Immunotherapy: Checkpoint Inhibitors For Prostate Cancer
An immune checkpoint inhibitor is a type of drug that blocks proteins on the immune cells, making the immune system more effective at killing cancer cells.
A checkpoint inhibitor called pembrolizumab has been approved for the treatment of tumors, including prostate cancers, that have specific genetic features. Pembrolizumab has also been approved for any tumor that has metastasized and has a high number of genetic mutations.
But relatively few prostate cancers have these features, and prostate cancer in general has largely been resistant to treatment with checkpoint inhibitors and other immunotherapies, such as CAR T-cell therapy.
Research is ongoing to find ways to help the immune system recognize prostate tumors and help immune cells penetrate prostate tumor tissue. Studies are looking at whether combinations of immunotherapy drugs, or immunotherapy drugs given with other types of treatment, may be more effective in treating prostate cancer than single immunotherapies alone.
Types Of Treatment For Prostate Cancer
First, lets recap prostate cancer treatment basics, which will depend on a range of factors, including cancer stage and symptoms. Early-stage cancers may be treated with active surveillance, meaning your doctor will closely monitor it to see if it starts to progress before actively treating it. Once treatment begins, it may include a combination of surgery, radiation, and hormone therapy. Advanced prostate cancers may be treated with a combination of hormone therapy, targeted therapy, chemotherapy, immunotherapy, and other drugs. So, whats new in the treatment field?
What Else Should You Consider
Remember, you have options, and itâs important to choose the one that works best for you. When choosing a treatment, think about:
- The risks. Talk to your doctor about the pros and cons of each type of therapy.
- The side effects. Consider whether or not youâre willing to deal with how the treatment might make you feel.
- Whether or not you need it. Not all men with prostate cancer need to be treated right away.
- Your age and overall health. For older men or those with other serious health conditions, treatment may be less appealing than watchful waiting.
Show Sources
American Cancer Society: âCan Prostate Cancer be Found Early?â âConsidering Prostate Cancer Treatment Options,â âHormone Therapy for Prostate Cancer,â âHow is Prostate Cancer Treated,â âProstate Cancer,â âWhat is Prostate Cancer?â âCryotherapy for Prostate Cancer,â âRadiation Therapy for Prostate Cancer,â âSurgery for Prostate Cancer,â âVaccine Treatment for Prostate Cancer.â
National Cancer Institute: âProstate Cancer Treatment.â
Prostate Cancer Foundation: âOther Treatment Options,â âProstatectomy ,â âRadiation Therapy,â âSide Effects,â âTreatment Options.â
UpToDate: âBone metastases in advanced prostate cancer: Management.â
Cancer.Net: âProstate Cancer: Types of Treatment.â
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Please Describe The Work Being Done By The Prostate Cancer Theranostics And Imaging Center Of Excellence
PROSTIC is the Prostate Cancer Theranostics and Imaging Center of Excellence, and we seek to do state-of-the-art research to deliver new paradigms for treatment of prostate cancer by seamlessly integrating clinical trials, preclinical, and discovery research. We have a multidisciplinary team, including nuclear medicine, medical oncology, radiation, oncology, urology, and laboratory-based doctors and researchers in our hospital and we have a strong patient-centered philosophy.
PROSTIC has 3 main aims that we’re really working on every day. first aim is to accelerate clinical trials. When we started this program, we had around 5 clinical trials open and we’re hoping by the end of next year to have 10 clinical trials open. These are using PSMA imaging or PSMA-targeted therapy theranostics to treat men with prostate cancer. And with these investigator-initiated trials, we’re trying to find areas of high-impact need that are not being addressed by other global trials being done to date.
Expert Review And References
- American Cancer Society. Treating Prostate Cancer. 2019: .
- American Society of Clinical Oncology. Prostate Cancer. 2020: .
- Tracy, CR. Prostate Cancer. eMedicine/Medscape 2020: .
- PDQ® Adult Treatment Editorial Board. Prostate Cancer Treatment Patient Version. Bethesda, MD: National Cancer Institute 2020: .
- PDQ® Adult Treatment Editorial Board. Prostate Cancer Treatment Health Professional Version. Bethesda, MD: National Cancer Institute 2020: .
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer . 2020: .
- Zelefsky MJ, Morris MJ, Eastham JA. Cancer of the prostate. DeVita VT Jr., Lawrence TS, Rosenberg SA, eds.. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Philadelphia, PA: Wolters Kluwer 2019: 70: 1087-1136.
