2014 Year in Review: Prostate Cancer

With the emergence of new biomarkers and tests, high-profile approvals of treatments for new indications, and the ongoing controversy surrounding PSA screening, prostate cancer remained very much in the headlines for 2014. Here are some of the most-read Urology Times articles on the disease, along with commentary by UT Editorial Consultant J. Brantley Thrasher, MD, and Editorial Council member Leonard G. Gomella, MD.

How to talk to patients about prostate cancer screening

In this article, John M. Hollingsworth, MD, MS, of the University of Michigan, Ann Arbor, outlines his patient discussion concerning prostate cancer screening, which includes defining what the PSA test is, why to screen or not to screen, the screening controversy, current guidelines, and decision aids.

Dr. Thrasher: This article is excellent. I have a similar conversation with my patients, and the take-homes from this article are several:

• Data from the European Screening trial did show a significant advantage to screening for men between the ages of 55 and 69. Additionally, with more time and maturation, this trial is showing more significance. The data were not as mature and were overlooked to a great degree by the U.S. Preventive Services Task Force.  

• None of the societies/organizations recommend mass screening but rather individualized screening based on age, comorbidities, race, etc.

• I make it clear to patients that each one of these decisions requires a discussion with the patient. The USPSTF was critical of PSA screening because it led to unnecessary treatment and complications. I tell the patients that each of these decision points is like a fork in the road.

I think this article was so popular due to the confusing messages that the patients are hearing, leading to a lot of difficulty for the urologists-they want to know the best way to discuss this with their patients.

The great prostate cancer 'hoax': A call to arms

In this blog post, urologist Henry Rosevear, MD, refutes claims made in the controversial book "The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster," and calls for reaching out to primary care physicians to educate them on the proper use of the PSA.

Dr. ThrasherDr. Thrasher: Dr. Rosevear correctly discusses these controversies and wisely states that they need to be discussed with the patient and primary care physicians. I find that many of our PCPs are hungry for our take on the PSA controversy and want to hear the data. I discuss the trials with them. I discuss the algorithm with them and go over how I counsel the patients. 

When I first started seeing urology patients prior to PSA, I remember distinctly that approximately one-third of the men who presented to us with back pain, urinary voiding issues, and even hematuria had advanced prostate cancerwhen we worked them up. I do believe, as Dr. Rosevear does, that this is the direction we would be heading back to if we just stop using PSA. I think the best thing that we can do is discuss this with our family practice and internal medicine colleagues and, just as important, have these discussions with the patients.
 

Next: New PCa tests mark era of personalized medicine

New prostate cancer tests mark era of personalized medicine

This feature, part of UT's ongoing "New Frontiers in Prostate Cancer" series, offers an overview of new prostate cancer biomarkers, with insight from key opinion leaders.

Dr. GomellaDr. Gomella: The controversies surrounding prostate cancer screening, diagnosis and treatment have made these new genomic tests of particular interest to urologists. As of November 2014, ConfirmMDx is the first genomic prostate cancer test to qualify for Centers for Medicare & Medicaid Services coverage, with other manufactures in the approval queue. Urologists beware: To qualify for coverage, the provider must register with the company’s CMS-approved Certification and Training Registry. The goal of the registry and the ongoing PASCUAL clinical utility trial is to determine whether the repeat prostate biopsy rate can be impacted by this particular genomic test.

MRI guiding future of prostate cancer diagnosis

Also from "New Frontiers in Prostate Cancer," this feature takes a look at magnetic resonance imaging-ultrasound fusion, which one thought leader says represents the gold standard for prostate biopsies today.

Dr. Gomella: The holy grail of transrectal ultrasound prostate biopsy (TRUS) used to be the hypoechoic lesion. With increasing use of TRUS biopsy through the 1990s, we learned that most prostate cancers were isoechoic and not visualized, making random systematic biopsy the standard of care. MRI-ultrasound fusion biopsy has brought back the hope that prostate cancers can be identified improving diagnostic accuracy.

Upfront chemo plus ADT dramatically improves survival

A 2014 study that showed a survival benefit of more than 1 year with a chemotherapy-hormonal therapy combination given prior to castration resistance was "very significant," according to Dr. Thrasher.

Dr. Thrasher: To me this makes a lot of sense. Many of the solid organ tumors that we treat respond well to hitting them early with chemotherapy instead of late when the tumors have changed dramatically after hormonal therapy. More follow-up is required to find out where those patients with smaller tumor burdens end up, but it certainly appears that all of these patients benefited from ADT plus docetaxel versus ADT alone.

This could very well be a new standard but will likely require validation from further studies.

Approval of enzalutamide pre-chemo a ‘game changer’

A big headline from fall 2014 was the FDA’s approval of enzalutamide (XTANDI) to treat metastatic castration-resistant prostate cancer in the pre-chemotherapy setting.

Dr. Thrasher: I don't think the landscape will differ much for the medical oncologists. They have been using the drug for some time now off-label. The urologists, however, might have a game changer in this drug. The mechanism of delivery and the fact that enzalutamide is very ‘Casodex-like’ would leave me to believe that the urologists will adopt this drug rather quickly.

It is a great drug and our experience has been that it is very well tolerated. I think urologists should embrace the drug, its use, and learn as much about it as they can.

Next: How 'low risk' is low-risk prostate cancer?

How ‘low risk’ is low-risk prostate cancer?

In this installment of "New Frontiers in Prostate Cancer," proponents of active surveillance for men with low-risk prostate cancer make their case for expansion of this management strategy.

Prostate Ca surveillance: Overcoming obstacles

In this column, urologist Robert A. Dowling, MD, identifies practical and logistical hurdles to implementing an active surveillance protocol and offers steps to take to overcome them.

How to manage post-prostatectomy incontinence

In this article, Teresa Danforth, MD, and David A. Ginsberg, MD, briefly review the evaluation of patients with PPI and discuss the benefits and drawbacks of conservative, pharmacologic, injection, and surgical treatments.

Protocol may eliminate need for opioids after RALP

More than 85% of patients undergoing robot-assisted laparoscopic prostatectomy may not require opioid analgesia either immediately post-op, in hospital, or upon release, according to a recent study.

Focal therapy: Magic bullet or unproven treatment?

This installment of "New Frontiers in Prostate Cancer" presents the arguments by proponents and opponents of this minimally invasive approach to low-risk prostate cancer.

Large study supports pre-prostate biopsy rectal cultures

Rectal colonization with a fluoroquinolone-resistant organism identifies men who are at significantly increased risk for an infectious complication following prostate biopsy, according to the findings of a recent multi-institutional international collaborative study.

Subscribe to Urology Times to get monthly news from the leading news source for urologists.