Before centering discussion on subsets of prostate cancer, panelists consider general challenges and unmet needs within the treatment landscape.
Alan Bryce, MD: Dr Lowentritt, what do you think are our most immediate critical unmet needs for the treatment and management of prostate cancer?
Benjamin Lowentritt, MD, FACS: It’s a great question, and you could take up the whole discussion with that. We talk a lot about escalating the level of care and intensifying treatments, but we also need to understand when we need to take a step back and can save the patient from some treatments or shorten a course, etc. From the completely localized setting, there’s a lot of further information on active surveillance and how to continue to get patients to stay on active surveillance or expand the use of it. That’s how we identify those patients who are most at risk of failing our straightforward therapies. How do we either monitor them differently, stratify them differently, and then intensify their therapies in a way that will be effective, that’s maybe more targeted or more specific to them and their specific characteristics?
Edwin Posadas, MD: Dr Lowentritt, as you say that, I was just thinking, I’m happy that the urologists put active surveillance on the map. We were one of the first cancer sites when active surveillance came to play, and now other tumor systems are following, but this idea of de-intensification is important. It was great to see that the NRG cooperative group has started to use genomic classifiers to think about de-intensifying certain androgen target regimens based on genomic risk. We’re starting to get there, to Dr Heath’s point, that we’re using molecular [testing]. It’s frustrating because I go to the meetings like ASCO [American Society of Clinical Oncology] and see all my friends who go through these complex molecular profiles, and we still have the Gleason score and PSA [prostate-specific antigen]. Then how big was that prostate when you put your finger in for the DRE [digital rectal examination]? Hopefully, as we get more elegant, given the larger number of options we have, we start to come up with greater…to help our men because we all know that the adverse effects of the treatment and the natural history we deal with are daunting. We’re going to do better, and it’s exciting to see that.
Alan Bryce, MD: Absolutely. De-intensification is something we’re going to be exploring, to Dr Posadas’ point. A lot of interest there. Dr Lowentritt, what about the issue around health disparities in prostate cancer? What do we know about that, and what are we doing to help overcome that?
Benjamin Lowentritt, MD, FACS: It’s a great question. We’ve had this understanding, especially among different racial groups, that there were different behaviors of prostate cancer. There were a lot of questions, was this environmental, was there some genetic or other kind of unrecognized component to it? Thankfully we’re starting to see the trials and the larger group evaluations, and we’re able to see that not only, yes, we know that cancer may be more or less aggressive in a group, but that there’s some evidence of different levels of response. I thought there were 2 papers at ASCO GU [Genitourinary Cancers Symposium] that showed the Hispanic American subset of patients may respond better to some of our treatments. We’ve seen previous evidence of that in the African American population. Even though there still are challenges with access among the minorities in the United States, we may be seeing that when they get access, they respond better.
This is a fascinating set of data that reinforces what we need to be doing to get into the communities and make sure we’re educating across all communities in ways that are effective to find the patients who can benefit more than the non-Hispanic White population that dominates most of the research trials we’ve had in the past. I think there’s exciting evidence for that. We need to ask, is there something else we can do other than pure race to predict this? How do we find out who are the groups that benefit most? The evidence is compelling that the response to therapy, maybe a variety of different therapies,seems to be better for prostate cancer in some of the Hispanic and Black or African American men, so it’s exciting.
Alan Bryce, MD: I agree. We were definitely seeing that the biggest driver is access. It’s socioeconomic. The genetics are different, and yet multiple data sets point to the fact that when patients are treated in similar environments, they’re getting similar outcomes. It’s this access piece of getting patients in early enough and getting them access to the highest level of care in order to get the best outcomes. More than anything else, we have an access issue.
Elisabeth Heath, MD, FACP: I think that includes technology. We’ve started off talking about imaging, and we know even if it was using the previous tracers to now with PSMA [prostate-specific membrane antigen], that disparity of access to the patients who are the most underrepresented and at risk. It’s not happening, so that’s not just treatment, but for sure technology, and imaging, and everything else.
Alan Bryce, MD: Screening, genetic testing, all of it, right? The full spectrum of medical care.
Edwin Posadas, MD: That’s part of the reason I’m excited about the digital pathology abstracts that were shown. We’ve talked about cost already with regard to PSMA screening, but this is a barrier that’s been felt with genetic testing, or molecular profiling of tumors. If we can get data out of a pathology slide image, and level the playing field for folks in terms of being able to give prognostic and predictive information, that’ll be great. I’m excited that we’re moving in these innovative directions in the field of prostate cancer.
Alan Bryce, MD: Absolutely.
Transcript edited for clarity.