Prostate Cancer Awareness Month With Ulka Vaishampayan, MD

Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm Keira Smith, and today I am joined by one of our Editorial Board Members, Dr. Ulka Vaishampayan. Thank you so much for coming on today.

Ulka Vaishampayan, MD: Thank you.

Oncology Data Advisor: We're having this interview today in honor of September being Prostate Cancer Awareness Month. In your opinion, why is it so important to raise awareness for prostate cancer?

Dr. Vaishampayan: Prostate cancer is very common. About one in four men, about the age of 50, who are being screened for prostate cancer, will find that as a diagnosis. Finding it early has a big significance because the earlier you find it, the more curable it is. There is a simple blood test and physical exam that you can use as a screening methodology to help early detection of prostate cancer. It is also important, besides monitoring the prostate-specific antigen (PSA) annually, to think about starting at an earlier age; if there are men with family members with prostate cancer, start at age 45 or, even at a baseline, at 40. African-American patients should ideally get a baseline PSA at age 45 and be rigorous about screening.

Also, there are a number of things that can impact the PSA level. Keep in mind that there are things like, if you are on medication for benign prostatic hypertrophy or depending on the clinical picture of some other medical conditions, can impact the PSA. But if you're on medication for benign prostate hyperplasia (BPH), definitely the cutoff for prostate cancer for the PSA screening should be lower than our traditional. Traditionally we expect a PSA about 4.0 to be considered for biopsy or at least have a discussion looking into diagnosis of prostate cancer. For patients who are on medication for BPH, that cutoff should be around 2.5.

Oncology Data Advisor: You mentioned prostate cancer screening and prevention; what are the current standards for these, and have there been any updates in the way that they're approached?

Dr. Vaishampayan: In screening, we are getting somewhat better in terms of screening. There are new tests that are being developed looking at blood tests to evaluate for presence of cancer. Currently though, the PSA remains our best go-to test—very easily available, overall a simple blood test that you can do once a year. I think it is important to think about screening for prostate cancer at age 50 or over, unless there are some special circumstances. Other advances in terms of early management, I think the treatment is getting better. So, even if you are diagnosed with early-stage prostate cancer, the new surgical techniques with robots and also cryotherapy and very exquisite planning techniques of radiation will help people get effective treatment with it actually having less and less long-term effects.

Oncology Data Advisor: Great. Have there been any new diagnostic techniques recently?

Dr. Vaishampayan: The big one I would say is if there is a high risk based on PSA or even for active surveillance. So, active surveillance for prostate cancer is becoming more and more adopted in the low-grade to intermediate-grade prostate cancer. So, not a very aggressive disease obviously, or high-risk disease that we have to treat, but for the patients who have very slow-growing, very early-stage prostate cancer, active surveillance is a valid option. Diagnostically, what allows us to separate out the high-risk from the low-risk is a couple of new things. One is a prostate magnetic resonance imaging (MRI), which is very useful in identifying high-grade or aggressive-looking areas within the prostate because we all know when we biopsy, we are getting a tiny piece and you could easily miss high-risk areas.

So, the imaging allows us to identify which areas are likely to be high-risk, and if they look like they are high-risk, we would avoid active surveillance and actually do treatment. The other thing is there are diagnostic techniques which are run on the tissue. When we biopsy, you can run a genomic score that allows us to identify—even if on basic pathology it's called low-grade or very early less aggressive disease—within the genomics, you can find out who of those patients is likely to have aggressive disease longer-term. So, that would be another way to run genomics on the tissue that we have available and identify the high-risk patients who should get active treatment versus the others who can go on active surveillance.

Oncology Data Advisor: Great, and I'm sure there have been a lot of advances in new therapies as well recently. What have some of these updates in therapeutic selection and management included?

Dr. Vaishampayan: Therapy is changing rapidly in this disease and very, very exciting advances are ongoing. In the last few years, we've basically altered the outcomes of advanced prostate cancer. So, in advanced prostate cancer, previously we used to say we only had hormone therapy, which is testosterone suppression therapy. That worked for about, on average, 18 months to 24 months, and then patients progressed and had rapidly symptomatic and progressive disease.

