An Emerging Treatment Option For Men With Recurring Prostate Cancer After Radiation Therapy
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Prostate cancer is often a multifocal disease, meaning that several tumors can be present in different parts of gland at the same time. Not all of these tumors are equally problematic, however. And its increasingly thought that the tumor with the most aggressive features called the index lesion dictates how a mans cancer is likely to behave overall. That concept has given rise to a new treatment option. Called partial gland ablation , and also focal therapy, it entails treating only the index lesion and its surrounding tissues, instead of removing the prostate surgically or treating the whole gland in other ways. Emerging evidence suggests that PGA controls prostate cancer effectively, but with fewer complications such as incontinence.
In February, researchers at Memorial Sloan Kettering Cancer Center in New York published findings that could pave the way for focal therapy in men with reoccurring prostate cancer. They focused specifically on men whose cancer had returned three to four years on average after initial treatment with radiation.
Their findings, while preliminary, suggest that MRI and biopsy results can allow doctors to select which patients with reoccurring prostate cancer might be eligible for PGA. The research was headed by Dr. Gregory Chesnut, an MSKCC urologist.
Developing Drugs For Different Targets
HER3 and a related protein called HER2 are common targets for cancer therapy, especially in breast cancer. But so far, HER2- and HER3-blocking drugs have been disappointing in treating prostate cancer. Dr. Sawyers says it may be possible to develop a treatment such as an antibody that would block these proteins in a different way than whats been tried before. Its compelling because there are already such antibodies in development for other conditions, he says.
Dr. Carver adds that one particular experimental antibody used in the lab has already shown that this approach is likely to be successful. The researchers reported this finding in the paper.
One of the strengths of doing research at MSK is the flow of information between lab scientists and doctors in the clinic, Dr. Rathkopf concludes. It gives us a more complete picture of whats happening, which can help us make treatment decisions in real time and improve outcomes for those in need of new therapies.
Memorial Sloan Kettering Cancer Center
Home Interests Cancer Research Memorial Sloan Kettering Cancer Center
Memorial Sloan Kettering Cancer Center
In 2001, the Sidney Kimmel Foundation for Cancer Research made a gift for translational research and direct patient care for those suffering from prostate and urologic cancers. The Foundations $25 million gift to Memorial Sloan Kettering Cancer Center resulted in the development of the state-of-the-art Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan Kettering. Co-chaired by Dr. Howard Scher, Chief Oncologist, and Dr. Peter Scardino, Sloan Ketterings Chief of Surgery, the Kimmel Center at Sloan Kettering sees thousands of patients weekly who participate in the latest research protocols and benefit from personalized treatments at what many consider the worlds leading cancer center.
The Gift
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Determining Your Treatment Options
Once your diagnostic tests are complete, well determine which of the following four clinical states best fits your condition. Each has different treatment goals as well as a set of treatment options that have been shown to be most effective at managing the disease.
We have vast experience in detecting prostate cancer and helping patients evaluate their options. Some risk factors place certain men at a higher risk of developing prostate cancer than others. If youre concerned about prostate cancer, contact our Bendheim Prostate Cancer Diagnostic Center to determine whether you have the disease or to get a better sense of your level of risk. At MSK, we offer diagnostic tests that can reveal evidence of the disease, including:
- blood tests for prostate-specific antigen levels
- digital rectal examination
- family history analysis
- diagnostic imaging studies
If tests indicate that you might have prostate cancer, our doctors can advise you on your treatment options.
Treatment Options For Prostate Cancer
For people with slow-growing prostate cancer, we offer active surveillance. Some prostate cancers grow so slowly they usually will not cause problems. Your doctors will regularly monitor the slow-growing tumor for any sign it is changing.
Some people are interested in surgery, or its recommended by their doctor. Our surgeons are among the worlds most experienced in performing prostate operations. Were always working to improve their safety and effectiveness. Radical prostatectomy is surgery to remove the prostate gland. We offer robotic as well as laparoscopic and open surgery. Our surgeons are also highly experienced in a procedure called salvage radical prostatectomy. It is sometimes an option when prostate cancer returns after treatment with radiation therapy.
