surgery, for example, cross a threshold suggesting there may be recurrence of disease, we typically begin by doing additional investigation and imaging to help localize or identify where that disease may be coming from. In the contemporary era, we have wonderful tools to help us achieve this, most notably PSMA [prostate-specific membrane antigen] PET [positron emission tomography] imaging, which is very good at identifying recurrence for patients who have biochemical recurrence. And in patients who are found to have metastatic disease, the escalation of treatment would typically involve systemic agents including androgen deprivation therapy, as well as novel antiandrogen treatments.

Transcript edited for clarity.

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