Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program

Addressing Challenges and Controversies in the Management of Prostate Cancer with Multidisciplinary Teams

The diagnostic and treatment landscapes of prostate cancer are rapidly evolving. This has led to several challenges and controversies regarding optimal management of the disease that outpace guidelines and clinical data. Multidisciplinary teams (MDTs) can be used to engage the array of specialists that collaborate to treat complex malignancies such as prostate cancer. While the rationale for the use of MDTs in prostate cancer is well known, ways to optimally use MDTs to address the challenges and controversies associated with prostate cancer management are less well understood. One area of MDT care that remains undefined is how MDTs can most effectively provide guidance on clinical decision-making in situations in which information from novel diagnostic testing (genetic testing, molecular imaging) is substantially different from the established clinical risk factors. In this review, we provide a clinical perspective on ways that MDTs can be used to address this and other challenges and controversies across the prostate cancer disease continuum, from diagnosis to end-of-life considerations. Beyond clinical scenarios, we also review ways in which MDTs can mitigate disparities of care in prostate cancer. Overall, MDTs play a central role in helping to address the daily vexing issues faced by clinicians related to diagnosis, risk stratification, and treatment. Given the accelerating advances in precision medicine and targeted therapy, and the new questions and controversies these will bring, the value of MDTs for prostate cancer management will only increase in the future.

[Active surveillance-much safety, little recruitment : Is it possible to extend the indication for "intermediate-risk" prostate cancer?]

BACKGROUND

In contrast to North America or Sweden, active surveillance (AS) has not yet become established in our country for suitable prostate carcinomas (PCa). The strict entry criteria specified by the guideline are not likely to improve the acceptance in the near future. In early detection, prostate-specific antigen (PSA) testing leads to high numbers of overtreatment. There are various reasons for the continued preference for radical surgery.

OBJECTIVES

The goal is to examine whether the heterogeneous group with intermediate-risk PCa contains tumors that may be eligible for AS.

MATERIALS AND METHODS

In the HAROW trial, 52 AS patients with differently defined intermediate-risk PCa were followed for a median of 85.6 months. Oncologic outcomes are reported.

RESULTS

Sixteen (30%) patients had a tumor of cT2b category, 21 (40%) had a Gleason score 3 + 4, 7 (14%) had ≥3 positive biopsy cores, 21 (40%) had a PSA >10 ng/ml, and 22 (42%) had a PSA density >0.2 ng/ml². Carcinoma-specific and metastasis-free survival were 100% and 96%, respectively. Thirty four patients discontinued AS in favor of invasive treatment, and an additional eight men maintained a noninvasive approach by switching to watchful waiting.

CONCLUSIONS

Efforts are under way to specify the criteria for patients with intermediate-risk PCa who may be eligible for AS. Tumors of cT2 category could be grouped together. The Gleason 4 fraction needs to be quantified because it determines the prognosis.

The Growth of Integrated Care Models in Urology

With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.

Rethinking prostate cancer screening: could MRI be an alternative screening test?

In the past decade rigorous debate has taken place about population-based screening for prostate cancer. Although screening by serum PSA levels can reduce prostate cancer-specific mortality, it is unclear whether the benefits outweigh the risks of false-positive results and overdiagnosis of insignificant prostate cancer, and it is not recommended for population-based screening. MRI screening for prostate cancer has the potential to be analogous to mammography for breast cancer or low-dose CT for lung cancer. A number of potential barriers and technical challenges need to be overcome in order to implement such a programme. We discuss different approaches to MRI screening that could address these challenges, including abbreviated MRI protocols, targeted MRI screening, longer rescreening intervals and a multi-modal screening pathway. These approaches need further investigation, and we propose a phased stepwise research framework to ensure proper evaluation of the use of a fast MRI examination as a screening test for prostate cancer.

Anti-androgen monotherapy versus gonadotropin-releasing hormone agonists in men with advanced, non-metastatic prostate cancer: a register-based, observational study

BACKGROUND

In randomised controlled trials, men with advanced, non-metastatic prostate cancer (PCa) treated with anti-androgen monotherapy (AA) had similar all-cause mortality as men treated with gonadotropin-releasing hormone (GnRH) agonists. Using real-world evidence (i.e., observational data), we aimed to further assess the difference in mortality between these two drug categories.

