Prostatepedia

Black Men - October 2023

Tue, 07 Nov 2023 16:47:00 GMT

This issue talks about Black Ment and Prostate Cancer>

Prostate cancer is a significant health concern affecting men worldwide, with disparities in its impact evident across different demographic groups. Among these, black men face a higher risk of developing prostate cancer and are more likely to experience aggressive forms of the disease. The intersectionality of race and health outcomes is a complex issue; addressing the disparities in prostate cancer among black men requires a multifaceted approach. Access to healthcare emerges as a critical factor, as barriers to early detection, timely high quality treatment, and high quality ongoing care contribute to the disproportionate burden borne by black men.

Prostate cancer is the second most common cancer among men globally, and black men exhibit higher incidence rates compared to other racial or ethnic groups. Studies have consistently shown that black men are not only more likely to be diagnosed with prostate cancer but also face a greater likelihood of aggressive forms of the disease. This elevated risk is attributed to a combination of genetic, environmental, and socio-economic factors. However, one of the most significant contributors to disparate outcomes is the unequal access to healthcare.

Access to healthcare encompasses a broad spectrum, ranging from preventative measures and early detection to timely and appropriate treatment. Unfortunately, black men often encounter barriers at various stages of this continuum. Economic disparities, inadequate health insurance coverage, and a lack of culturally competent healthcare providers contribute to delayed or neglected screenings. Socioeconomic factors, such as lower income levels and higher rates of unemployment, can limit the ability to afford regular healthcare services, including routine screenings for prostate cancer.

Cultural factors also play a role in access to healthcare. Distrust of the medical system, historical injustices, and cultural norms may dissuade black men from seeking medical attention until symptoms are severe. This delayed engagement with healthcare can result in more advanced stages of prostate cancer upon diagnosis, limiting treatment options and worsening outcomes.

To address these disparities, community outreach initiatives are crucial. Increasing awareness about prostate cancer, emphasizing the importance of regular screenings, and providing information about available resources can empower black men to take charge of their health. Culturally sensitive education campaigns, delivered through trusted community leaders and organizations, can help dispel myths, reduce stigma, and foster a more proactive approach to healthcare.

Improving access to healthcare also involves addressing systemic issues. Policies that expand healthcare coverage, reduce economic barriers, and promote diversity within the healthcare workforce can contribute to more equitable health outcomes.

In each of the discussions that follow, key opinion leaders in prostate cancer detection and treatment talk about long understood aspects of the problem, new insights into the black experience of prostate cancer, and potential avenues for addressing entrenched disparities.

Link to this month's issue

Imaging - March - April 2023

Tue, 13 Jun 2023 13:34:00 GMT

This issue focuses on two major advances in imaging that should both have major impacts on the care men with prostate cancer receive.

The first is that it is now clear that MRI is superior to transrectal ultrasound as a method to make the initial diagnosis of prostate cancer. Actually, the superiority of MRI has been apparent for some years. One major advantage of MRI is that it is superior to transrectal ultrasound in visualizing the cancer.

In fact, ultrasound is so inadequate in seeing the cancer that the subsequent biopsy is essentially done blind with the cancer only detected if by chance the biopsy needle hits the cancer. As a result, it has been common practice to do multiple blind biopsies on both sides of the gland.

In contrast, MRI tells the physician the precise location of the cancer and as a result, the biopsy is targeted rather than blind. As an added advantage, MRI is most likely to miss small, indolently growing cancers that do not require treatment.

While transrectal ultrasound may not be able to reliably visualize the cancer, it can be useful in guiding the biopsy of a cancer detected by MRI. With this approach, the MRI image showing the cancer location is fused with the ultrasound image that visualizes the prostate gland and surrounding structures. The urologist can then use this fused image to accurately biopsy the cancer while minimizing the risk of damage to normal tissue.

The second major advance is the development of the PSMA-PET scan. The PSMA-PET scan represents a dramatic advance in visualizing prostate cancer that has spread outside the gland to lymph nodes, bone or other organs. It has proven its utility in newly diagnosed patients in detecting cancer outside the gland in patients who might otherwise be candidates for radical prostatectomy.

It is also of use in determining the extent of the cancer in those with more advanced disease. Finally, it is the most sensitive approach to finding the location of cancer recurrent after surgery or radiation. In addition, the PSMA antibody used to carry the isotope needed to image the cancer can be used to deliver radiation of sufficient intensity to treat the cancer.

The combined impact of these two imaging advances is potentially large. If these are not yet available your area, it is worthwhile to travel to gain access.

Charles E. Myers, Jr. MD

Interviews:

Michael Hofman, MD
Imaging and Treatment

Declan Murphy, MD
Imaging and Theranostics

Ali Arafa, MD
PSMA-PET Change Treatment?

Link to the Flip Book version of Prostatepedia

Metastatic Hormone-Sensitive - January - February 2023

Wed, 12 Apr 2023 21:13:00 GMT

This issue covers some of the advances made in treating men with metastatic prostate cancer who have not yet received hormonal therapy.

