Monday, January 23, 2023

Standard Of Care Prostate Cancer

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Chemotherapy For Prostate Cancer

Standard of Care in Metastatic Prostate Cancer

The decision on when to start chemotherapy is difficult and highly individualized based on several factors: What other treatment options or clinical trials are available. How well chemotherapy is likely to be tolerated. What prior therapies you have received. If radiation is needed prior to …

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Biochemical Recurrence Without Metastatic Disease After Exhaustion Of Local Treatment Options

Prognosis

4. Clinicians should inform patients with PSA recurrence after exhaustion of local therapy regarding the risk of developing metastatic disease and follow such patients with serial PSA measurements and clinical evaluation. Clinicians may consider radiographic assessments based on overall PSA and PSA kinetics.

5. In patients with PSA recurrence after exhaustion of local therapy who are at higher risk for the development of metastases , clinicians should perform periodic staging evaluations consisting of cross-sectional imaging and technetium bone scan.

6. Clinicians may utilize novel PET-CT scans in patients with PSA recurrence after failure of local therapy as an alternative to conventional imaging or in the setting of negative conventional imaging.

Treatment

7. For patients with a rising PSA after failure of local therapy and no demonstrated metastatic disease by conventional imaging, clinicians should offer observation or clinical trial enrollment.

8. ADT should not be routinely initiated in this population . However, if ADT is initiated in the absence of metastatic disease, intermittent ADT may be offered in lieu of continuous ADT.

Biomarkers And Other Systemic Therapies

Given the dramatic increase in available therapies for advanced prostate cancer over the past 10 years, there is a renewed urgency to identify predictive biomarkers that can guide treatment selection. A number of promising molecular approaches continue to be investigated, but as of yet there is no assay that has been prospectively demonstrated to lead to improved oncologic outcomes.

In addition to PARP inhibitors, immunotherapies have also emerged as a key therapeutic modality in a large number of solid tumors. Aside from sipuleucil-T, these treatments have generally shown less efficacy in advanced prostate cancer compared to other malignancies, in part related to the relatively low tumor mutational burden of most prostate cancers.171 However, as described in guideline statement 34, there is likely to be a subset of prostate cancer patients who are uniquely sensitive to immunotherapy particularly those patients who have tumors that have a high mutational burden .172 Ongoing trials continue to explore whether immune checkpoint inhibitors, vaccine-based therapies, or oncolytic viruses may have broader utility in men with advanced prostate cancer.

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How Is Prostate Cancer Treated

Lorenzo asked his doctors about survival and side effects and talked to friends and family members before deciding on treatment. He shares his story in this blog post.

Different types of treatment are available for prostate cancer. You and your doctor will decide which treatment is right for you. Some common treatments are

  • Expectant management. If your doctor thinks your prostate cancer is unlikely to grow quickly, he or she may recommend that you dont treat the cancer right away. Instead, you can choose to wait and see if you get symptoms in one of two ways:
  • Active surveillance. Closely monitoring the prostate cancer by performing prostate specific antigen tests and prostate biopsies regularly, and treating the cancer only if it grows or causes symptoms.
  • Watchful waiting. No tests are done. Your doctor treats any symptoms when they develop. This is usually recommended for men who are expected to live for 10 more years or less.
  • Surgery. A prostatectomy is an operation where doctors remove the prostate. Radical prostatectomy removes the prostate as well as the surrounding tissue.
  • Radiation therapy. Using high-energy rays to kill the cancer. There are two types of radiation therapy
  • External radiation therapy. A machine outside the body directs radiation at the cancer cells.
  • Internal radiation therapy . Radioactive seeds or pellets are surgically placed into or near the cancer to destroy the cancer cells.
  • If Treatment Does Not Work

    Pin on Prostate cancer

    Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

    This diagnosis is stressful, and for some people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

    People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

    After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

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    Androgen Deprivation Therapy Recommendations For Advanced Or Metastatic Disease

    See the list below:

    • ADT is a preferred initial treatment for symptomatic metastatic prostate cancer because androgenic effects promote the growth and malignant transformation of prostatic tissue

    • ADTs include luteinizing hormone receptor agonists , gonadotropin-releasing hormone receptor agonists and antagonists , and complete androgen blockade

    • CAB includes medical castration with an oral antiandrogen or surgical castration

    • Patients who do not show an adequate suppression of serum testosterone may be considered for CAB

    • Monotherapy with nonsteroidal antiandrogens is less effective but these agents are associated with fewer hot flashes and fatigue and do not impair libido

    • If hormone therapy fails, that therapy should be continued into and through the next hormone manipulation