MATERIAL AND METHODS

We emulated a trial using data from Prostate Cancer data Base Sweden 3.0. We specifically focused on men diagnosed in 2006-2012 with high-risk PCa who had no distant metastasis. They either received primary hormonal therapy with AA (n = 2078) or GnRH agonists (n = 4878) who were followed for a median time of 5 years. Risk of death from PCa and other causes was assessed using competing risk analyses and Cox proportional hazards regression analyses, including propensity score matching.

RESULTS

The cumulative 5-year PCa mortality was lower for men treated with AA (16% [95% confidence interval, CI, 15-18%]) than men treated with GnRH agonists (22% [95% CI 21-24%]). The 5-year other cause mortality was also lower for men on AA (17% [95% CI 15-19%] compared to men on GnRH agonists (27% [95% CI 25-28%]). In regression analyses, the risk of PCa death was similar, GnRH agonists versus AA (reference), hazard ratio (HR) 1.08 (95% CI 0.95-1.23), but the risk of death from all causes was higher for men on GnRH agonists, HR 1.23 (95% CI 1.13-1.34). Consistent results were seen in the propensity score-matched cohort.

CONCLUSION

Our results indicate that the use of AA as primary hormonal therapy in men with high-risk non-metastatic PCa does not increase PCa-specific mortality compared to GnRH. Using AA instead of GnRH agonists may result in shorter time on/exposure to GnRH-treatment, which may reduce the risk of adverse events associated with this treatment.

Prolaris Cell Cycle Progression Test for Localized Prostate Cancer: A Health Technology Assessment

BACKGROUND

Prostate cancer is very common and many localized tumours are non-aggressive. Determining which cancers are aggressive is important for choosing the most appropriate treatment (e.g., surgery, radiation, active surveillance). Current clinical risk stratification is reliable in forecasting the prognosis of groups of men with similar clinical and pathologic characteristics, but there is residual uncertainty at the individual level. The Prolaris cell cycle progression (CCP) test, a genomic test that estimates how fast tumour cells are proliferating, could potentially be used to improve the accuracy of individual risk assessment. This health technology assessment sought to determine the clinical utility, economic impact, and patients' perceptions of the value of the CCP test in low- and intermediate-risk localized prostate cancer.

METHODS

We conducted a systematic review of the clinical and economic evidence of the CCP test in low-and intermediate-risk, localized prostate cancer. Medical and health economic databases were searched from 2010 to June or July 2016. The critical appraisal of the clinical evidence included risk of bias and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also analyzed the potential budget impact of adding the CCP test into current practice, from the perspective the Ontario Ministry of Health and Long-Term Care. Finally, we conducted qualitative interviews with men with prostate cancer, on the factors that influenced their treatment decision-making.

RESULTS

For the review of clinical effectiveness, we screened 3,021 citations, and two before-after studies met our inclusion criteria. In one study, the results of the CCP test appeared to change the treatment plan (from initial to final plan) in 64.9% of cases overall (GRADE rating of the quality of evidence: Very low). In the other study, the CCP test changed the treatment received in nearly half of cases overall, compared with the initial plan (GRADE: Very low). No evidence was available on clinical outcomes of patients whose treatment was informed by CCP results. For the review of cost-effectiveness, 100 citations were identified and screened. No studies met the inclusion criteria. In our economic evaluation, we estimated that publicly funding the CCP test would result in a total net budget impact of $41.3 million in the first 5 years, mostly due to the cost of the CCP test. In our model, the relatively small cost savings ($7.3 million) due to treatment change (increased use of active surveillance and decreased use of interventional treatment) was not large enough to offset the high cost of the test. Patients viewed the test as potentially helpful but, due to the complexity of treatment decision-making, were unsure the test would ultimately change their treatment choices.

CONCLUSIONS

We found no evidence to demonstrate the impact of the Prolaris CCP test on patient-important clinical outcomes. The limited evidence available shows that the test appears to provide information that, when considered in addition to clinical risk stratification, may change the treatment plan or actual treatment for some low- and intermediate-risk prostate cancer patients. As a result, there is insufficient data to inform the cost-effectiveness of the CCP test. Publicly funding the CCP test would result in a large incremental cost to the provincial budget.