In patients with high-volume metastatic disease, the current standard treatment is the combination of hormonal therapy with docetaxel chemotherapy. In patients healthy enough to tolerate the addition of chemotherapy, the addition of docetaxel results in much better survival.

One major advance reviewed in this issue is the impact of adding either abiraterone or daurolutamide to the combination of hormonal therapy with docetaxel. In patients with large-volume disease, the addition of the third drug results in improved cancer control. Note that both trials looked at adding additional testosterone blockade to the hormonal therapy plus docetaxel combination. This leaves open the question of whether it is beneficial to add docetaxel to the combination of hormonal therapy and abiraterone or daurolutmide.

For the last several years of prostate cancer treatment, there have been two schools of thought about when to initiate therapy in men with recurrent prostate cancer. One school has favored delaying treatment until symptoms or medically threatening disease develop. Advocates of this approach note that cancer treatment is toxic and delaying treatment might offer patients a longer period of high quality of life.

The second school of thought noted that the risk of treatment-resistant cancers being present increases as cancer cells increase. Thus, the high-volume disease is more likely either resistant before therapy starts or emerges earlier once treatment has started.

As this issue illustrates, which approach is correct depends on the treatment context. For example, docetaxel is an effective addition when added to hormonal therapy for high volume, but not low volume disease. In contrast, it appears that drugs like abiraterone, enzalutamide, apalutamide or daurolutamide, originally introduced for men with castration-resistant prostate cancer (CRPC), are also effective when used earlier in the course of disease.

This issue also discusses some of the challenges and opportunities for biomarker development in prostate cancer. Biomarkers are tests that can help guide treatment decisions by providing information about the tumor's molecular characteristics or the patient's response to therapy. Biomarkers can help identify patients who are more likely to benefit from a specific treatment or may need a different or more aggressive approach.

One example of a biomarker that has been approved by the FDA for prostate cancer is the prostate-specific antigen (PSA) test. PSA is a protein produced by prostate cells that can be measured in blood samples. PSA levels can indicate how well a patient is responding to hormonal therapy or other treatments. However, PSA is not a perfect biomarker, as it can be influenced by other factors, such as inflammation or benign prostatic hyperplasia (BPH).

Another example of a biomarker that is being investigated for prostate cancer is circulating tumor DNA (ctDNA). ctDNA is DNA that is released by tumor cells into the bloodstream and can be detected by sequencing techniques. ctDNA can provide information about the genetic mutations and alterations that are present in the tumor and may affect its sensitivity or resistance to certain drugs. ctDNA can also help monitor tumor evolution and progression over time.

However, some limitations and challenges are associated with biomarker development and validation for prostate cancer. For instance, not all tumors shed ctDNA into the blood, and ctDNA levels may vary depending on the tumor burden and location. Moreover, there is a need for standardized methods and criteria for biomarker testing and interpretation across different laboratories and clinical trials.

In summary, this issue provides an overview of some of the recent advances and ongoing research in the field of prostate cancer treatment and biomarker development. Click on the following link to view this issue.

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Chemotherapy - November - December 2022

Wed, 12 Apr 2023 21:05:00 GMT

It is now customary to treat men with newly diagnosed advanced prostate cancer with Lupron and Docetaxel. In a major advance, we now know adding the androgen blocking drugs abiraterone or daurolutamide to this two drug combination significantly improves cancer control. This advance is the major topic of this issue.

It is important to appreciate that the clinical trials involved have limitations. One is that trials did not include a third arm with either Lupron plus abiraterone or daurolutamide.

This has led some to question whether the latter two hormonal agents might replace Docetaxel with little loss in cancer control, while allowing patients to postpone exposure to chemotherapy. Hopefully, this question will be addressed in a timely fashion.

Charles E. Myers, Jr., MD

P4
Rahul Aggarwal, MD
Chemotherapy For
Prostate Cance

P8
Andrew J. Armstrong, MD
Chemotherapy for
Prostate Cancer

P14 Jorge A. Garcia, MD, FACP
Chemotherapy for
Prostate Cancer Today

P20 Cora N. Sternberg, MD
Chemotherapy for
prostate cancer today

P24 David VanderWeele, MD
Brian M

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Immunotherapy - October 2022

Wed, 12 Apr 2023 20:59:00 GMT

Immunotherapy has an interesting status in prostate cancer treatment research. It has attracted some of the best minds in prostate cancer research and motivated innovative laboratory and clinical research. However, we currently have only one agent FDA-approved for the treatment of prostate cancer, Provenge (Sipuleucel-T). Provenge is a cell-based vaccine that involves harvesting a patient’s immune cells, growing them up in large number and exposing these cells to a fragment of a protein found on prostate cancer cells. These cells are then infused back into the patient. This triggers an immune response to the cancer.

Provenge was approved by the FDA in 2010 for the treatment of patients with metastatic hormone resistant prostate cancer because it improved survival. One factor that has limited the use of Provenge is that patients often experience no shrinkage of cancer metastases nor a drop in the PSA. On the plus side, this vaccine has minimal side effects compared to most cancer treatment options.

Among the various immunotherapeutic approaches discussed in this issue, the immune check point inhibitor, B7-H3, looks promising. In this issue, Dr. Emmanuel Antonarakis covers the current status of agents that target B7-H3, including dramatic results in an early small trial in pre-prostatectomy patients. In addition to its role in protecting cancer cells from the immune system, this protein also appears to foster metastatic spread by stimulation invasion and abiogenesis.

Charles E. Myers, Jr., MD

P4
Lawrence Fong, MD
Frontiers in
Immunotherapy

P8
Oliver Sartor, MD
Immunotherapy For
Prostate Cancer in 2022

P10
James Gulley , MD
Immunotherapy Today

P14 Emmanuel Antonarakis, MD
Advances in Immunotherapy

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Testing - July 2022

Tue, 30 Aug 2022 14:48:00 GMT

The processes involved in cancer treatment are and the greater the odds you will defeat your enemy. As you read this issue, consider how you might use additional testing to improve your treatment plan. often presented using military metaphors. How often have you heard that a patient is battling cancer? As I write, Ukraine is in a historic battle to prevent Russian from taking over the country. By all accounts, they have been much more successful than most experts had expected.

This early success is the result of several factors. First, intelligence agencies from the US and other NATO members gave the Ukrainians valuable information about the location of Russian troops and their supply lines. Second, the same allies supplied arms to the Ukrainians that were an excellent fit for the situation on the battlefield. Third, the Ukrainians proved to be better skilled, lead and motivated than the Russians.

This issue is devoted to advances in tests used to identify patients with prostate cancer and to better define possible treatment options. I have always envisioned this as equivalent to gathering military intelligence prior to the start of a war. The more you understand about your opponent, the better your strategy will be and the greater the odds you will defeat your enemy. As you read this issue, consider how you might use additional testing to improve your treatment plan.

Charles E. Myers, Jr., MD

Link to July's Prostatepedia

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Theranostics - May 2022

Mon, 06 Jun 2022 10:16:00 GMT

This issue is devoted to the first successful theranostic treatment for prostate cancer.

The strategy involves a two step approach and derives it's name from the combination of the terms therapeutics and diagnostics.

First, PSMA imaging is done by linking an antibody to the PSMA molecule to a radioactive isotope optimized for imaging. If the imaging scan picks up metastatic cancer that avidly binds the imaging agent, a second anti-PSMA preparation loaded with lutetium-177 is injected.

This radioactive isotope emits beta particles with sufficient intensity kill the PSMA-expressing cancer cells. The resulting antitumor responses are sufficiently impressive that this treatment is likely to become FDA-approved

Charles E. Myers, Jr., MD

Click here to view the article

Radiation Therapy - March 2022

Mon, 28 Mar 2022 12:25:00 GMT

Intro:

This issue offers a concise overview of the major trends in radiation therapy. This is timely as some of these advances are already altering treatment in a major way.

From the patient's point of view, one of the significant problems with radiation therapy was the time commitment: treatment took up to 8 weeks. Several approaches have been tested to reduce the time needed for treatment. The best-established alternative is stereotactic radiation, which takes less than a week. This approach is discussed by Dr. Zelefsky, who has played a major role in the development of this technique.

Imaging of normal and cancerous tissue plays a critical role in radiation therapy. Clearly delineating the extent of the cancer in relation to surrounding normal tissue aids treatment planning, resulting in better odds of cancer control and minimizing normal tissue damage. The PSMA scan represents a major advance in our ability to identify small metastatic prostate cancer lesions. While this is likely to revolutionize radiation therapy of oligometastatic disease, much work remains to be done on the details of who is most likely to benefit.

Hormonal therapy of metastatic prostate cancer has been revolutionized by abiraterone and the newer androgen receptor blockers. Clinical trials in progress are testing whether these agents might also improve adjuvant hormonal during radiation therapy.

Finally, molecular tools provide us with an increasingly clear understanding of the mechanisms that determine the behavior of cancer cells. These tools are now being tested do their capacity to guide radiation therapy. One such approach, the Decipher panel, is undergoing extensive evaluation.

Charles E. Myers, Jr., MD

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Immuno-oncology - December 2021

Tue, 11 Jan 2022 01:18:00 GMT

We only have one FDA-approved immunotherapy for prostate cancer, Provenge (sipuleucel-T). However, that may be about to change. Research on how to harness the immune system to treat cancer is advancing rapidly on a broad front.

