AUA 2017: Tumor Board: Prostate Cancer
The first case was a healthy 57-year-old Caucasian male with an elevated PSA in 2017 to 6.29 (free/total ratio of 12%) after a previous PSA in 2015 of 3.47 ng/mL. The patient’s family history was significant for his father being diagnosed with prostate cancer at the age of 64, and he was otherwise continent, potent, with a normal DRE. As Dr. Stephenson notes, his PCPT risk calculation was significant for a 12% risk of Gleason ≥3+4 prostate cancer. Next steps posed to the panel included (i) prostate biopsy, (ii) multiparametric MRI +/- targeted biopsy, (iii) 5-alpha reductase inhibitor, or (iv) a biomarker (4K score or PHI). Dr. Loeb notes that we should be are “beyond the point that we should be basing decisions based on PSA” and that we should be “incorporating biomarkers such as PHI and 4K score”, noting that “PHI improves specificity above and beyond free PSA.” Subsequently, Dr. D’Amico mentioned that patient life expectancy and comorbidity score needs to be assessed for these patients. Dr. Loeb subsequently mentioned that the utilization of MRI in these scenarios allows targeted biopsies up front, but that given the clinical information provided we would still proceed with prostate biopsy anyway. The patient did eventually undergo a prostate biopsy, demonstrating Gleason 3+4 disease in 4 cores with cribiform pattern. The patient went on to have a radical prostatectomy with extraprostatic extension.
The second case was a healthy 52-year-old male with an elevated PSA to 4.53 ng/mL and negative family history of prostate cancer, with a normal DRE, mild lower urinary tract symptoms and no issues with erectile function. The patient underwent a prostate biopsy, which had 2/12 cores positive with Gleason 6 disease, both cores <1 mm, a prostate volume of 32cc and PSA density of 0.14. The panel was then given six options for next steps (i) radical prostatectomy, (ii) external-beam radiotherapy, (iii) brachytherapy, (iv) active surveillance, (v) repeat biopsy +/- mpMRI, or (vi) genomic testing. Dr. D’Amico notes that in young patients, particularly those of non-Caucasian race have a higher likelihood of harboring high risk disease, and patients should be considered for either a repeat prostate biopsy, markers or imaging prior to enrolling in active surveillance. Dr. Loeb then mentioned that patients should receive a confirmatory biopsy within 6-12 months and that the patient should also have an MRI prior to the next biopsy in order to allow targeted biopsy as part of the confirmatory biopsy. Dr. Kibel noted that at his institution, MRI is incorporated into this space, particularly in patients that have not had a confirmatory biopsy.
The third case was a healthy 57-year-old male with an elevated PSA to 5.99 in 2015 (free/total ratio of 9%), with a history of a prior PSA of 2.00 ng/mL in 2004. He had no family history of prostate cancer, a normal DRE, minimal lower urinary tract symptoms, and was continent/potent. He then underwent an MRI that demonstrated a 1.6cm PIRADS 5 lesion in the right mid/base with suspected extraprostatic extension. A targeted/systematic biopsy of the lesion demonstrated 2/2 cores positive in the MRI lesion for Gleason 3+4 disease (3mm) and the systematic biopsy showed 2/14 cores positive for Gleason 4+3 disease (1mm and 8.5mm right base/mid). Of note, intraductal carcinoma was also present. The panel was then given the following treatment options (i) robotic or open prostatectomy, (ii) brachytherapy +/- ADT, (iii) IMRT or SBRT +/- ADT, (iv) focal therapy, or (v) active surveillance. Dr. D’Amico notes that if this patient was considering radiation treatment in this patient, the concomitant ADT would likely be long-term given his age. However, Dr. D’Amico notes that in a healthy 57-year-old male he favors surgical treatment in this setting namely because patients may have a secondary, long-term malignancy and it is important to have all of the pathologic information necessary to proceed with radiation therapy. As Dr. Kibel astutely summarized, we should be thinking about whether patients are going to (i) live long enough to require treatment, (ii) live long enough to fail that treatment, and (iii) live long enough to need further treatment.
The final case was a 68-year-old healthy male with a longstanding history of BPH-related symptoms for many years. In the remote past he had a PSA elevation from 3.7 to 9.1 ng/mL, but refused a prostate biopsy. Subsequently he represented with a PSA of 45 ng/mL, a firm prostate on DRE, and biopsy Gleason 8 disease in multiple cores. A subsequent bone scan demonstrated diffuse osseous metastases, however CT of the abdomen/pelvis demonstrated no lymphadenopathy. His Karnoffsky performance status was an adequate 90%, and his hemoglobin, GFR and alkaline phosphatase were all normal. The panel was then provided with the following treatment options (i) LHRH agonist alone (add biccalutamide for flare only), (ii) LHRH agonist + bicalutamide, (iii) LHRH agonist + bicalutamide + six cycles of docetaxel, or (iv) LHRH antagonist + abiraterone acetate + prednisone. Dr. Smith notes that this patient is a good candidate for early docetaxel in addition to standard ADT, stating that patients with the highest likelihood of garnering the greatest benefit from early chemotherapy are those who are young with extensive metastatic disease. He subsequently mentioned that patients receiving abiraterone or enzalutamide in the chemo-naïve setting are likely to benefit, but to stay tuned for the reporting of two randomized controlled trials to be presented at ASCO next month.
Moderator: Andrew Stephenson, Cleveland Clinic, Cleveland, OH, USA
Panelists: Anthony D’Amico, Brigham and Womens Hospital and Dana Farber Cancer Institute, Boston, MA, USA; Stacy Loeb, New York University, New York, NY, USA; Matthew R. Smith, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA; Adam S. Kibel, Harvard University, Boston, MA, USA
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA