Moving Treatments Earlier in Prostate Cancer Can Prevent Progression, Additional Treatment

With new therapies, it’s possible to justify using more aggressive treatments on earlier-stage disease with the hope that it will prevent additional treatment down the line, said Stephen Freedland, MD, director of the Center for Integrated Research in Cancer and Lifestyle at Cedars Sinai.

Understanding which patients will progress is important, though, he added. However, current prognostic factors, such as prostate-specific antigen (PSA), that can be used to identify patients at risk of progression, are only prognostic and not predictive.

At the American Urological Association (AUA) annual meeting, Freedland presented in a session on treatment sequencing and survival of localized or locally advanced prostate cancer in the real world.

Transcript

Why is it important to understand the ideal sequencing of treatments and the burden of subsequent treatments for localized or locally advanced prostate cancer?

We're developing a lot of new—we the field, not me, personally, but the field is developing a lot of new—therapies for localized prostate cancer. In the past, they've been used for late-stage [disease], but they're now being applied to earlier stage—really understanding that a lot of patients with early-stage disease will progress to late-stage disease. The idea is, if we can treat them early and aggressively and prevent some of those progressions, even though we're being more aggressive, we can actually prevent subsequent treatments down the road and ultimately lead to better outcomes. That's the hope. So, really understanding what the journey is for those patients is really important.

How might your findings presented at AUA change decisions around primary treatment with radical prostatectomy or radiotherapy and subsequent treatment decisions once progression occurs?

I think what we're finding is that a fair number of patients do go on to need subsequent therapies. We need to better identify who those patients are. But I think it tells us that there is room to do better and that we need to do better for our patients to prevent some of those late-term outcomes. I think it opens the door to us being more aggressive early, up front, and then taking our foot off the pedal. You know, we've done an aggressive treatment, stop, and hope that that did the trick.

How do we identify who will progress? Are there any ways of more accurately predicting progression that are being studied?

Yeah, there's a lot of research. I mean, we certainly know patients with higher PSA, higher Gleason [score], [and] greater tumor burden [are more likely to progress]. There [are] multiple genetic tests that can be done on the tumor to help us understand how aggressive it's going to be. But the challenge is, most of the treatments and most of the prognostic factors we have now are that: are prognostic, they're not predictive. If a patient walks in the door with bad disease, I know he has bad disease. I just don't know what to do about it. I think that's the next generation of those sorts of tests. We're not fully there yet.