Now we have a number of medications. We have chemotherapy, we have immunotherapy, we have oral hormonal therapies that are extremely effective against this disease, and recently there was a radiopharmaceutical that was approved—also a PSA-targeted agent that releases radiation by attaching selectively to the prostate cancer cells. So, that is another exciting advantage. Radiopharmaceuticals have, in general, been used in this disease before. Clearly there are FDA approvals of things like radium-223, which was also effective and remains effective with overall survival benefit in patients with bone-only disease. The prostate-specific membrane antigen (PSMA) targeted radiation is actually effective against all the different areas of disease that express PSMA. So, that has changed things dramatically.

The other big diagnostic and therapeutic scan is the PSMA positron emission tomography (PET) scan, and that has altered dramatically how we look at this cancer. If it is an early-stage relapse where only the PSA is going up after surgery, radiation, whatever the patient has had before treatment-wise, then looking at a PSMA scan will tell us and identify those small areas of cancer where previously we didn't find any evidence of disease until the PSA was much, much higher—20 to 30 range and above on our conventional computed tomography (CT) scan and bone scan. We typically do not find any evidence of disease spread at PSAs of less than 10 or even 20. PSMA PET scan, however, will identify those areas of disease and allow us to do early intervention with radiation—a very focused radiation called stereotactic radiation to those areas and maybe alter the course of the disease.

Long term, we are not quite sure yet, but at least it will allow patients to be able to delay androgen deprivation therapy or hormone testosterone suppression therapy, which of course has a number of side effects. Specifically—I mean besides the hot flashes and fatigue—there is bone loss, there is increased risk of fractures, and there is a small increased risk of cardiac events and dementia; things like that that have been shown. So, if we can delay or avoid starting the androgen deprivation therapy, that is a worthy goal in these relapsed patients. Because of that, we are finding metastatic disease earlier and earlier, and hopefully with these effective treatments we'll be able to at least limit the duration of how long we treat these patients and put them in remission. So, hopefully long-term we don't have to keep on going on the therapy longer-term.

The other big change in therapy has been that early treatment in metastatic disease. Previously we used to wait until patients progressed on one avenue of therapy, which was the hormone injections, and then we use the second-line and the third-line therapies. Now, there is more and more evidence that tells us that using a doublet therapy or treatment intensification upfront is definitely contributing to longer-term life expectancy. So, because of that, if in an otherwise healthy patient, if they have metastatic disease, it is important to consider not just androgen deprivation therapy but adding chemotherapy with docetaxel and doing oral agent—one of the androgen receptor inhibitors such as enzalutamide, apalutamide, or darolutamide, and also abiraterone and prednisone.

Oncology Data Advisor: Great. It's so exciting that there have been so many new advances recently. In light of September being Prostate Cancer Awareness Month, what are some of the ways that clinicians can better raise awareness of prostate cancer and also help advocate for their patients?

Dr. Vaishampayan: I think clinicians should consider and discuss prostate cancer screening and elicit family history in every patient on an average. It is important to have that discussion and talk to patients that early detection is going to save lives—the earlier we find any cancer, for that matter, but clearly for prostate cancer. We are lucky enough to have a screening technique that is fairly effective to use. So, absolutely, I think it is important to advocate and say this is a potentially preventable cancer with screening.

Oncology Data Advisor: Great. Well, thank you so much for coming on today to talk about all these new updates and the ways that we can help to raise awareness.

Dr. Vaishampayan: Thank you.

About Dr. Vaishampayan

Ulka Vaishampayan, MD, is a Professor of Internal Medicine and the Director of the Phase 1 Program at the University of Michigan Rogel Cancer Center. She is also the Chair of the Southwest Oncology Group (SWOG) Advanced Renal Committee, a member of the National Cancer Institute (NCI) Renal Task Force, and a board member of the Michigan Society of Hematology/Oncology. Dr. Vaishampayan specializes in the treatment of genitourinary malignancies, including prostate cancer, bladder cancer, and renal cell carcinoma, and her research focuses on translational drug development.

Transcript edited for clarity. Any views epressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.