Management of Advanced Prostate Cancer in Urology: Update on Androgen Receptor Inhibitors - Episode 2

Risk Stratification in Advanced Prostate Cancer

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Ashley E. Ross, MD, PhD, leads the discussion on risk stratification in advanced prostate cancer and approaching prostate cancer screening.

Neal Shore, MD, FACS: Ash, if could you amplify on that, and then I’d love for you to comment on some of the work that you’re doing in risk stratification. Let’s be clear, and we all understand that the goal of the USPSTF [United States Preventive Services Task Force] was recognizing that in the early 2000s we were overbiopsying and overtreating low-grade prostate cancer, or what we now should be calling grade group 1 and grade group 2. And so, in some series, it’s up to 35%, 40%, maybe even more patients who could benefit from active surveillance. The challenge is the grade groups 3, 4, and 5, who as long as they have reasonable actuarial survivals, they need to be treated, certainly with localized disease and with metastatic disease. But Ash, what are you thinking about now? How are you educating the residents and fellows at Northwestern University Feinberg School of Medicine?

Ashley E. Ross, MD, PhD: Thank you. I would echo a lot of what Vivek said. In my practice, both now in Northwestern and when I was in Texas, after the USPSTF guidelines came out, there was a lot of confusion among primary care. Some wanted to abandon the issue, and unfortunately we’re now seeing a surge in higher stage cases. That all said, there are more data for how we almost risk-stratify for men coming into an initial biopsy. So the idea of using the PSA [prostate specific antigen] as it was intended as a highly sensitive, not very specific test, and then with things like the Stockholm3 test MRI data, with the precision data, with biomarkers like 4Kscore, PHI [Prostate Health Index], etc, doing a better job of deciding who we’re going to biopsy or not. This is to A, limit the detection of low-risk, low-grade disease, and B, avoid biopsies where we’re not going to find any cancer because it’s not there. At least among the internal medicine community at Northwestern and our associated hospitals, there’s been a renewed vigor among primary care. They’re both also seeing this trend toward later stage presentation, which they haven’t seen for decades, and then understanding that for us as a urologic community, we are not hungry to find low-grade cancers. These AJCC [American Joint Committee on Cancer] stage I up to IIB, we’re going to watch them, we don’t even want to find most of the very low-risk cancers, if at all.

The hard part is going to be when we look at our system and we look at utilization of this, one is educating urologists and other people out there and internists that it’s safe to go back to screening, we’re not going to take everyone directly to biopsy and we’re not going to treat everyone we find with cancer. And we want to implement these newer tests like MRI, which has the best evidence. How do we bring that to underrepresented populations, how do we reach out to populations that are not as engaged with their primary care? One thing is going to be unifying the message around, we want to screen again with algorithmic screening, and we want to reinforce that. And second is access to care even beyond having an internist, how do we get access to those advanced metrics? That’s going to be a real challenge. But right now, as the patients are presenting more with metastatic disease and we’re seeing that growing population, the good news and one of the focuses of this discussion is going to be we do have evolving and better options for those men, and that’s good.

But the challenges that we’ve framed are that metastatic disease is increasing. It’s really increasing because of lack of screening. We’re going to try to walk that back, but there are going to be a lot of challenges. And the second reason, which they touched on, that metastatic disease is somewhat increasing is maybe we’re going to see some stage migration too. As was mentioned, when we see people now with AJCC stage IIC and above— NCCN [National Comprehensive Cancer Network] unfavorable intermediate-risk or above disease—we now have FDA approval of a couple of PET [positron emission tomography] agents. The PyL PSMA [prostate-specific membrane antigen] agent is the most recently approved. That one is being distributed by…and we’re going to see insurance coverage for it become better and better, particularly in the new year. For me, I would say based on some of the data out there, for all my stage IIC disease and higher, I’m going to be doing PET PSMA. And we might see a stage migration toward lower volume metastatic disease for people who we used to think by conventional imaging were just clinically localized.

Neal Shore, MD, FACS: You brought up a lot of really great points.

Transcript Edited for Clarity