For example, the treatment of hematologic malignancies, such as leukemias, lymphomas, and multiple myelomas, has been revolutionized by the CAR-T technique. This approach involves removing the patient’s T-cells and inserting a gene that causes the T-cell to recognize and attack the cancer of interest. These modified T-cells are then grown in large numbers in the lab and infused back into the patient, where they, hopefully, attack the patient’s cancer. While this approach has been established in the treatment of hematologic malignancies, carcinomas, such as prostate cancer, have proved to be more difficult to target. As you will read about later in this issue, early results suggest we may finally have a promising CAR T treatment for prostate cancer.

Antibodies’ role in the immune system is to specifically bind to proteins that are present on an invading infectious organism. This can then interfere with the function of that protein. Alternatively, antibody binding can target the invading organism for destruction. An example very much in the news is the neutralizing antibodies binding to the spike protein of the COVID-19 virus. The ability of antibodies to bind to targets with great specificity has been used in innovative ways. In this issue you will read about antibodies linked to radioactive isotopes to image or destroy cancer cells. Another approach is to create molecules that can link to a T cell at one end and the cancer cell at the other end, with the hope that bringing these two cells into proximity will cause the immune cell to attack the cancer cell.

Even when T cell manage to invade a mass of prostate cancer cells, the environment within the cancer mass tends to inactivate these immune cells. Progress in identifying the mechanisms by which the cancer inactivates the immune cells is discussed along with various strategies to reverse the inactivation.

Charles E. Myers, Jr., MD

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Chemotherapy - September 2021

Tue, 12 Oct 2021 14:47:00 GMT

This issue is focused on when to use Taxotere (docetaxel) chemotherapy. Taxotere (docetaxel) is most commonly used after hormonal therapy options have lost their effectiveness.

However, the CHAARTED trial showed that this is not necessarily the best option for all patients. This trial involved randomizing newly diagnosed men with metastatic prostate cancer to Lupron (leuprorelin) alone versus Lupron (leuprorelin) plus Taxotere (docetaxel) chemotherapy. Patients in both groups were divided into those with extensive disease versus those without extensive disease. The results showed a dramatic survival benefit for Taxotere (docetaxel) for those with extensive disease, but not in those patients with less extensive disease. The overall survival for those with extensive disease was 51.2 months on Lupron (leuprorelin) plus Taxotere (docetaxel) versus 34.4 months for those on Lupron (leuprorelin) alone. As cancer clinical trials go, this is a rather dramatic improvement in overall survival. The results of the CHAARTED trial were subsequently confirmed by the STAMPEDE trial.

Despite the clear survival benefit to early Taxotere (docetaxel), many patients with extensive disease do not receive early Taxotere (docetaxel), but rather proceed to exhaust all hormonal therapy options first. Perhaps the major reason for this is that many prostate cancer patients are very reluctant to go on chemotherapy. First, many have family or friends who have received aggressive multi-drug chemotherapy for other cancers that was extremely toxic. Second, many men think that going on chemotherapy means that the end is near. Neither of these objections reflect the reality of Taxotere (docetaxel) treatment. In this issue, our experts review the many advantages to early Taxotere (docetaxel) administration. I hope this leads more patients with extensive disease to take advantage of Taxotere (docetaxel) as part of their initial treatment.

Charles E. Myers, Jr., MD

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Imaging - June 2021

Tue, 27 Jul 2021 14:50:00 GMT

This issue is focused on the PSMA scan, which represents a major advance in prostate cancer imaging. This technique allows us to image prostate cancer metastases to bone and other sites down to 2-4 mm, far below the threshold of the commonly used CT and MRI scan.

The PSMA scan looks to improve the management of prostate cancer at several points in the natural history of this cancer. In men with newly diagnosed prostate cancer, this scan will improve our ability to identify men with early metastatic disease. These men are likely to recur after radical prostatectomy and can better be treated by approaches that take into consideration the extent of their disease.

In patients with metastatic disease, this scan is much better than the CT and bone scan in identifying the sites of metastatic disease. This will likely improve our ability to identify oligometastatic disease as well as direct radiation therapy in this setting. It is also likely to do a better job documenting response to systemic treatment as well as progression.

It is important to recognize that this scan has certain limitations. While this scan is quite sensitive, it does have a lower limit of 2-4 mm in the size of the metastases it can visualize. Additionally, there are prostate cancers that produce little or no PSMA and are thus not identified by this scan. Some metastatic lesions have been shown to have areas that are PSMA negative and areas that are positive. Thus treatment targeted at PSMA positive cancer might foster the emergence of PSMA negative cancer.

Charles E. Myers, Jr., MD

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Testing - April 2021

Tue, 08 Jun 2021 15:01:00 GMT

This issue represents a rather detailed look at the current state of blood and tumor tissue testing in prostate cancer. The PSA is the classic example against which new tests can be compared. The PSA is largely useful in so far as the measured value is proportional to the total mass of prostate tissue, normal plus malignant. As a screening tool, PSA elevation can signal the presence of cancer and the PSA rate of increase can reflect the pace of cancer growth.

Unfortunately, other processes, such as prostatitis, can also cause PSA elevation and aggressive cancers can make less PSA per gram of tissue. These factors have limited the value of the PSA for screening.

