Integrating New Therapies Into the Prostate Cancer Continuum

Beth Fand Incollingo @fandincollingo
Published: Thursday, May 09, 2013
IPCC PanelAttendees at the 6th Annual Interdisciplinary Prostate Cancer Congress gathered in New York City on March 16 to review the latest strategies and therapeutic agents available for patients with the disease, and to build consensus about their application. In the wake of the approval of several novel treatments for prostate cancer—including anti-androgens enzalutamide and abiraterone and immunotherapy sipuleucel-T — a special focus this year was “Integrating New Therapies into the Prostate Cancer Continuum.”

Panel and audience members considered several case studies and discussed the treatment options they thought were best. The cases were presented by event co-chair Leonard G. Gomella, MD, and discussed by a panel that included co-chair Daniel P. Petrylak, MD; Robert Dreicer, MD, MS; E. David Crawford, MD; and Susan F. Slovin, MD.

Case 1

Gomella: The patient is a 55-year-old white male. His father died of prostate cancer at 65 years of age, and no other family members have any history of prostate cancer. The patient is worried and wants to be checked, although he’s done some reading and is doubtful about the value of the prostate-specific antigen (PSA) test. What do you tell him?
Dreicer: The patient is at risk since he had a first-degree relative who was impacted. Screening is reasonable for him.

Petrylak: I’d tell him that PSA has its implications. If it’s elevated, he’ll need a biopsy, and then he’ll have to choose either local therapy or observation. I would do it if I were him. But he needs to know what the studies say.

Slovin: I would explain the pros and cons and then leave it up to him, although I probably would give him the strong arm because his risk is at least two-fold higher than John Doe’s next door as a result of his family history. I’d also make sure he’s had a screening colonoscopy.

Crawford: One family member probably doesn’t increase your risk a lot. You’ve got to have two or three to be at a higher risk.

Gomella: The patient has his PSA tested and it’s deemed normal at 1.1 His digital rectal exam is normal. Can you tell him he doesn’t have prostate cancer?

Crawford: No. Based on the results of the Prostate Cancer Prevention Trial [in which 15% of men with PSAs of <4 ng/mL were found to have prostate cancer],1 he still faces a risk. I’d do a prostate cancer gene 3 (PCA3) test on him.

Gomella: Even though he hasn’t had a biopsy yet, you would jump the fence on the PCA3 and use it sort of off-label? The labeled indication is to see if a second biopsy is needed.

Crawford: Yes.

Gomella: What I tell my residents—and my patients—is that we’re finding our way with PCA3, but that we have a lot of questions. Still, I’d rather have a PCA3 in the bank in case some breakthrough comes up over the next couple of years.

Which of the following treatment options would you recommend in this setting?
  1. Perform a biopsy
  2. Repeat the PSA test
  3. Check free-to-total PSA
  4. Check PCA3

Case 1. Audience Response*

Case 1: Audience Response
So, you can’t tell the patient he doesn’t have prostate cancer. What would you do next?

Slovin: I would ask him to repeat a PSA in a short period of time to get a sense of how rapidly it’s going up.

Gomella: Let’s assume he had a biopsy a year ago that was completely normal. Now he comes in and his PSA has gone up to 5. He still has a normal digital rectal exam. What would you do next?

Petrylak: He needs a repeat biopsy. I would do a saturation biopsy.

Gomella: How about PCA3, if he didn’t have it before?

Petrylak: It probably would be appropriate, but I still think he’s going to need a biopsy.

Gomella: What about free-to-total PSA? Is anyone using that anymore? We asked this question two years ago and just about everybody put their hands up, and now, as I look around, there seems to be a lot of cooled enthusiasm.

Petrylak: I’d do a PCA3 first, though.

Gomella: I agree, although it does scare me a little bit that his PSA has had such a rapid rise.

Crawford: The PCA3 would make me feel better about doing another biopsy.

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