San Diego, CA USA (UroToday.com) JIn this session, Dr. Cooperberg opened by noting a >50% drop in age-adjusted prostate cancer mortality since the early 1990s. This victory is attributable to early detection and better treatment. However, prostate cancer is a global killer and is rising.
So, what treatment is best?
Based on PIVOT trial, one can argue that RP is more effective than watchful waiting alone. With regard to the question of radiation therapy versus surgery in high-risk men, the preponderance of data would suggest an approximately 50% risk reduction with surgery upfront compared to primary radiotherapy. This is most pronounced in intermediate and high risk disease with the best outcomes seen in multimodal therapy (surgery followed by radiation). Several randomized, controlled trials (RCTs) in this space are expected to return results in the next few years. For patients with M0 disease, some have considered neoadjuvant chemotherapy. CALGB 90203 is an RCT exploring this questions with results expected in about a year.
Perhaps the most important concept is the need to personalize decisions. Currently, we are at about 80% accuracy with risk stratification (CAPRA, D’Amico, etc) alone. However, perhaps the most relevant are the affymetric gene readouts offered by tests like decipher which is now available in both the biopsy and post-prostatectomy space.
Regardless, these questions must be answered. In the wake of the 2012 USPSTF grade D recommendation against the use of PSA screening, prostate cancer diagnosis across all risk types has occurred. On the one hand, this is a good thing since low risk disease is being diagnosed less frequently. However, a reduction in diagnosis of high risk disease will result in more metastatic disease (it is a mathematical certainty!).
In conclusion, Dr. Cooperberg summarized his talk by stating that there is a growing body of evidence suggesting a greater role for local therapy (including surgery) in high-risk prostate cancer. Aggressive multi-modal treatments need to be personalized and tailored to maximize both length and quality of life. High risk prostate cancer is increasingly treated aggressively in the US but many cases are still undertreated with ADT monotherapy. Delayed diagnosis is the worst undertreatment and our collective data must drive change at the policy level.
Presented By: Matthew R. Cooperberg, MD
Written By: Benjamin T. Ristau, MD; Fox Chase Cancer Center, Philadelphia, PA at the 2016 AUA Annual Meeting - May 6 - 10, 2016 – San Diego, California, USA
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