For patients who are post prostatectomy or radiation therapy, there are fewer issues and the PSA doubling time is a widely used prognostic indicator for patients with recurrent disease.

How do the other tests discussed in this issue act to provide additional or more accurate information about prostate cancer?

Genomic tests can provide information on important functional differences between normal tissue and cancer. Perhaps the best example of this are mutations in the DNA repair genes, BRCA2 and ATM. Germline mutations in these genes increase the risk of prostate cancer and the resultant cancers tend to be more aggressive. These mutations can also develop as prostate cancer progresses and have been observed in 20-30% of hormone resistant cases.

Furthermore, cancer cells bearing these mutations are more likely to respond to drugs that inhibit PARP, a different DNA repair protein. Thus, testing for BRCA2 or ATM tells us about changes in the cancer’s ability to repair DNA damage, shed light on the risk of aggressive disease, and help select effective treatment. Tests like these that reveal functional differences between normal and cancer cells have great promise to improve treatment of prostate cancer. This approach has already been successfully applied to other cancers, such as non-small cell lung cancer, where it has revolutionized treatment.

Genomic changes need not be assessed at such a focused fashion as is done with BRCA2. Instead, multigene DNA, RNA, or protein patterns can be measured and tested for their ability to predict cancer aggression or response to standard therapy. Examples of this approach include the Decipher, Oncotype Dx, and Prolaris tests.

These tests can be viewed as supplementary to or even competitive with standard histologic evaluation by a pathologist. This has naturally led to some controversy about their role. In this issue, Dr Epstein does an effective job critically comparing histology versus the genomic approach. In my view, the relative role of the two ways of assessing future cancer behavior is still very much an open issue.

We hope you enjoy this issue as much as we have enjoyed putting it together.

Charles E. Myers, Jr., MD

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Immuno-Oncology and PARP Inhibition - November 2020

Fri, 20 Nov 2020 02:44:00 GMT

Three topics dominate this issue: the current status of the Provenge (sipuleucel-T) vaccine, the status of other immunotherapy techniques under development, and the use of poly ADP ribose polymerase (PARP) inhibitors. Behind these specific topics, this issue illustrates how the treatment paradigm has been shifting. Prostate cancer treatment selection has traditionally been done without knowledge of the specific molecular characteristics of a given patient’s cancer. The revolution in molecular biology increasingly allows a clinician to test for these molecular changes and then tailor the treatment to the patient and his cancer. These techniques are also providing other benefits. We now know some of the mechanisms that allow prostate cancer to evolve resistance to existing treatment options. This knowledge then leads to new drug development or new approaches to immunotherapy. One example of this is the new generation of antiandrogens, starting with Zytiga (abiraterone acetate) and Xtandi (enzalutamide).

PARP inhibitors are a new class of drugs that are a direct outcome of research on molecular changes that have a profound impact on prostate cancer biology. This story starts with the discovery of gene mutations associated with familial breast cancer: breast cancer type 1 and type 2 susceptibility proteins. These are abbreviated as BRCA-1 and BRCA-2. These two proteins are involved in DNA repair, and when they are inactivated by mutations, DNA repair is less efficient, leading to a greater likelihood that cancercausing mutations will develop. In cells with BRCA-1 or -2 mutations, some residual DNA repair does take place using the PARP. This allows sufficient DNA repair for the cancer cell to survive. If PARP is also inactivated, the cancer cell dies. This led to the development of drugs to inhibit PARP. These drugs proved to be more useful in BRCA-1 or -2 mutant ovarian rather than breast cancer and are now standard in the treatment of ovarian cancer.

Studies have shown that men who inherit mutationally inactivated BRCA-2 are at increased risk of developing prostate cancer. These cancers tend to be very aggressive, rapidly becoming resistant to hormonal therapy and are associated with short survival. BRCA-2 mutations are relatively uncommon in men with newly diagnosed prostate cancer, but they become more common as the cancer progresses through standard treatments. Clinical trials have shown that PARP inhibitors have useful activity against prostate cancer that has mutations in BRCA-2 and other DNA repair mutations. As a result, PARP inhibitors are now approved for the treatment of prostate cancer.

As discussed by several interviewees, there are reasons to think that combining PARP inhibitors with immunotherapy might prove beneficial. This issue also contains information about which patients are most likely to benefit from Provenge (sipuleucel-T).

In general, patients with less extensive disease and a slower prostate-specific antigen (PSA) doubling time tend to do better. Finally, a range of potentially new approaches to immunotherapy of prostate cancer are discussed. If you fit the eligibility requirements, you might want to consider entering one of the clinical trials.

Charles E. Myers, Jr., MD

Link to November's Prostatepedia

Chemotherapy - August 2020

Tue, 25 Aug 2020 19:36:00 GMT

This issue marks a new era for this publication as it is the first to be published under the NASPCC umbrella. We anticipate that this will allow us to reach a much larger audience.