Radiation therapy uses high-energy beams to treat cancer. It works by damaging the cancer cells and making it hard for them to reproduce and spread.
Our radiation oncology team is one of the most experienced in the world in treating prostate cancer with many types of radiotherapy. Our oncologists have broad experience with:
- Stereotactic hypofractionated radiation therapy
- Low-dose-rate permanent seed implants
- High-dose-rate temporary seed implants
Aggressive cancers: Theres risk of it spreading into tissues next to the prostate, or to lymph nodes. In such cases, we combine treatments such as hormone therapy, brachytherapy, and external beam radiation therapy.
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Survivability For Prostate Cancer According To Stage
Relative survival looks at a persons chances of surviving after diagnosis compared to a healthy person from the general population who shares similar characteristics, such as age, sex, and race.
For prostate cancer, relative survival depends on the stage of the disease . It is important to note that this prognostic grouping, also established by the UICC, is more accurate than stage grouping in assessing a survival prognostic.
Prognostic Grouping Of Prostate Cancer
TNM prognostic grouping for prostate cancer is based on the stage, PSA level and Gleason score. This grouping is more accurate in predicting a prognosis than TNM staging alone. It goes without saying that the lower the scores, the best outlook and chance that your cancer can be successfully treated without the cancer coming back .
In contrast, if the prognosis is darker for men with higher scores, there may still be treatment options to control your cancer, improve your quality of life and prolong your survival.
Doctors also use nomograms to predict a prostate cancer prognosis. Nomograms are predictive tools.
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How Does The Blood Test Determine The Level Of Heterogeneity
The test, which was developed by Epic Sciences, involves placing a blood specimen onto a glass slide and staining it to distinguish normal blood cells from CTCs. A machine then scans the slide to analyze various features of the CTCs, including size and shape. It works like facial recognition software used at airport security. The software can quickly identify a CTC by examining these features.
Researchers can then select individual cells of interest, pick them up from the slide, and check for genetic abnormalities. By looking at variation in CTC appearance and an individuals genetic makeup, we can assign a heterogeneity score to that patient.
The study showed that a high heterogeneity score correlated with poorer response to the hormone therapy.
Choosing Your Treatment Options
Once your diagnostic tests are complete, we will know more about your condition. You may have:
- No cancer
- Clinically localized disease
- Rising PSA after treatment, such as surgery or radiation
- Metastatic disease
Each has different treatment goals and treatment options for best managing the disease.
We have deep experience in finding prostate cancer and helping our patients understand their options. Some risk factors mean you have a higher chance of developing prostate cancer. If youre worried about prostate cancer, contact our Bendheim Prostate Cancer Diagnostic Center. Through testing, they can tell you if you have the disease and your level of risk. MSK offers the following diagnostic tests:
- Blood tests for prostate-specific antigen levels
- Digital rectal examination
- Family history analysis
- Diagnostic imaging studies
If tests show you may have prostate cancer, our doctors can talk with you about your treatment options.
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How Could This Technology Change The Treatment Of Prostate Cancer
Knowing the level of heterogeneity of a patients prostate cancer could be used to help select the treatment to which a patient is more likely to respond. For example, if a patient has a high level of heterogeneity in their CTCs, the clinician would choose chemotherapy rather than hormonal therapies sparing the patient side effects or problems that may result from a treatment likely to be ineffective. This would provide a clear clinical benefit.Also, unlike a tissue biopsy, blood samples are noninvasive and easily obtained at any time, so treatment adjustments could be made sooner.
This is really groundbreaking technology. CTCs are very small in number compared with other cells in the bloodstream approximately one cell in a billion so being able to isolate them reliably and analyze them quickly is an important advance.
Before we can make this particular liquid biopsy part of routine practice, we first need to validate it in a clinical trial, which we are now designing to conduct through the Prostate Cancer Clinical Trials Consortium. This will give us definitive answers about how well it predicts patient outcomes. But this type of test was not even conceivable just a few years ago the technology is evolving so quickly its incredible.
