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Key Clinical Updates in Prostate Cancer
Multiparametric MRI (mpMRI) has emerged as the imaging study of choice for localized prostate cancer detection and characterization. Suspicious prostatic lesions may then be sampled via MRI-guided needle biopsy or via MR Fusion (in which prostate MRI images are fused in real-time with images from an ultrasound-guided needle biopsy). Such an approach may improve discovery of potentially life-threatening disease while limiting overdetection of indolent prostate cancer or unnecessary prostate biopsies.
NCCN guidelines recommend considering germline genetic testing in men presenting with localized high-risk, regionally advanced, or metastatic disease. Commercially available cancer tissue RNA-based assays are available for further risk assessment after prostate cancer diagnosis; these may help determine the need for and timing of prostate cancer treatment as well as treatment intensity.
A secondary data analysis from the Prostate, Lung, Colorectal, and Ovarian trial demonstrated that baseline PSA for younger men in their 50s can predict long-term risk of prostate cancer and can be used to tailor PSA screening intervals.
Active surveillance is now the preferred initial treatment recommendation for men with well-differentiated prostate cancer and low-risk clinical features.
Results from the PEACE-1 trial demonstrate that a three-drug regimen, with androgen deprivation therapy, docetaxel and abiraterone acetate used together, provides the best survival outcome for men with hormone-naïve metastatic cancer. With this regimen, the median survival for men with de novo metastatic prostate cancer is now expected to be 5 years.
Poly(ADP-ribose) polymerase (PARP) inhibitors represent a novel class of anticancer agents with some activity against prostate cancer particularly those harboring mutations in genes important for homologous recombination such as BRCA1, BRCA2, and ATM. There are two FDA-approved PARP inhibitors available for men with metastatic castrate-resistant prostate cancer with these genetic alterations.
Kovac E et al. JAMA Netw Open. [PMID: 31940039]
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GENERAL CONSIDERATIONS
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Prostate cancer is the most common noncutaneous cancer and the second leading cause of cancer-related death in American men with an estimated 248,530 new prostate cancer diagnoses and 34,130 prostate cancer deaths in 2021. The clinical incidence, however, does not match the prevalence of the disease. Autopsy studies have demonstrated that more than 40% of men over age 50 years have prostate cancer, and its prevalence increases with age with 30% of men aged 60–69 years and 67% of men aged 80–89 years harboring the disease at autopsy. Prostate cancer is an extremely heterogenous disease and most of these occult cancers are small, indolent, and organ-confined cancers with few occult cancers having regional or metastatic disease. Although the global prevalence of prostatic cancer at autopsy is relatively consistent, the clinical incidence varies considerably (highest in North America, Europe, the Caribbean, Australia/New Zealand, and Southern Africa, and lowest in Northern Africa and Asia). In 2020, prostate cancer was the leading cause of ...