- Parker C, Castro E, Fizazi K et al . Prostate cancer: ESMO clinical practice guidelines for diagnosis, treatmentand follow-up. Annals of Oncology. 2020: 31: 1119-1134. .
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Help Getting Through Cancer Treatment
People with cancer need support and information, no matter what stage of illness they may be in. Knowing all of your options and finding the resources you need will help you make informed decisions about your care.
Whether you are thinking about treatment, getting treatment, or not being treated at all, you can still get supportive care to help with pain or other symptoms. Communicating with your cancer care team is important so you understand your diagnosis, what treatment is recommended, and ways to maintain or improve your quality of life.
Different types of programs and support services may be helpful, and can be an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help.
The American Cancer Society also has programs and services including rides to treatment, lodging, and more to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists.
Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
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Chemotherapy For Prostate Cancer
Patients who no longer respond to hormone therapy have another option.
The chemotherapy drug docetaxel taken with or without prednisone is the standard chemotherapy regimen for patients who no longer respond to hormone therapy. Docetaxel works by preventing cancer cells from dividing and growing. Patients receive docetaxel, along with prednisone, through an injection. Side effects of docetaxel are similar to most chemotherapy drugs and include nausea, hair loss, and bone marrow suppression . Patients may also experience neuropathy and fluid retention.
Docetaxell, when used with or without prednisone, was the first chemotherapy drug proven to help patients live longer with advanced prostate cancer. The average survival was improved by about 2.5 months when compared to mitoxantrone with or without prednisone. Docetaxel has the best results when given every three weeks as compared to weekly dosing.
Cabazitaxel is another chemotherapy drug, used in combination with the steroid prednisone, to treat men with prostate cancer. Cabazitaxel is used in men with advanced prostate cancer that has progressed during, or after, treatment with docetaxelâââââââ .
Side effects in those treated with cabazitaxel included significant decrease in infection-fighting white blood cells , anemia, low level of platelets in the blood , diarrhea, fatigue, nausea, vomiting, constipation, weakness, and renal failure.
How Prostate Cancer Is Treated
In cancer care, different types of doctorsincluding medical oncologists, surgeons, and radiation oncologistsoften work together to create an overall treatment plan that may combine different types of treatments to treat the cancer. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as palliative care experts, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, and others.
The common types of treatments used for prostate cancer are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patients preferences and overall health.
Cancer treatment can affect older adults in different ways. More information on the specific effects of surgery, chemotherapy, and radiation therapy on older patients can be found another section of this website.
Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer:
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How Psma Lights Up Cancer Cells
In 2021, the U.S. Food and Drug Administration issued national approval to two new prostate cancer imaging tests based on similar technology. On a PET scan, the test lights up the cancerous cells that would otherwise be hidden, enabling doctors to precisely target treatment.
Both advances in imaging and therapy rely on targeting PSMA, which is not found on most normal cells but is overexpressed in cancer cells, especially those that have spread. The PSMA molecule was cloned at MSK in the early 1990s.
The Molecular Imaging and Therapy Service, led by Heiko Schöder, played a key role in the development and testing of a slightly different PSMA-directed imaging technology at MSK.
This advance is the result of years of work by the community of physicians promoting the use of PSMA agents, Dr. Schöder says. Its gratifying to see a collaborative effort result in a breakthrough that has the potential to make a difference for so many patients with advanced prostate cancer.
Before receiving the therapy, patients in the VISION trial were scanned with PSMA-directed PET imaging to make sure enough PSMA was present in the cells to make them likely to respond to the treatment. If so, they received the radioactive drug by injection over four to six sessions, spaced six weeks apart.
As a next step, Dr. Morris and colleagues are looking into using the PSMA-directed therapy earlier rather than only after the prostate cancer has spread.
Michael Morris
Active Surveillance And Watchful Waiting
If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.
Active surveillance. Prostate cancer treatments may seriously affect a person’s quality of life. These treatments can cause side effects, such as erectile dysfunction, which is when someone is unable to get and maintain an erection, and incontinence, which is when a person cannot control their urine flow or bowel function. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many people may consider delaying cancer treatment rather than starting treatment right away. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.
ASCO encourages the following testing schedule for active surveillance:
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A PSA test every 3 to 6 months
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A DRE at least once every year
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Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
Treatment should begin if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, if the cancer causes pain, or if the cancer blocks the urinary tract.