As an old hand in the field, it is very gratifying to see the steady stream of high-quality clinical trials define the best treatment options for those with advanced disease. The good news is that, for most patients with advanced disease, you and your physician have a range of options so that treatment can be tailored to your situation.

For patients with newly diagnosed metastatic prostate cancer, a vast majority of patients should no longer be treated solely with testosterone suppressing agents, such as LHRH agonists like Lupron (leuprolide). Instead, they should receive these agents combined with either Taxotere (docetaxel) or one of the newer androgen antagonists, such as Xtandi (enzalutamide). Indeed, the literature on cytotoxic chemotherapies, like Taxotere (docetaxel), is so intertwined with anti-androgens that these hormonal agents occupy a considerable portion of this issue. This serves patient interests well, as many will need to discuss anti-androgens as an alternative to chemotherapy. This issue is information-dense and it is not practical to highlight all of the key points in this introduction. Instead, I would like to highlight two relatively new drugs that look as if they might have a major impact. The first is Nubeqa (darolutamide), which is FDA-approved and in the same drug family as Xtandi (enzalutamide) and Erleada (apalutamide). The latter two cross the blood-brain barrier (BBB) and can impair brain function and can be associated with seizures. Nubeqa (darolutamide) does not cross the BBB and is much less likely to cause central nervous system toxicity (CNST). The second drug is Relumina (relugolix), an oral drug that blocks the production of testosterone much more effectively than Lupron (leuprolide). In comparison, Relumina (relugolix) has a lower risk of cardiovascular events, but it is not yet approved for the treatment of prostate cancer.

Each of our interviewees discusses the impact of the Novel Coronavirus on the management of prostate cancer patients. The good news is that, with proper precautions, it is possible to give chemotherapy safely despite the pandemic.

Charles E. Myers, Jr., MD

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Imaging - October 2019

Sat, 02 Nov 2019 15:36:00 GMT

This month we’re talking about” “imaging for prostate cancer.” “Imaging technology is advancing” “rapidly and is transforming” “both prostate cancer diagnosis” “and offering new insight into” “how prostate cancer spreads” “throughout the body. Less clear,” “of course, is how these new” “advances will impact treatment.”

“Dr. Ammar Chaudry of City of” “Hope gives us a good overview” “of the kinds of imaging techniques” “men are likely to encounter during” “their prostate cancer journey.”

“Dr. Oliver Sartor breaks down” “for us the five different types” “of PET scans available today—” “how they work, when they’re” “used, the kinds of information” “they provide, and how their” “results impact treatment.”

“Dr. Thomas Hope offers an in-depth” “analysis of the newest advances” “in imaging, including PSMA” “targeted imaging compounds,” “C-11 Choline, and C-11 ACETATE.” “He also updates on the progress” “of UCSF’s application to the” “FDA for the 68Ga-PSMA-11 scan.” “If that application is approved, in” “about June 2020, the scan will be” “available for you at both UCSF and” “UCLA. That application is unique” “in the sense that UCSF did not” “make it proprietary—which means,” “ultimately, that the 68Ga-PSMA-11” “scan may well become readily” “available to many of you in” “a few short years.”

“There are several issues ways” “that improved imaging might” “improve the management of” “prostate cancer. First, the standard” “imaging techniques used to stage” “prostate cancer, the bone scan” “and CT scan, are well known” “to miss bone and lymph node” “metastases in many patients.” “This is part of the reason so” “many patients progress after” “initial treatment with surgery” “orradiation. Improved imaging” “techniques are likely to do a better” “job detecting metastases that are” “currently missed by bone scan and” “CT scan. This would allow patients” “with early metastatic disease to” “receive more effective treatment” “than local therapy solely directed” “at the prostate gland.” “Second, improved imaging” “techniques are important to” “the rapidly evolving treatment” “of oligometastatic disease.” “This approach is based on the” “concept that there are patients” “who have a limited number” “of cancer metastases and that” “treatment of these metastatic” “deposits with radiation might slow” “cancer progression or even induce” “a durable remission. The better” “we are able to detect the true” “extent of the metastatic disease,” “the more effectively the cancer” “can be targeted.”

Charles E. Myers, Jr., MD

Link to October's Issue

Erectile Dysfunction - September 2019

Wed, 18 Sep 2019 02:27:00 GMT

For men just diagnosed with prostate cancer, the threat treatment poses for sexual function looms large and can play a major role in which treatment they choose. It can even lead some men to choose to avoid or delay treatment. It can even lead some men to avoid tests that can lead to the diagnosis of prostate cancer so that they are not confronted with the possible loss of sexual function. In this review, we will try to put these issues into perspective to help patients think more clearly about decisions they face.