How To Be Your Own Best Advocate
Alan Gelband has an undetectable PSA. Two years after robotic prostatectomy for organ-confined prostate cancer, he has come through diagnosis, treatment and recovery, and life is good. But he will never forget what it was like during that time, and because of that, he shares what he has learned with other men who are just starting this journey that no one wants to take.
If you are newly diagnosed with prostate cancer, Gelband wants you to know that there is more hope now than ever before but its up to you to take charge of your health care, to learn as much as you can about your stage of cancer and the best way to treat it, and then to maximize your chance of success by finding the right doctor to perform that treatment. I strongly believe that the most important advocate that you have is you, he says.
Here are a few valuable lessons he has learned:
Still, he was torn over what to do. I was dead set against surgery, he recalls, but I spent a good deal of time studying the published outcome statistics on radiation and surgery. Gelband talked to Michaelson, who referred him to the Harvard radiation oncologist, DAmico. He looked at my records and recommended surgery. Vincent Laudone, M.D., chief of robotic surgery at MSK, performed the procedure. I was very happy with the results, Gelband says.
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Clinical Centers Of Excellence
The Memorial Sloan-Kettering Cancer Center Sidney Kimmel Center for Prostate and Urologic Cancers is striving to defeat metastatic prostate cancer through aggressive efforts in prevention, detection, diagnosis, research, and treatment.
That will change in the next 10 years for most men, Dr. Scardino said. The MSKCC Sidney Kimmel Center for Prostate and Urologic Cancers is striving to make that happen through aggressive efforts in prevention, detection, diagnosis, research, and treatment.
There are limited options for the prevention of prostate cancer. Lack of a genetic test makes it even more difficult to determine a patient’s risk of developing the disease.
MSKCC is conducting studies to identify men at increased risk of developing prostate cancer who might benefit from chemoprevention. Recent trial results indicate that prophylactic use of these agents is not linked to the development of more aggressive tumors, as was shown in a previous study.
“That is the most important thing that is going on in the prevention of prostate cancer today,” said Dr. Scardino.
Early diagnostic efforts
Hans Lilja, MD, PhD, a clinical laboratory physician at MSKCC, holds patents for his development of free PSA assays.
“Free PSA is now a standard test worldwide in determining who should have a biopsy if they have prostate cancer,” said Dr. Scardino.
In addition, MSKCC researchers are studying how a single PSA test can predict younger men’s risk for prostate cancer.
New Diagnosis: Where Do I Start
You are not alone. The good news is that most prostate cancers are slow-growing and that with early detection and treatment, it can be cured. Increasing your knowledge by reviewing sections such as Coping with cancer, Choosing your treatment as well as other areas of the web site helps relieve the stress and helps make decisions clearer.
Over the last 12 months, approximately 4,600 Quebecers were diagnosed with prostate cancer. This represents an average of 12 men per day. You are definitely not alone in your fight against prostate cancer. The good news is that we know most prostate cancers are slow-growing, which means that with early detection and treatment, it can even be cured.
Once diagnosed, men will go through understandable and normal reactions, such as fear, denial, anger, helplessness and feeling of loss of control over their life. Once reality sets in, a constructive way to deal with the disease is to learn as much as you can about it. Increasing your knowledge about prostate cancer helps relieve the natural fear of the unknown, and makes the decision-making process easier.
Frequently Asked Questions
Click here for the full list of prostate cancer-related FAQs.
Questions about survival
Talk to your doctor about your prognosis. A prognosis depends on many factors, including:
- your age
- certain characteristics of the cancer
- the treatments chosen
- how the cancer responds to treatment
We are here for you
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Symptomatic treatment of an enlarged prostate usually involves a combination of medication and lifestyle changes. A diet rich in fruits and vegetables may be the best option if you suffer from chronic urination. It will help the body adjust to the increased size of the prostate. Also, taking regular urination intervals will help retrain the bladder to function properly. Inactivity also contributes to urine retention, and cold temperatures can increase the urge to urinate.
