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Home » EU Health, Health, Prostate Cancer

Improving prostate cancer treatment

Submitted by on 28 Sep 2015 – 09:07

Multiparametric MR imaging in conjunction with biomarker and genomic data will hopefully generate a cancer risk map score for the entire prostate. Prof. Dr. med. Mathias Goyen says this obviates the need for invasive biopsy in the future

GE HealthcareProstate cancer is generally known as a disease that is most common at older ages and then remains extremely slow to develop (to the point of often going undetected all life). Yet, this masks an uncomfortable truth that attending urologists are confronted with on a daily basis: namely, that the shifting demographics of the European population, the diverse aetiology of prostate cancer (with some types being absolutely aggressive) and with pervasive shortcomings in diagnostic techniques such as prostate biopsy (see below), urologists are still not able to confidently predict on a patient to patient basis whether someone is more likely to die from or with their cancer.
While the latter would require a care pathway based mainly around active surveillance, the former would of course suggest urgent need for a range of treatment options, ranging from radical prostatectomy to hormone therapy. Even in the case of active surveillance, available techniques still centre on prostate biopsy and ultrasound imaging, leaving a lot of room for improvement.

Prostate Cancer’s frightening epidemiology
There is an estimated 1.1 million new cases of prostate cancer a year worldwide (417,000 in Europe), which makes it the most common male cancer in the UK, Germany, Europe and the US. It is also the second most common cancer for men worldwide – even in a country like Germany, which has a 93% five-year survival rate, prostate cancer is the third most common male cause of death.

Barring drastic innovation in prostate cancer diagnosis and care pathways, these figures are certain to increase in a rapidly ageing society.
How should we be responding? Care Pathways and Active Surveillance regimes have to be optimised for better patient management and decision-making. The two big enablers for these changes have to be technological advances and political change in healthcare systems and reimbursement structures.

Addressing deficiencies of biopsy
As for prostate biopsy, a lot of prostate cancer diagnosis and care currently relies on the histological evaluation of prostate tissue via tissue biopsy. Prostate biopsy currently remains the most common means to achieve a final diagnosis, but it must be guided by the best possible imaging technology to increase accuracy in grading and staging.

Various biopsy techniques have improved upon one another over the decades, but they are still plagued by inaccuracies and high false-negative rates. It is a huge clinical problem for attending physicians and a huge economic inefficiency for healthcare systems that a negative biopsy (tissue biopsy shows no sign of cancer) does not necessarily mean a “no disease status” – since there is a good chance that the biopsy needle simply missed the tumour . On the other hand, a positive biopsy might still not have come from the clinically most relevant – i.e. most aggressive – tumour, leading to wrong decisions in treatment schedules.

Therefore, more and more prostate cancer specialists call the incorporation of magnetic resonance imaging (MRI) fusion into prostate biopsies the gold standard in prostate cancer imaging and diagnosis. Generally, MRI-trans rectal ultrasound (TRUS) fusion biopsy involves taking a high-resolution, preferably 3 T MRI examination and then, at a separate appointment, fusing these data with real-time ultrasound images to help guide biopsy procedures.

Fusion biopsies deliver important clinical advantages, including use in men with a rising PSA despite multiple negative biopsies. In men with a PSA of 4.0 to 10.0 ng/mL, the typical 12-core TRUS biopsy finds cancer 27% to 40% of the time, leaving around 70% of men with a negative biopsy—but not necessarily free of prostate cancer.

MRI-TRUS-fusion biopsies yield a much lower false-negative rate than random 12-core biopsies. So the impact of high-quality 1.5 and 3 T MRI is to select more patients with higher-grade and higher-volume disease for biopsies. One of the future goals is to incorporate the MRI into the screening paradigm to possibly allow some men to avoid biopsy altogether.

From outdated treatment pathways to holistic decision-making
The Gleason score is still instrumental in determining a patient’s treatment regime, as predicted patient disease outlook in prostate cancer depends on tumour stage, grade (Gleason score) and PSA level. GE healthcare’s goal is to develop an end user application where all the right type of clinical and biomarker data, combined with multiparametric MR imaging are pulled together into a risk map score for each region of the prostate.

We also plan to bring in proteomic and genomic data for precision medicine. To be successful, any imaging system must provide unprecedented image quality, be cost effective, easy to site and provide for easy and quick patient positioning.

Summary
Although MRI-TRUS-fusion biopsies are too new to be pronounced a gold standard, use of MRI in evaluating men who have had multiple repeat biopsies should ultimately be a standard of care and will completely change the paradigm by which we think of prostate cancer from one-size-fits-all to a very individualized approach

Prof. Dr. med. Mathias Goyen is Chief Medical Officer – Oncology at GE Healthcare