Dr Angela Jia Outlines Decisions on Treatment or Observation in Prostate Cancer

Most urologists follow prostate-specific antigen (PSA) closely to determine treatment in patients with prostate cancer, as well as various risk factors, explained Angela Jia, MD, PhD, radiation oncologist, University Hospitals, and assistant professor of medicine, Case Western Reserve University School of Medicine.

Transcript

What are the patient or tumor characteristics you look for to determine observation or treatment initially for prostate cancer?

When you have a patient in front of you and the PSA is not detectable after surgery, I think for most of us, we are not giving adjuvant therapy in that moment. We're following them very closely on PSA, and letting that PSA tell us if he were to have a biochemical recurrence.

I think the scenario where there may be a little bit of practice variation would be when he has those certain very high-risk factors. Node-positive disease, Gleason score 8 or 9, involvement of several vesicles of T3B. And certainly, if the PSA never became undetectable—the PSA was detectable—then you are thinking, “OK. This patient may be needing salvage therapy sooner or later.” And at that point, it's also a consideration of where is he in terms of his urinary recovery from surgery. When can I safely give the salvage radiation? Do I need to bring in a hormonal therapy? That would be androgen deprivation therapy, ADT.

A lot of times, for radiation oncologists, when you know salvage radiation is needed and that hormone therapy is also needed, we put the patient on hormonal therapy as he continues to recover…to buy you time—because the moment they're on hormone therapy, they are being treated—to buy you some time for urinary recovery before you give the salvage radiation.

At what point might the decision be made to switch from observation to treatment?

I would say it's a mixture of, what were his risk factors and the PSA. I mentioned the risk factors before. The T stage…is how much does this cancer come out of the prostate? N stage [is] whether lymph nodes were involved or not. The Gleason score. What was the PSA after surgery? How fast is the PSA increasing? What we call PSA doubling time. How long has it been since surgery? From surgery to biochemical recurrence. And then also, genomic classifiers. In particular, the 22-gene genomic classifier is very prognostic and useful, in addition to molecular scans like a PET scan.