First, I should point out that prostate cancer and its treatment do not represent the most common threat to male sexual function. The most common medical cause of male sexual dysfunction is cardiovascular disease that damages the blood flow to the penis. In fact, loss of erectile function can often be an indication of developing cardiovascular disease and is associated with a greater risk of heart attack or stroke. As you might expect, this scenario is more likely if you have hypertension, diabetes, or elevated cholesterol or triglycerides. Management of these risk factors for cardiovascular disease can often improve erectile function. These issues are quite common in men with prostate cancer and can make impotence from prostate cancer treatment more likely. If you want to preserve sexual function, you should work with your physician to optimize cardiovascular health.

Second, I should point out that as prostate cancer progresses it can impair sexual function. The arteries and nerves to the penis sit on either side of the prostate gland. As the cancer grows, it will engulph these arteries and nerves, resulting in the loss of sexual function. As a result, if you have clinically significant cancer and need treatment, the no treatment option will not prevent loss of sexual function. This path might only serve to delay for a while that loss.

Charles E. Myers, Jr., MD

Link to September's Issue

Chemotherapy - August 2019

Tue, 13 Aug 2019 20:29:00 GMT

Many patients fear chemotherapy not only because of its side effects but also because of what the need for chemotherapy implies about their prognosis. Fortunately, each physician we spoke with this month addresses both issues.

Taxotere (docetaxel), the chemotherapy drug most commonly used to treat prostate cancer, is usually used to treat patients with an aggressive form of this disease. However, multiple randomized trials have shown that this drug prolongs survival. We see the most dramatic impact in patients who have extensive metastatic disease at the time of diagnosis. The CHAARTED trial showed that initial treatment with Lupron (leuprolide) plus Taxotere (docetaxel) was markedly more effective than Lupron (leuprolide) alone in prolonging survival. There is a definite benefit to receiving the drug, if you need it.

The most common side effect of Taxotere (docetaxel) is fatigue, which is usually mild after the first dose, but worsens with each subsequent dose. Sometimes, this limits the total number of doses administered. Usually, this side effect disappears over time. Exercise lessens its potency, and each physician in this issue recommends exercise.

Taxotere (docetaxel) damages the nerves in the hands and feet. This leads to a feeling of numbness and tingling in the fingers and toes called neuropathy. This grows in severity with each dose of the drug, but when stopped in a timely fashion, the side effect is reversible.

In 2003, Gedlicka et al. reported that alpha lipoic acid minimized nerve damage (https://academic.oup.com/ annonc/article/14/2/339/153613). Since the publication of this paper, we recommended two 300 mg tablets of time-release alpha lipoic acid twice a day during Taxotere (docetaxel) treatment in my practice. It appears to have a marked impact on the severity of this side effect.

Taxotere (docetaxel) damages the production of hair and nails. Hair loss can be prevented by chilling the scalp as the drug is administered. Chilling the hands and feet also seems to lessen the nail damage.

Prolonged Taxotere (docetaxel) treatment can also damage and block the tear ducts, causing tears to flow. Some physicians recommend inserting silicon rubber tubes in the tear ducts when the symptoms first appear. Once the tear ducts have closed, repair is much more difficult.

Many chemotherapy drugs cause a drop in hemoglobin, white cells, and platelets. While these can be a problem with Taxotere (docetaxel), it is milder than in the multidrug combinations used for other common cancers, such as breast cancer. Transfusions can be used if the drop in hemoglobin becomes clinically significant. Low white cell count can be managed with granulocyte stimulating factor (G-CSF). While a low platelet count can be managed by platelet transfusions, these lose their effectiveness over time. This can be a major problem in a few patients.

Patients on Taxotere (docetaxel) often experience inability to taste food. Patients have often reported that bland creamy foods are easier to eat. Overall, the side effects of Taxotere (docetaxel) develop gradually as the number of cycles on the drug accumulates. If treatment is limited to six cycles, these side effects are usually mild and reversible. Most patients have nearly complete recovery within 6 months. If the cancer is still sensitive to the drug, a second round can be effective and well tolerated.

Charles E. Myers, Jr., MD

This month's Prostatepedia

Genomics Clinical Trials - July 2019

Fri, 05 Jul 2019 19:12:00 GMT

This issue is devoted to the genetics and genomics of prostate cancer, which is one of the most promising and exciting areas of prostate cancer research. Already, this line of investigation is having a major impact. For example, by better defining the genomics of patients entering clinical trials, there can be a marked reduction in the number of patients needed to reach statistical significance. This can potentially reduce the costs of drug development dramatically.

Research into the role of genetics and genomic alterations in the biology and treatment of prostate cancer are still at a much earlier stage than it is for breast cancer. While laboratory studies have discovered a wide range of genes that might act to determine prostate cancer behavior in the clinic, proof that these changes actually determine outcome in the clinic are rather limited. There are even fewer examples where drugs attacking these changes have been FDA-approved for the treatment of prostate cancer.

The PD-1 inhibitor, Keytruda (pembrolizumab) is at present the only example. In 2017, this drug

was approved to treat cancers that show mismatch repair or microsatellite instability. These mutations are found in a small proportion of prostate cancer patients.

