More Options to Treat Prostate Cancer

Cancer is personal and requires a tailored approach-from decisions about screening to weighing the best options for treatment.

Advances in prostate cancer treatment options, new imaging techniques and more sophisticated understanding around screening approaches have created a new landscape for the disease.

"Some recent discoveries are truly practice-changing for those patients dealing with recurrent prostate cancer," said Stephen Freedland, MD, a urologist and director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai Cancer.

Prostate cancer, which affects a walnut-sized gland that helps make semen, is the most common cancer in men in the U.S., other than skin cancer, according to the American Cancer Society. About one in eight men will develop prostate cancer in their lifetime. Prostate cancer is also the second-leading cause of cancer death in men, after lung cancer.

For some, the condition is slow-growing and may never require treatment, just an active surveillance approach to monitoring the disease. For those with aggressive prostate cancer, surgery and radiation are the go-to options. Unfortunately, the cancer returns within 10 years for about one-third of these patients, Freeland said.

Freedland and colleagues conducted an international study with such patients that resulted in publication in The New England Journal of Medicine, and new approvals from the Food and Drug Administration and treatment guidelines from the National Comprehensive Cancer Network.

Read: Promising New Options for Treating Aggressive Prostate Cancer

Stephen J. Freedland, MD

New Treatment Options for Aggressive Prostate Cancer

A standard treatment for tumors that return is androgen deprivation therapy, also known as hormone therapy or ADT. Prostate cancer tumors thrive in the presence of testosterone, and eliminating the hormone from the body stifles tumor growth. However, testosterone cannot be completely eliminated, and the therapy can result in difficult side effects-including sexual dysfunction.

Investigators studied 1,068 prostate cancer patients from 17 countries who had recurrent prostate cancer. One-third of the patients in the randomized trial received hormone therapy and enzalutamide, a medication that blocks the effects of testosterone. The drug prevents any testosterone lingering in the bloodstream from stimulating cancer growth.

Another group of patients received only the enzalutamide, without any other therapy to lower the amount of testosterone in the body.

A third group received the standard treatment of hormone therapy alone.

The combination of the medication, enzalutamide and the hormone therapy reduced the risk of the cancer spreading or death by 58% compared to ADT alone. Taking only enzalutamide also had significant benefits, though was not as effective as the combination therapy, with metastasis and death risk reduced by 37% over hormone therapy alone.

"We now have two ways to treat these cancers that are better than the tools we've had in the past," Freedland said. "The way we've been doing it for many, many years is not good enough. This is the natural evolution of a dozen years' worth of studies."

While Freedland expects most patients would opt for the combination therapy, having an additional option is an important development, especially as the enzalutamide alone may better preserve sexual function.

"What this study showed for the first time ever is that we can give a really potent drug without effectively castrating a person and actually get benefits with a different side effect profile that may be very appealing to some patients," Freedland said.

Read: Reprogramming Prostate Cancer Tumor Cells

Detecting the Spread of Cancer

Patients with aggressive prostate cancer also have newer options for monitoring tumors and detecting if the cancer has spread to other parts of the body. Positron emission tomography scans have been used to detect many cancers but have only been available for prostate cancer in the last couple of years. Older scans used radioactive molecules that stuck to other cancer cells-allowing them to show up in the images-but not to prostate cancer. New scans can detect prostate specific membrane antigens, or PSMA, proteins on the surface of prostate cancer cells.

"It's a big revolution because we can pick up cancer a lot sooner once it's spread," Freedland said. "Now it's a matter of evaluating how aggressive we need to be when we detect cancers that have spread to the lymph nodes, bones or other areas."

Personalized Approach to Screening

Not every person with a prostate will necessarily be screened for prostate cancer, Freedland said. Instead of a blanket approach to screening, current guidelines call for shared decision-making: A patient and doctor discuss medical history and personal risk, and then they decide the best course.

The most common testing method is a blood test that measures prostate-specific antigen, a protein produced by both cancerous and healthy prostate tissue. Elevated levels might indicate cancer, or they could be caused by an inflamed or enlarged prostate. Test results can be nuanced. There are benefits to identifying cancers early, when they are most treatable. However, there's also a chance that a cancer could be discovered that doesn't require treatment but causes significant stress and anxiety.

"As a urologist, I tend to be very pro-screening," Freedland said. "Having a conversation where we come to an understanding of the risks and benefits is important, and it's each individual's choice to make."

Read: Radiation Therapy as Effective as Surgery for Prostate Cancer