The Challenge of Precision Medicine in mCRPC

Raoul S. Concepcion, MD, FACS
Published: Monday, Feb 18, 2019
Raoul S. Concepcion, MD, FACS

Raoul S. Concepcion, MD, FACS

Over the past decade, we have used the terms personalized medicine and precision medicine interchangeably. For the most part, patient care has always been personalized. Yes, some want to make it more standardized. Still, to adequately manage and treat our patients, we have to consider many comorbidities when providing a treatment benefit that minimizes the impact on quality of life. For example, what should be the oral agent of choice as first or second line of therapy in the management of metastatic castration-resistant prostate cancer (mCRPC)? Or, if a patient has localized prostate cancer, will surgery or radiation therapy provide the best chance of cure? It all depends.

Case in point: Among patients with mCRPC who have been heavily pretreated with multiple lines of current therapy, immunotherapy seems to benefit those who test positive for microsatellite instability (MSI) or have biallelic loss of CDK12 with inactivation. We are also well aware of androgen receptor (AR) splice variant mutations that seem to directly correlate with treatment pressure selection, limiting the subsequent use of AR modulating agents. Testing for this in select patients will be essential, as we have more and more approved agents. Finally, because we have now established that lethal prostate cancer has a definite hereditary pattern, it will be imperative to incorporate genetic testing panels for potential treatment selection as well as to provide adequate family counseling.

Nothing has been stated in this missive that we have not heard before. For the most part, all of us entered urology, especially urologic oncology, for the challenge and satisfaction of extirpative surgery and reconstruction. However, to remain leaders in the management of our oncologic patients, we need to have total knowledge of the disease and not limit ourselves to the adoption of and adaptation to newer surgical techniques. It may take a restructuring of our current practice models, but we need to embrace, understand, and incorporate all these new technologies, both surgical and nonsurgical, to be at the forefront of precision medicine for our patients.
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