There are a number of mutations targeted by drugs that are in advanced testing, so this list may expand rapidly. One of the more promising targets is BRCA2. Mutations that alter the function of this gene are known to be involved in breast and ovarian cancer. Cancer cells with these BRCA2 mutations become dependent on the protein, PARP, for their survival and drugs that inhibit PARP can be effective therapy. Studies on patients with advanced prostate cancer show that altered BRCA2 is found in 10-30% of cases. PARP inhibitors have shown significant activity in early clinical trials. Randomized controlled trials needed for FDAapproval are in progress.

Genomic information can also be used to determine how likely prostate cancer is to behave aggressively. This can help identify patients who are likely to do well with active surveillance or to be at low risk for recurrence after an initial attempt at curative treatment.

While genomics promises to revolutionize the treatment of prostate cancer, this revolution requires support from the patient community. The key studies can only be done if patients elect to participate in these trials. For this reason, we made sure to provide you with information on how to become involved in this process.

Charles E. Myers, Jr., MD

July's Issue

Helping Other Patients - June 2019

Mon, 10 Jun 2019 01:59:00 GMT

In June, we’re talking about ways in which you as a patient can benefit from and in turn contribute to the prostate cancer community.

What do we mean by that? Chances are, when you were first told that you had prostate cancer, you were afraid. Once that fear passed—if it did—you realized you had some decisions to make. There are a lot of controversies in how the medical profession treats prostate cancer; the path is not always clear. Shared decision-making means that you, as a patient, have to participate and form your own opinion: you can no longer just leave everything up to the discretion of your doctor. This is a good thing, but it does require more effort on your part. Most of you turned to friends and family or began searching online for more information. Some of you joined support groups where you learned from other men with the disease.

The things you learned as you moved through that process are valuable —whether your cancer is under control or not. Your experience will help other men in countless ways.

How can you share that experience with others?

You can join a support group. You can even start a support group if you live in a community without an active group. (Read carefully the conversations with Silicon Valley support group leader Rupen Sheth and Us TOO’s Director of Support Group Services Terri Likowski about how to go about this.) You can even join an online support group if making it out to a monthly in-person meeting isn’t possible.

But what if that type of interaction really doesn’t fit with your personality or lifestyle? You can potentially get involved with clinical research advocacy. We published a conversation with the chair of the Southwest Oncology Group’s patient advocate committee last month, and this month, we feature a conversation with their Patient Advocate Tony Crispino, who works with leaders in prostate cancer research on cutting edge clinical trials.

Or, your cancer itself can contribute to our global prostate cancer community. How? If you’ve got metastatic prostate cancer, your blood or saliva can help researchers build a genomic registry of prostate cancer so that they can learn as much as they can about prostate cancer. Read Dr. Eli Van Allen’s conversation to find out about how to join and what types of strides his Metastatic Prostate Cancer Project has been making in the past year and a half.

The point is that some greater good can come from your prostate cancer journey. You can contribute to our efforts to eradicate this disease: whether it’s in the form of sharing your story with a friend over a cup of coffee or helping researchers decode the information carried within your blood.

Charles E. Myers, Jr., MD

Link to June's Issue

Clinical Trials - May 2019

Tue, 28 May 2019 16:39:00 GMT

In May, we’re talking about clinical trials for prostate cancer patients. We also have an ulterior motive: we would love it, if after reading this issue, each and every one of you asks your doctor if there is a clinical trial that is appropriate for you. Why? Clinical trials are the only path to furthering our understanding about how and why prostate cancer occurs—and progresses—in some people and not others. It’s also the only way we can develop new and better ways to treat prostate cancer. But all of that is lofty and altruistic.

How do you, as an individual patient, benefit from joining a clinical trial? First, you may be able to access treatments, procedures, or imaging that you would not otherwise be able to access.

And even if you’re on the control arm of a study, you’ll get standard of-care, which could mean drugs, scans, or procedures at a reduced cost. At the very least, when you join a trial you will be more rigorously monitored by the study team, which could lead to better outcomes for you. Studies show that patients on clinical trials tend to do better than those not on clinical trials, even if they get the same treatment.

When should you consider looking for a trial? Right after you’re diagnosed. Just ask your doctor if there are any trials that are right for you. There may not be. But by asking, you’re letting her know that you’re interested so that, the next time she runs across a trial looking for patients like you, she’ll be sure to bring it to your attention.

Once you enter a trial, make sure you let the investigators know that you’re interested in the results. Of course, given both prostate cancer’s long natural history and the clinical trial process, those results may not come for many years after your actual participation, but let the researchers know that you’d like to know the results once they’re available.

As you’ll read in the conversation with Ms. Merith Basey, too many clinical trial results go unreported in the United States and on a global scale. How can you help? As Ms. Basey points out, if you graduated from a United States university, call or write your alma mater to let them know that you’d like the administration to ensure that every trial conducted under their auspices is reported—whether those results are positive or negative.

Charles E. Myers, Jr., MD

Link to May's Issue.