What have been the biggest changes in the way you treat prostate cancer over the past few years?

Urology Times Journal, Vol 49 No 09, Volume 49, Issue 09

“New and different drugs indicated at different points in the treatment cycle have been the biggest change," says 1 urologist.

Urology Times® reached out to 3 urologists (selected randomly) and asked them each the following question: What have been the biggest changes in the way you treat prostate cancer over the past few years?

“It’s probably the number of people we’ve put on observation, maybe 25% more than in the past.

With some low-grade tumors, sophisticated tests, like Prolaris, can identify specific markers in specific tumors to determine, based on molecular markers, if patients are acceptable candidates for observation.

It seems to be working. Some patients on observation have fallen out and needed treatment because something changed, their [prostate-specific antigen] or re-biopsies. Multiparametric MRIs have changed the way we manage these men.

My partner has found several people on observation, that due to multiparametric MRI, followed by fusion biopsy, we’re found had more aggressive tumors. We considered them reasonable candidates for observation at the time, but things changed. They have more aggressive disease, more lesions.

A lot of 77 to 79-year-old men have numerous high-grade tumors. Otherwise, they’re healthy and happy, so what do you offer them? Operating isn’t the first choice.

Radiation is an option; even kinder is cryoablation. It’s actually well-tolerated and highly underused. It can control the disease. These guys are alive well into their 80s, when they might not have been.

Alternately, we’re also finding low-grade tumors we’re comfortable watching. Confirmatory tests, like Prolaris, can indicate a guy is safe to observe, with good data behind them.

That’s been a big change. Multiparametric MRIs and fusion biopsies have become standard. We used to repeat biopsies every 1 ½ to 2 years to monitor people on observation. I’ll tell you, talking a guy into a second or third biopsy, the guy says, ‘Forget it. I’m good.’ With MRI, we can actually see lesions—if there are none, we leave it alone. If they’re high risk, we do accurate, targeted biopsies, which patients appreciate. That’s changed things a lot.”

Clifford Johnson, MD

Hendersonville, North Carolina

“New and different drugs indicated at different points in the treatment cycle have been the biggest change. Enzalutamide [Xtandi], for example, was approved—initially for a very specific indication, but indications keep broadening, so we keep being able to use those drugs earlier in the advanced prostate cancer process. So I think medicines are the biggest things that are different.

Another thing that’s changed in my practice is the Axumin PET scan and being able to localize the recurrence much more accurately. It’s much more sensitive in identifying the recurrence in the bone scan than the traditional CT.

That made a huge leap in the past 10 years. It’s the fastest change in that part of what we do. I don’t think there’s any more research, any more exciting things going on than in prostate cancer, or in urology overall right now.

It’s made a definite difference in the results we’re getting. It’s well-established in these drug studies that people are living much longer with the progression of their cancer and they’re living with fewer symptoms from the cancer, so it’s improving quality of life and survival.

The foundation of care is still the hormone shots we’ve been doing for decades, and side effects are the same. These medications are added on top of injections, so a lot of time you have similar side effects, but patients are getting better control of their tumor burden, feel better overall, and they’re healthier.”

Robbie Hurtt, MD

Conway, Arkansas

“In terms of localized disease, it’s not that we have different treatment options, but that we do those things differently. For example, we still do surgery, but now we do it robotically. We do brachytherapy; we’ve just changed how we do it.

With active surveillance, patients now are aware of why we’re doing it. They understand the rationale, so they are on board. They don’t feel that urge to cut out any sign of cancer immediately because they know we can keep track of the cancer’s progression without endangering them. We don’t have to convince them, like we used to, that watchful waiting is a viable alternative. That makes it a lot easier to put men on active surveillance.

As for advanced disease, medical oncologists now handle a lot of that, but we are still involved too.

We’re not starting androgen deprivation as early. We don’t necessarily start androgen deprivation until symptoms start to occur, unless there is a major event or huge spike in PSA. When we do treat, we aren’t starting hormones like LHRH agonist and receptor antagonists until later. That’s something patients obviously prefer.

It has definitely made a difference in the patients’ quality of life. Patients can go on surveillance for years before we start androgen suppression.”

Stephen Strup, MD

Louisville, Kentucky