Oncology Prostate Cancer


Localised Prostate Cancer – What the Medical Oncologist Needs to Know Aditya Bardia1


and Michael A Carducci2 1. Clinical Fellow, Division of Medical Oncology; 2. Professor of Oncology and Urology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University


Abstract


Prostate cancer is the most commonly diagnosed cancer among men and the second leading cause of cancer-related deaths among men in the US. In the post-prostate specific antigen (PSA) era, about 85% of all prostate cancers diagnosed are clinically localised prostate cancers. Most cancers are diagnosed in asymptomatic men, and T1c (stage I) is the most commonly diagnosed stage of prostate cancer. Consequently, medical oncologists are increasingly being asked to participate in multidisciplinary prostate cancer clinics and provide recommendations on localised prostate cancer, particularly related to active surveillance as well as neoadjuvant and adjuvant therapies such as androgen deprivation therapy (ADT) and chemotherapy. This article reviews the potential role of the medical oncologist as a team member in the management of localized prostate cancer. The role of active surveillance as well as neoadjuvant and adjuvant therapies such as ADT and chemotherapy is discussed in detail. The long-term adverse effects of ADT and potential supportive measures are also reviewed.


Keywords Localised prostate cancer, androgen deprivation therapy, adjuvant, active surveillance, risk stratification


Disclosure: Aditya Bardia has no conflicts of interest to declare. Michael A Carducci is a consultant for sanofi-aventis, Novartis, Amgen, and Johnson & Johnson. Received: 4 May 2010 Accepted: 3 February 2011 Citation: European Urological Review, 2011;6(1):26–32 Correspondence: Michael A Carducci, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, CRB1 1M59, 1650 Orleans Street, Baltimore, MD 21231, US. E: carducci@jhmi.edu


The Magnitude of Localised Prostate Cancer Prostate cancer is the most commonly diagnosed cancer among men and the second leading cause of cancer-related deaths among men in the US. It is estimated that approximately 192,280 new cases of prostate cancer were diagnosed in the US in 2009 alone;1


this accounts


for about 25% of all new cancer diagnoses in men in the US for 2009. It is estimated that one in six men will develop prostate cancer over their lifetime. Thus, prostate cancer is an important public health issue. Prostate-specific antigen (PSA) has revolutionised screening and treatment decision-making in prostate cancer, although recently there has been much controversy regarding the utility of PSA screening.2,3 Indeed, the widespread use of PSA screening has led to a dramatic shift in the epidemiology of prostate cancer. Based on data from the Cancer of the prostate strategic urologic research endeavor (CaPSURE), a disease registry of 8,685 men with various stages of prostate cancer, Cooperberg et al.4


reported that the percentage


of men with low-risk prostate cancer increased from 29.8% in 1989– 1992 to 45.3% in 1999–2001 (p<0.0001). Similarly, a population-based study based on the Surveillance, epidemiology, and end results (SEER) programme reported that from 1988 to 2003, the age-adjusted incidence of stage IV prostate cancer significantly declined by 6.4% each year, and the proportion of men diagnosed at younger ages with poorly differentiated tumours or who underwent a radical prostatectomy (RP) significantly increased over time.5


Given the impact of PSA, the epidemiology of prostate cancer is broadly divided into the pre-PSA and post-PSA era. In the post-PSA era, about 85% of all prostate cancers diagnosed are in asymptomatic men and are clinically localised prostate cancers (i.e confined to the prostate at the time of diagnosis).6


Indeed, clinical stage T1c (stage I) is 26


the most commonly diagnosed stage of prostate cancer. It should be noted that, while PSA >4ng/ml is considered the traditional cut-off in PSA screening,7,8


recent studies suggest that there is no PSA threshold below which having the risk for prostate cancer is zero.9


Another


parallel trend with the increase in low-volume, localised prostate cancers in the post-PSA era has been the increase in medical oncology consultation for localised prostate cancer. Medical oncologists are increasingly being asked to participate in multidisciplinary prostate cancer clinics and provide curbside opinions from colleagues related to localised prostate cancer. The medical oncologist is being asked to review data and provide directions in formal consultation, particularly on active surveillance, to provide recommendations on neoadjuvant and adjuvant therapies, and to discuss clinical trials, if available. This article reviews the potential role of the medical oncologist as a team member in the management of localised prostate cancer. We will present four common case scenarios and use them as a platform to discuss how a medical oncologist may affect the care of a patient with localised prostate cancer.


Localised Prostate Cancer – The Role of the Medical Oncologist Case Study 1


A 70-year-old retired engineer was found to have a rise in PSA on his yearly screenings from 2.8 to 4.1ng/ml in the past year. He was in average health for his age, and denied any bothersome symptoms. His physical examination, including digital rectal examination (DRE), was unremarkable. A 12-core prostate biopsy was then performed. Pathological examination showed that two of the 12 cores were involved on the left with Gleason 3+3 (moderately differentiated) and <50% of cores were positive, and no peri-neural invasion was


© TOUCH BRIEFINGS 2011


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