Invasive treatment of enlarged prostate includes medication that relieves the pressure on the urethra and bladder. However, if the condition is severe, it may require surgical intervention. If treatment is not successful, the enlarged prostate can become a potentially life-threatening disease. As the hormone levels in the body change, the enlarged prostate can lead to various complications, including urinary retention and even cancer. This is why it is critical to see a doctor for further evaluation.
A physician can recommend a number of treatments to address an enlarged prostate. An enlarged prostate will require surgery to relieve the symptoms. In most cases, surgical treatment for an enlargement of the penis is enough. Moreover, a doctor may recommend a course of treatment based on symptoms. A TURP procedure is not painful and requires less recovery time than open surgery. The recovery period will be shorter and less traumatic.
Risk Of Progression Of Prostate Cancer
Prostate cancer can also be classified based on the risk of recurrence . For this assessment, that can impact your choice of therapeutic approach, we take into account your clinical stage, PSA level, and Gleason score.
Low risk
Your cancer may be at low risk of spreading if:
- Your PSA level is less than 10 ng/mL
- You Gleason score is 6 or less
- Your cancer is stage T1 or T2a
Medium risk
Your cancer may be at medium risk of spreading if:
- Your PSA level is between 10 and 20 ng/mL
- Your Gleason score is 7
- Your cancer is stage T2b
High risk
Your cancer may be at high risk of spreading if:
- Your PSA level is higher than 20 ng/mL
- Your Gleason score is 8, 9 or 10
- Your cancer is stage T2c, T3 or T4
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Prostate Cancer Risk Assessment And The Ucsf
Prostate cancer is the most common cancer diagnosed among American men, and causes more deaths annually among men than any other tumor except lung cancer. However, only a small proportion of prostate cancers diagnosed are ultimately lethal. A large majority of men found to have prostate cancer ultimately die of other causes, most commonly cardiovascular disease. All available treatments for prostate cancer carry a risk of complications, side effects, and other impacts to the patient’s long-term quality of life. Before making a decision regarding treatment for prostate cancer it is important to estimate the likelihood that a given tumor will recur after treatment, progress, and pose a threat to life.
Clinical Trials And Research
OHSU scientists lead the field in the study of prostate cancer. Patients have access to promising new treatments through our network of clinical trials. We are also pursuing novel ways to develop the the treatments of tomorrow.
Clinical trials: We offer clinical trials that offer eligible patients a chance to try a treatment that is not widely available. Your care team will talk with you about whether a trial is right for you.
Research:
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New Radiation Therapy For Prostate Cancer Reduces Deaths Study Shows
By the time Michael Rosenblums prostate cancer was discovered, it was already at a late stage. Hed initially sought medical help because of excruciating back pain, but, during an exam, doctors found a tumor on his spine and tests revealed a skyrocketing prostate-specific antigen, or PSA, score. Chemotherapy didnt help much, so when doctors offered the opportunity to be in a clinical trial for a new experimental treatment, Rosenblum jumped at it.
The trial was investigating a new, potentially groundbreaking type of treatment for prostate cancer, a therapy that specifically targets a protein on the cancer cells. The treatment, part of a new class of liquid radiation drugs, obliterates most prostate cancer cells without hurting the surrounding tissue.
Its wonderful. I have no symptoms or anything, said Rosenblum, a 75-year-old retiree, who was diagnosed four years ago. He participated in the clinical trial at Memorial Sloan Kettering Cancer Center in New York. “My PSA went from 100 … to zero.
Higher PSA levels suggest that prostate cells are growing, which may indicate cancer.
Results from the trial Rosenblum participated in were released Thursday ahead of the annual meeting of the American Society of Clinical Oncology. The study finds that the new drug reduced the risk of death by 38 percent in patients with advanced prostate cancer. Progression of the disease was reduced by 60 percent.
The patients who received the new drug got it intravenously once every six weeks.