Mr. Wolinsky’s PC story was used as an introduction to every speaker talk in the this year’s session. He discussed his journey, which started with a DVD in the backroom of a urology office. He reports that 6 years ago, it was challenging to find a practitioner who would help him understand the different treatment options and, more specifically, assist him in navigating the AS option. Mr. Wolinsky reported that at the time of his diagnosis, he had to become his own advocate and see at least three different urologists until he finally felt comfortable with his therapy decision. The journalist emphasized the importance of patient education and the management of expectations during AS. A recent trial called REASSURE ME uses mindfulness therapy to help patients cope with the anxiety related to AS with the hope that more individuals remain on an AS protocol.
Mr. Wolinsky observed the underuse of AS in the United S tates compared with Canada, where up to 90% of patients with low-risk PC are managed with this type of expectant management. He stated that the penetrance of AS has been improving stateside, but still remains low at 60%.
The remainder of the session was used for a panelist discussion based on several patient scenarios. The first patient scenario presented was that of a 61-year-old man with a family history of PC and a prostate-specific antigen (PSA)of 6.5 who is found to have Gleason 6 PC in 4/12 cores. The audience is asked to initially vote on different treatment modalities using the audience response system, with the results as follows: 62% would recommend AS, with 29% suggesting radical prostatectomy. The discussion began with talk of AS’s safety in patients with a strong family history of PC. Dr. Laurence Klotz discussed family-history inflation in PC, which is related to the overtreatment area of the disease, where most of those treated presented with PC that was low grade and low stage. There are emerging data that patients with BRCA germline mutations tend to progress to metastatic disease, which brings up the point that genetic testing should be done in all patients placed on an AS protocol. Dr. Eeles stated that the data currently available is rather limited, and the incidence of BRCA mutations in PC is so low that further analysis of the data is required before making generalizations.
The second patient scenario was similar to the first one, but this individual presented with a PSA of 15 and Gleason 6 disease in 1/12 cores. The discussion about this patient focused on imaging and the need to further evaluate for occult disease. The panel agreed on performing a prostate magnetic resonance imaging test in this patient. If the test proved negative, most practitioners would feel comfortable placing the patient on AS. Dr. Klotz quoted his data, which stated that in the patient with Gleason 6 disease and negative magnetic resonance imaging, PSA elevation in the 15-to-20 range had no impact on progression.
The third and final patient scenario was again a 61-year-old man with a PSA of 6.5, but with Gleason 3+4=7 disease in 1/12 cores and 20% of that core being compromised by pattern 4 disease. The audience was asked to vote, with 18% recommending AS, 45% radical prostatectomy, and 28% radiation-based therapy. Dr. Freddie C. Hamdy of the University of Oxford noted that although this patient had Gleason 4 pattern, he still should be considered a strong candidate for AS. Dr. Klotz was not so optimistic, though, reporting that with long term follow-up, this patient had a 20% risk of progressing to metastatic disease and, thus, further risk stratification was needed in this patient cohort for AS to be performed safely.
Presented By: Howard Wolinsky, MS, Medill School of Journalism, Northwestern University
Written By: Andres F. Correa Society of Urologic Oncology Fellow, Fox Chase Cancer Center
at the 2017 Genitourinary Cancers Symposium - February 16 - 18, 2017 – Orlando, Florida USA