Improving outcomes in veterans with oropharyngeal squamous cell carcinoma through implementation of a multidisciplinary clinic

BACKGROUND

Treatment of head and neck cancer is complex, and a multidisciplinary clinic may improve the coordination of care. The value of a head and neck multidisciplinary clinic has not yet been established in oropharyngeal squamous cell carcinoma (SCC).

METHODS

A retrospective review was conducted of Veterans Affairs patients with oropharyngeal SCC undergoing concurrent chemoradiation before and after implementation of the head and neck multidisciplinary clinic.

RESULTS

Fifty-two patients before and 54 patients after multidisciplinary clinic were included in this study. Age, tobacco use, and p16+ status were similar between groups. With multidisciplinary clinic, time to treatment decreased, and utilization of supportive services, including speech pathology, dentistry, and nutrition increased. The 5-year disease-specific survival rate increased from 63% to 81% (p = .043) after implementation of the multidisciplinary clinic. Multivariate analysis showed that disease stage (p = .016), p16 status (p = .006), and multidisciplinary clinic participation (p = .042) were predictors of disease-specific survival.

CONCLUSION

Implementation of a multidisciplinary clinic improved care coordination and disease-specific survival in patients with oropharyngeal SCC. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1106-1112, 2017.

Abiraterone acetate and prednisone in chemotherapy-naïve prostate cancer patients: rationale, evidence and clinical utility

Abiraterone acetate 1000 mg/day, combined with prednisone 5 mg PO twice daily, is indicated for the treatment of metastatic castration-resistant prostate cancer (mCRPC). Abiraterone acetate is the oral prodrug of abiraterone, a specific CYP17 inhibitor that blocks androgen biosynthesis within the adrenal glands, testes and tumor microenvironment. In a phase III trial of men with asymptomatic or minimally symptomatic, chemotherapy-naïve mCRPC, treatment with oral abiraterone acetate plus prednisone led to a statistically significant improvement in the co-primary endpoints of overall survival and radiographic progression-free survival when compared with placebo plus prednisone. In long-term follow-up of phase III trials, the incidence of corticosteroid-associated adverse events was 25.5% in the abiraterone acetate plus prednisone arm compared with 23.3% in the placebo plus prednisone arm. The need for regular patient monitoring and appropriate management of symptoms during long-term use of prednisone must be placed in context with the improvement in survival seen with abiraterone plus prednisone. Within the multidisciplinary environment that is emerging to meet quality and cost imperatives, abiraterone acetate plus prednisone is suitable for use in the chemotherapy-naïve population with minimal symptoms as well as in patients who have been treated with docetaxel and may have symptomatic disease. Ongoing trials are evaluating the role of abiraterone acetate plus prednisone in patients with nonmetastatic CRPC and metastatic hormone-sensitive prostate cancer, while further trials in the mCRPC setting are evaluating its use in combination regimens.

Construction of a fusion plasmid containing the PSCA gene and cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) and its anti-tumor effect in an animal model of prostate cancer

Cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) is a negative regulator of T cell activation, which competes with CD28 for B7.1/B7.2 binding, and which has a greater affinity. Fusion of specific antigens to extracellular domain of CTLA4 represents a promising approach to increase the immunogenicity of DNA vaccines. In this study, we evaluated this interesting approach for CTLA4 enhancement on prostate stem cell antigen (PSCA)-specific immune responses and its anti-tumor effects in a prostate cancer mouse model. Consequently, we constructed a DNA vaccine containing the PSCA and the CTLA-4 gene. Vaccination with the CTLA4-fused DNA not only induced a much higher level of anti-PSCA antibody, but also increased PSCA-specific T cell response in mice. To evaluate the anti-tumor efficacy of the plasmids, murine models with PSCA-expressing tumors were generated. After injection of the tumor-bearing mouse model, the plasmid carrying the CTLA4 and PSCA fusion gene showed stronger inhibition of tumor growth than the plasmid expressing PSCA alone. These observations emphasize the potential of the CTLA4-fused DNA vaccine, which could represent a promising approach for tumor immunotherapy.