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Treating Fast Growing Prostate Cancers

Posted Aug 24 2008 1:49pm
ANNOUNCER: The profile of the typical man who is first diagnosed with prostate cancer is changing. That's largely due to the increasingly routine blood screening of men over fifty for a protein called PSA, often a signal of prostate disease.

JAMES A. EASTHAM, MD: So if you start checking earlier men, it's almost a self-fulfilling prophecy that you'll find these cancers at a younger age. The point is also you'll find them at an earlier, more curable stage as well.

ANNOUNCER: Another trend, of course, is longer lifespan. That means men are more likely to die from their prostate cancer, even if it grows very slowly.

JAMES A. EASTHAM, MD: Men aren't dying as young as they used to. So in some ways, they're living long enough to be bothered by their prostate cancer. And a man who's 50 has probably a 30-year life expectancy. If he's diagnosed with prostate cancer, it's unlikely that in that 30-year period of time, the cancer won't grow.

ANNOUNCER: So it may be more important than in years past to use aggressive treatments, at least in some cases. This is called "adjuvant therapy," meaning additional therapy after primary treatment with surgery or radiation, to guard against recurrence. But there are often difficult side effects, so doctors don't want to treat people unnecessarily.

DANIEL P. PETRYLAK, MD: It's important for us to select which patient is going to have very aggressive disease or which patient simply can be cured with local treatment.

ANNOUNCER: Sorting out how aggressive a particular prostate cancer is likely to be is not easy.

JAMES A. EASTHAM, MD: One of the difficulties that we have is identifying or characterizing a cancer as being slow growing or fast growing. That's one of the active areas of research, is to try to identify newer ways to characterize a cancer, because you would obviously treat a faster growing cancer perhaps aggressively or as a slower growing cancer, you might even be able to watch.

ANNOUNCER: Doctors traditionally use three factors in trying to determine how aggressive a particular cancer might prove to be.

DANIEL P. PETRYLAK, MD: Gleason score is a measure as to how aggressive a cancer is. So if we look at the cancer under the microscope, the less aggressive lesions appear to be more organized, and the most aggressive lesions almost look like spaghetti. They're very, very disorganized. So the Gleason score is a way of measuring the degree of organization and disorganization. The more disorganized the higher the Gleason score and hence the higher the chance of the cancer coming back.

ANNOUNCER: The second factor is whether or not the disease has spread to nearby lymph nodes. These glands, which are part of the immune system, are often the first place prostate cancer spreads when it has metastasized.

DANIEL P. PETRYLAK, MD: The third factor is the extent of the local disease, whether there is a high percentage of the prostate involved with tumor, also whether the prostate cancer has invaded into the seminal vesicles, or whether the prostate cancer has penetrated the capsule and is outside the surgical margins. These are other things that we look for in the pathology after the prostate has been removed.

ANNOUNCER: There are some newer techniques, too. One called PSA velocity, measures how the PSA count changes over time. Some doctors believe if PSA rises quickly, it may signal particularly dangerous disease. So, what can be done when these factors point to an especially aggressive cancer?

DANIEL P. PETRYLAK, MD: Firstly, if their lymph nodes are involved, we generally will recommend that the patient undergo hormone therapy. And there's been evidence that demonstrates that those patients who immediately receive hormone therapy after having their prostates out — and these are the patients with positive lymph nodes — will do much better and will live longer than those patients who do not receive the immediate hormone therapy.

ANNOUNCER: Following surgery or radiation not only with hormonal therapy, but also with chemotherapy and other treatments, may also prove to be effective. Right now, these approaches are under study.

JAMES A. EASTHAM, MD: What the newer trials will likely look at is combining those traditional methods with other strategy very early based on risk, not necessarily based on: Ah, he has cancer. But: He has a high risk of failing, even though we can't find anything with X-rays or even PSA, we're going to treat him with an additional therapy be it hormonal therapy, chemotherapy, biological therapy in order to enhance the cure rate.

ANNOUNCER: One set of preliminary data suggests the possible value of adjuvant chemotherapy.

DANIEL P. PETRYLAK, MD: There is a very small study of 96 patients; 48 of these patients had no evidence of cancer outside of the prostate. And what was done was they randomized patients to receive either hormone therapy or hormone therapy plus mitoxantrone-prednisone chemotherapy. And it seems that there is a better survival in those patients who receive the chemotherapy. But we have to be very cautious because it's a very small study, and we're currently doing a randomized trial of more than 1300 patients to see whether the survival advantage is true or not.

ANNOUNCER: Many doctors and researchers hope the future of prostate cancer treatment might become more similar to the treatment of other types of cancer.

JAMES A. EASTHAM, MD: Certainly the hope in prostate cancer is that we catch up to other cancers. That we learn as they have in breast cancer and in colon cancer that treating with combinations of therapies early on seems to provide the patient with more benefit.

ANNOUNCER: Given the limited knowledge the role of chemotherapy in treating prostate cancer, advances depend on participation in clinical trials.

JAMES A. EASTHAM, MD: My hope is that these results from the chemotherapy trials will encourage urologists, medical oncologists to consider enrolling their patients in these important clinical studies which are the only way to answer these questions. Get your patients, if they're at high risk, involved in one of these trials, so we can address what is the best way for a patient to be treated, to maximize cure and minimize toxicity.

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