Health Report: Comprehensive view of a complex disease – Prostate Cancer

Prostate cancer is a serious concern for many men today. The American Cancer Society estimates that in 2015 there will be more than 220,000 new cases of prostate cancer in the United States, along with more than 27,000 deaths from the disease. 

While the first response may be to advocate for aggressive treatment, that is not always advisable. Prostate cancer is a complex disease that exists on a broad spectrum.

“Some cases of prostate cancer are highly aggressive and pose significant risk of death,” said Ramdev Konijeti, M.D., a urologic oncologist with Scripps Health. “But other cases are nonaggressive and carry relatively low risk. The key is to identify which patients have more aggressive cancer and would therefore benefit from more aggressive treatments.”

PSA Screening

Use of the prostate-specific antigen (PSA) test for prostate cancer screening became widespread in the 1990s, but the tool is both clinically valuable and flawed. There are men who have high PSA numbers and no cancer, and others who, despite normal PSA results, still have the disease. But it’s the best initial screening test available.

Because the PSA test has these shortcomings, the medical community has developed a more nuanced approach to its results, individualizing care for each patient. PSA numbers must be put into context with ethnicity, family history and other risk factors. In addition, one test may not tell the complete story. A series of PSAs can show if the numbers are changing over time. 

When caring for patients with prostate cancer, the primary goal is to understand the aggressiveness of their particular cancer and design a treatment plan accordingly. This is critically important. Over-treating a patient with less aggressive disease can lead to severe side effects and poor quality of life. Too little treatment can contribute to failure to control the cancer and possibly raise the probability of loss of life.

The long-term outlook is good. Diagnostics companies are developing new tests that read a tumor’s genome and provide clues about its aggressiveness. This emerging field is showing great promise, but more research needs to be done.

Approaches to Care

Patients with a slow-moving form of prostate cancer often choose a strategy called “active surveillance.” With this approach, patients can be tracked through a series of PSA tests and biopsies. As a result, they don’t have to rush into surgery, radiation or hormone therapy.

Active surveillance allows patients to avoid the life-altering consequences of aggressive treatment. But if the cancer changes course, clinicians still have a full arsenal of treatments available.

There are a number of highly effective treatment options for prostate cancer patients today. Minimally invasive robotic surgery is an effective option in appropriately selected individuals. Techniques to deliver radiation to the prostate, such as intensity-modulated radiotherapy and proton therapy, offer the potential to more precisely deliver treatment to the affected organ while minimizing damage to surrounding structures. These approaches can reduce side effects and improve recovery times.

Research Advances

In the laboratory, major advances have been made against metastatic cancer. Prostate cancer progression can be accelerated by testosterone, so one of the mainline therapies has been to block the hormone to keep the disease from progressing. Newer medications block the body’s ability to respond to testosterone, as well as the cancer’s ability to make its own testosterone, providing a more targeted approach that can reduce side effects.

There has also been a revolution in immunotherapies, which can sensitize immune cells, improving their ability to attack prostate tumors. This new generation of therapeutics is having a powerful impact in a variety of cancer types. For prostate cancer, these treatments remain experimental, but show a great deal of promise.

Looking Forward

From a broader perspective, the notion of organ-specific cancers may be growing obsolete. Some in the medical community are moving away from labeling cancer by its organ of origin. Instead, cancers may soon be grouped by their genetic mutations. A specific molecular abnormality may cause prostate cancer, but it may also drive breast or colon cancer. This relatively new understanding of cancer genomics will eventually help clinicians better target cancers based on each tumor’s specific mutations and hopefully extend life.

For more information, visit scripps.org/KUSI or call 858-240-5075.

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