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Home » EU Health, Health, Prostate Cancer

Latest twists in PCa diagnosis and treatment

Submitted by on 14 Jul 2017 – 09:25

Prof Dr Hein Van Poppel, Adjunct Secretary General – Education, European Association for Urology, provides an overview of the latest in the fast moving field of prostate cancer diagnosis and management

Population based PSA screening has remained contentious over the last 20 years. Today, with longer follow up in the European randomized prostate cancer screening study (ERSPC) it is clearly shown that screening decreases prostate cancer mortality while the numbers to test and the numbers to treat to avoid one prostate cancer death continue to decrease, and get close to the figures known for breast cancer screening. Therefore, the EAU today clearly states that men should not be subjected to PSA testing without counselling them on the potential risks and benefits, but one should offer an individualised risk adapted strategy for early detection to the well informed man with good performance status and a life expectancy of at least 15 years. The guidelines of the EAU, also reported in the “White Paper on Prostate Cancer”, specify the modalities of PSA screening.

To avoid over-diagnosis, the use of multiparametric MRI has shown to become instrumental. MRI ignores low grade insignificant cancers, does avoid biopsy and its complications and at the same time decreases overtreatment of low risk cancer. MRI is becoming the key examination, even the first examination to be done in a men who are at risk of having prostate cancer.

While still some Gleason 3 + 3 are found either with systematic biopsies or at TURP, oncologic urologists know that the vast majority of these cancers can be managed with active surveillance, including repeated PSA testing, repeated mpMRI and eventually re-biopsy. Not only in elderly patients but also in younger patients active surveillance will become widely applied. Further research on biomarkers should further help the urologists to better distinguish between insignificant and aggressive cancers. By doing so, one will be able to also safely surveil a number of Gleason 3 + 4 cancers.

The best local treatment for aggressive prostate cancer remains surgery as shown by long term follow up studies and registries. Since they showed that at 15 years follow up, the prostate cancer mortality can be twice as high after primary treatment with radiotherapy, there is today a trend of offering surgery to the most aggressive and high risk prostate cancers.

The surgery, performed open or laparoscopically (eventually robot assisted) is complemented with extensive lymph node dissection. Multidisciplinary tumour boards can after the surgery, looking at the definitive pathology, the post-operative PSA, the wishes of the patient, … decide on when and where radiotherapy can be used in an adjuvant or salvage setting and when hormonal treatment is mandatory.

Another newcomer in the staging and follow up of prostate cancer is the Choline- or even better the PSMA-PET-CT. Its use is rapidly increasing in patients that had earlier surgical or radiation treatment for presumably localised disease and that present with PSA relapse after one or two local treatments. With the nuclear imaging we are now faced with a new disease, the oligometastatic hormone naïve prostate cancer, an entity that we didn’t know or recognize years ago. Instead of treating those patients with hormones, nowadays many high volume centres deliver metastasis directed therapies (MDT) (surgical removal of lymph nodes, radiotherapy to lymph nodes or to solitary bone metastases) but it is obvious that randomized trials will need to position this MDT.

The last important newcomer follows after three randomised clinical trials showing that the early administration of six times Docetaxel together with conventional hormonal manipulation improves survival in the newly diagnosed metastatic prostate cancer patient. The beneficial effect is more pronounced in more advanced metastatic disease but the combination of chemotherapy plus hormonal therapy should be discussed in all new metastatic prostate cancer patients.

With an increasing complexity of the management of prostate cancer today, the patients need to be involved and correctly informed. The patient information leaflets prepared by the EAU and translated in many European languages are an excellent starting point to empower the patient to discuss his situation with his caregiver.