    Gonadotropin-releasing hormone agonists:

    Gonadotropin-releasing hormone antagonists:

    • Pure GnRH antagonists suppress testosterone and avoid the flare phenomenon associated with GnRH agonists
    • Important for patients with no prior hormone treatment who are diagnosed with significant metastasis.
    • Degarelix: 120 mg SC × two doses , then, after 28 days, monthly maintenance doses of 80 mg SC
    • Relugolix: Loading dose of 360 mg PO × 1, then 120 mg PO once daily

    Nonsteroidal antiandrogens for noncastrate-resistant disease:

    Chemohormonal therapy for hormone-sensitive metastatic disease

    Castrate-resistant metastatic disease

    Treatment By Cancer Type

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    Multidisciplinary Nature Of Treatment In Todays Advanced Prostate Cancer Care Paradigm

    As the therapeutic landscape evolves to include increasingly complex combinations of systemic therapies with or without local therapies, advances in imaging, and germline and somatic genetic testing, treating men with advanced prostate cancer is increasingly one that must embrace multidisciplinary management approaches. Team members should include urologists, medical oncologists, and radiation oncologists at a minimum when supporting treatment decisions for advanced disease. Additional specialists may also include genitourinary pathology, genetic counseling, palliative care, and holistic specialists, as appropriate, in addition to primary care. Best practices must also include clinicians comfortable describing the use of germline and somatic genetic testing, and when advanced imaging techniques could be optimally used or avoided. Radiologists and nuclear medicine specialists are valuable in helping to accurately interpret scans. Palliative care team members may also play a key role when treating men with symptomatic metastatic disease. Palliative care itself is an interdisciplinary, holistic approach to managing an advanced disease such as prostate cancer with a guarded prognosis. It can include controlling symptoms that are physical, psychological, spiritual, and social. The goal of palliation is to prevent and relieve suffering and to support the best possible QOL for the patient and family.

    Treating Advanced Prostate Cancer

    Prostate Specific Membrane Antigen (PSMA) PET: The New Standard of Care for Imaging Prostate Cancer

    If the cancer has reached an advanced stage, it’s no longer possible to cure it. But it may be possible to slow its progression, prolong your life and relieve symptoms.

    Treatment options include:

    • hormone treatment

    If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.

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    Good Prostate Cancer Care

    Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.

    You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.

    You should also be told about any clinical trials you may be eligible for.

    If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.

    Surgery Versus Watchful Waiting

    The most significant report comparing surgery with watchful waiting was produced by Bill-Axelson et al.2 in 2005. They reported the final results from the Scandinavian prostate cancer group study a randomised, prospective study following nearly 700 men with early prostate cancer over a 10-year period . Importantly, this is the only report to show a survival benefit with any singular modality treatment. During a median period of 8.2 years, death due to prostate cancer occurred in 14.4% of men assigned to watchful waiting versus 8.6% in the surgery group. Table 1 shows that the difference in the cumulative incidence of death due to prostate cancer increases from 2.0% after 5 years to 5.3% after 10 years, for a relative risk of 0.56. Admittedly these may be small benefits but, more significantly, results showed a considerable reduction in metastatic disease of 1.7% to 10.2% at 5 years and 10 years, respectively. Because clinical manifestations of disseminated disease virtually always precede death, this finding may herald a further lowering of the risk of death due to prostate cancer in the radical prostatectomy group after a longer period of follow-up.2

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    Choosing A Treatment Option

    Treatment Options for Localized or Locally Advanced Prostate CancerA man diagnosed with localized or locally advanced prostate cancer has 3 major treatment options: Active Surveillance, surgery, and radiation therapy. For patients whose cancer appears more aggressive, combination treatment may be recommended. For …

    Your Cancer Care Team

    Prostate Cancer

    People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.

    The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.

    Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.

    When deciding what treatment is best for you, your doctors will consider:

    • the type and size of the cancer
    • what grade it is
    • whether the cancer has spread to other parts of your body

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    Starting The Diagnostic Process

    Not everyone follows the same diagnostic process. Some people may be helped through the process by their family doctor, while others may be helped by a specialist or a Diagnostic Assessment Program .

    In many cases, a family doctor is the first contact point in the process of diagnosing cancer and is the one to refer a patient to a specialist or DAP.

    To check if a DAP is available in your area, go to our map of DAP locations.

    Certain Factors Affect Prognosis And Treatment Options

    The prognosis and treatment options depend on the following:

    • The stage of the cancer .
    • The patients age.
    • Whether the cancer has just been diagnosed or has recurred .

