Increasing the use of active surveillance for prostate cancer in younger men

Contemporary Review of Multimodality Imaging of the Prostate Gland

Tissue changes and the enlargement of the prostate, whether benign or malignant, are among the most common groups of diseases that affect men and can have significant impacts on length and quality of life. The prevalence of benign prostatic hyperplasia (BPH) increases significantly with age and affects nearly all men as they grow older. Other than skin cancers, prostate cancer is the most common cancer among men in the United States. Imaging is an essential component in the diagnosis and management of these conditions. Multiple modalities are available for prostate imaging, including several novel imaging modalities that have changed the landscape of prostate imaging in recent years. This review will cover the data relating to commonly used standard-of-care prostate imaging modalities, advances in newer technologies, and newer standards that impact prostate gland imaging.

Integration of magnetic resonance imaging into prostate cancer nomograms

The decision whether to undergo prostate biopsy must be carefully weighed. Nomograms have widely been utilized as risk calculators to improve the identification of prostate cancer by weighing several clinical factors. The recent inclusion of multiparametric magnetic resonance imaging (mpMRI) findings into nomograms has drastically improved their nomogram's accuracy at identifying clinically significant prostate cancer. Several novel nomograms have incorporated mpMRI to aid in the decision-making process in proceeding with a prostate biopsy in patients who are biopsy-naïve, have a prior negative biopsy, or are on active surveillance. Furthermore, novel nomograms have incorporated mpMRI to aid in treatment planning of definitive therapy. This literature review highlights how the inclusion of mpMRI into prostate cancer nomograms has improved upon their performance, potentially reduce unnecessary procedures, and enhance the individual risk assessment by improving confidence in clinical decision-making by both patients and their care providers.

Case Study of Noni Extract in Men with Very Low-Risk or Low-Risk Prostate Cancer

The optimal treatment strategy for patients with early prostate cancer (PCa) is unknown. We explored the feasibility of administering noni supplementation to modify gene expression of a relevant clinical signature in the prostate of men on active surveillance for PCa. A total of 6 participants with low-risk (n=5) to very low-risk (n=1) PCa who were candidates for active surveillance received 6200 mg/day of noni in capsule form for 1 year; median age was 65.5 years (range, 58-75 years). Participants were tested for serum prostate-specific antigen (PSA) levels every 3 months. At 12 months, they underwent a repeat transrectal ultrasound-guided prostate biopsy. These biopsy samples were queried for expressing 12 key genes and rates of apoptosis, angiogenesis, and proliferation. The primary outcome was the change in expression of the 12 genes that comprise the Oncotype DX prostate cancer test from baseline to 12 months of noni supplementation. Noni was well tolerated, with only 1 participant reporting side effects of grade 2 diarrhea, requiring a drug holiday of 7 days. Median serum PSA slightly increased from 7.1 ng/mL (4.4-9.7 ng/ mL) prior to therapy to 7.9 ng/mL (5.7-10.2 ng/mL) on therapy. Changes were observed in the expression levels of several genes, including FAM13C, KLK2 (associated with the androgen pathway), and GSTM2 (associated with cellular organization) at 12 months. Noni supplementation was associated with favorable clinical parameters, including stable serum PSA among most patients and no evidence of tumor on repeat biopsy, and correlated with modulation of numerous genes and proteins.

Impact of biopsy perineural invasion on younger prostate cancer patients after radical prostatectomy

OBJECTIVES

To identify the potential indicators for higher-risk disease and poor outcome in younger prostate cancer (PCa) patients (age ≤ 50) who had undergone radical prostatectomy (RP) in the prostate-specific antigen (PSA) era.

MATERIALS AND METHODS

A total of 186 PCa cases of age ≤ 50 who underwent RP between 2003 and 2010 at our center were included for study. High-risk disease after RP was defined as cases with pre-PSA ≥ 20 ng/ml and/or Gleason score (GS) ≥ 4 + 3 and/or pT stage ≥ 3. The poor outcome group was defined as cases with biochemical recurrence (BCR) and/or metastasis (Mets) and/or all-cause death. Multivariate logistic regression models were performed to identify independent risk factors for both high-risk disease and poor outcome.

RESULTS

Among 186 younger PCa patients aged ≤ 50, 36 cases (19.5%) had high-risk disease and 24 cases (12.9%) had poor outcome. The presence of biopsy perineural invasion (BxPNI) was significantly associated with high-risk disease and showed a trend to correlate with worse outcome in univariate analysis. On multivariate logistic regression analysis, BxPNI was shown to be a significant independent risk factor with covariate of D'Amico for poor outcome (p = 0.047) and an independent risk factor with covariate of BxGPC for high-risk PCa excepting the variables to define high-risk disease (p = 0.013). Prognostically, cases with BxPNI showed a poor BCR-free survival in univariate analysis but did not reach significance (p = 0.063).

CONCLUSION

Our results show that BxPNI could be considered as a risk classification factor to identify the best candidates among younger PCa patients for further treatment and may also be used for developing active surveillance (AS) selection criteria for younger PCa patients.