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A New Type Of Pet Scan
One breakthrough is the approval of a new technology to detect advanced prostate cancers: prostate-specific membrane antigen PET scanning. It works by using radioactive tracers that attach to a protein called PSMA often found on prostate cancer cells, per the American Cancer Society. PSMA PET scanning has the potential to significantly change how we treat men with high-risk, clinically localized prostate cancer as well as recurrent prostate cancer, says Sam Haywood, M.D., urologist at the Glickman Urological and Kidney Institute at Cleveland Clinic in Ohio. By more sensitively detecting prostate cancer metastasis, this allows for the appropriate staging and treatment.
Are There Side Effects
The treatments for prostate cancer also can affect your body in other ways. Side effects can include:
- Loss of your ability to get a woman pregnant
- Leaky bladder or loss of bladder control. You might also need to pee a lot more often.
Side effects are another thing to think about when youâre choosing a treatment. If theyâre too tough to handle, you might want to change your approach. Talk to your doctor about what you can expect. They can also help you find ways to manage your side effects.
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Reproducibility Of Brachytherapy Results
The results achieved in the US appear exportable to the UK. In Guildford, UK, we have treated over 800 patients and prospectively assessed outcomes of both PSA-free survival using the ASTRO criteria as well as continence, potency and quality of life parameters using validated questionnaires.
The results of our first 300 patients treated with median follow-up of 45 months show an overall actuarial PSA-free survival of 93% at 5 years.8
Stratified by risk group, the actuarial survivals were 96%, 89% and 93% for low-, intermediate- and high-risk disease, respectively. There was no statistical difference in survival between hormone naive patients and those treated with 3 months neo-adjuvant therapy, .
Research Into Treatment For Prostate Cancer
Before new treatments can be introduced, they need to be tested thoroughly. This is so we can be sure that they work and that they are safe.
Go to Cancer Research UKs clinical trials database if you are looking for a trial for prostate cancer in the UK. You need to talk to your specialist if there are any trials that you might be able to take part in.
Some of the trials on this page have now stopped recruiting people. It takes time before the results are available. This is because the trial team follow the patients for a period of time and collect and analyse the results. We have included this ongoing research to give examples of the type of research being carried out on prostate cancer.
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Combination Radiation And Endocrine Therapy
Sometimes, patients receive hormone therapy in combination with external beam radiation therapy for the treatment of prostate cancer. This treatment uses a high-energy X-ray machine to direct radiation to the prostate tumor. For patients with intermediate or high risk prostate cancer, studies show this combination is more effective at slowing the disease than endocrine therapy or radiation therapy alone.
Radiation can also come in the form of a monthly intravenous drug called Xofigo. Xofigo is approved for use in men who have advanced prostate cancer that has spread only to the bones. Candidates should have also received therapy designed to lower testosterone. The drug works by binding to minerals within bones to deliver radiation directly to bone tumors. A study of 809 men showed that those taking Xofigo lived an average of 3 months longer than those taking a placebo.
Two other similar drugs are samarium-153 and strontium-89 .
Emerging Therapies For Prostate Cancer
Researchers are pursuing several new ways to treat advanced prostate cancer. Vaccines that alter the body’s immune system and use genetically modified viruses show the most promise. One vaccine technique works by manipulating blood cells from the patient’s immune system and causing them to attack the prostate cancer.
Blood is drawn from the patient. From the blood sample, cells that are part of the immune system are exposed to cells that make up prostate cancer. Then the blood cells are placed back in the body, with the hope that they will cause other immune system cells to attack the prostate cancer. In a more traditional type of vaccine, the patient is injected with a virus that contains PSA. When the body is exposed to the virus, it becomes sensitized to cells in the body that contain PSA and their immune system attacks them.
Immune or genetic therapy have the potential to deliver more targeted, less invasive treatments for advanced prostate cancer. This would result in fewer side effects and better control of the prostate cancer.
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How Lupsma Is Changing The Prostate Cancer Space
At the recent 2021 Prostate Cancer Foundation Scientific Retreat, Michael S. Hofman, MBBS , FRACP, FAANMS, FICIS, presented the latest research on LuPSMA for the treatment of advanced prostate cancer.1 He gives an overview on current LuPSMA clinical trials and what these trials hope to accomplish in the prostate cancer space. Hofman is a nuclear medicine physician and director of the Prostate Cancer Theranostics and Imaging Center of Excellence , Melbourne, Australia.