    Treatment options also may depend on the following:

    • Whether the patient has other health problems.
    • The expected side effects of treatment.
    • Past treatment for prostate cancer.
    • The wishes of the patient.

    Most men diagnosed with prostate cancer do not die of it.

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    Alternative Treatment Recommendations For Localized Prostate Cancer

    Other treatments that have been used in the initial management of localized prostate cancer include the following:

    • Particle beam therapy

    Cryotherapy:

    • Cryotherapy involves using transrectal ultrasonographic guidance percutaneous cryoprobes are placed and used to freeze prostate tissue

    • This treatment is not preferred as a standard curative treatment option but may be used in select patients with localized prostate cancer or as focal therapy in low-risk patients

    • Can also be considered as salvage therapy after failed radiation therapy

    • Complications include tissue sloughing, perineal ecchymosis, stricture or contracture, incontinence, impotence, and fistula formation between the urinary and gastrointestinal tracts

    High-intensity focused ultrasound:

    • Acoustic ablative technique that uses ultrasound to induces immediate and irreversible coagulative necrosis with sharply delineated boundaries performed under spinal anesthesia on an outpatient basis
    • Widely used outside the United States approved for ablation of prostate tissue by the US Food and Drug Administration in 2015
    • Used for both whole-gland treatment and focal therapy

    Particle beam therapy :

    A New Standard Of Care For Low

    New Standards of Care for Advanced Prostate Cancer

    Men diagnosed with metastatic prostate cancer will often not undergo local treatments of the primary prostate tumor, such as surgery or radiation. Primary hormone therapy has long been the standard of care, although recently the addition of docetaxel or abiraterone to ADT has become a standard of care option. In March, the National Comprehensive Cancer Network released its 1.2019 version of guidelines for prostate cancer. For men with low-volume metastatic disease who have not previously been treated with hormone therapy, there is an important update: the option of radiation therapy to the prostate in addition to ADT .

    Digging deeper into trial results

    This update is based on results of a large randomized controlled trial called STAMPEDE.

    But before STAMPEDE, there was another trial called HORRAD, the first study adding RT to ADT in patients with metastatic prostate cancer. In the analysis of all 400+ patients in the HORRAD trial, there was no difference in overall survival. Taken at face value, adding RT didnt work. Case closed?

    Not so fast..because when researchers looked at a small subset of patients who had a low number of metastatic disease sites, they saw a suggestion of a survival benefit.

    A large European trial

    But wait.what about side effects of radiation? The study also assessed toxicity, and found no difference in rates of severe events between the two treatment arms.

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    Surgically Removing The Prostate Gland

    A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

    Like any operation, this surgery carries some risks, such as urinary incontinence and erectile dysfunction.

    In extremely rare cases, problems arising after surgery can be fatal.

    It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

    Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

    You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .

    Dr Wise On Unmet Needs In The Standard Of Care In Prostate Cancer

    In Partnership With:

    David R. Wise, MD, PhD, discusses unmet needs in the standard of care in prostate cancer.

    David R. Wise, MD, PhD, assistant professor, the Department of Medicine, the Department of Urology, the NYU Grossman School of Medicine, NYU Langone Health, discusses unmet needs in the standard of care in prostate cancer.

    Several options comprise the current standard of care in prostate cancer, including hormone suppression as the backbone of treatment, Wise says. However, multiple studies have now showed that treatment should be intensified with the addition of a second agent beyond androgen suppression, such as docetaxel , abiraterone acetate , apalutamide , or enzalutamide , Wise explains.

    Moreover, a subset of patients with low-volume, metastatic prostate cancer can be intensified with low-dose, prostate-directed radiation therapy, Wise continues. The next important step in research will involve examining the benefit of further intensifying treatment, Wise concludes.

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    Prostate Cancer Imaging: Standard Of Care And Limitations

    Phillip Kuo, MD, PhD: Hello and welcome to this Uro View video series titled, Gallium-68 PSMA Targeted PET Imaging in Prostate Cancer: Staging and Outcomes. My name is Phillip Kuo. I am a professor of medical imaging, medicine, and biomedical engineering at The University of Arizona in Tucson. Im very honored to be joined today by my colleague Dr Andre Abreu, a urology surgeon at the Keck Medical Center of the University of Southern California in Los Angeles, California. In todays discussion, we will discuss the role of gallium-68 PSMA -targeted PET imaging, its impact on staging, outcomes, and its role specifically when treating prostate cancer. Lets get started. For the lead off question, Id like to ask Dr Abreu, what are your feelings about the standard of care for prostate cancer imaging?

    Transcript edited for clarity.

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