Not All High-Risk Prostate Cancer is Equal
“The fact there is such variation in the clinical outcomes of men with high-risk prostate cancer suggests that we should not treat everyone the same.”
When a man is diagnosed with prostate cancer, doctors look at his PSA level, clinical stage, and the Gleason score of the biopsy tissue samples to assign that cancer a risk factor. “Knowing whether it’s low, intermediate, or high-risk prostate cancer can help patients and their physicians determine roughly how aggressive the cancer is,” says Trinity Bivalacqua, M.D., Ph.D., “and that, in turn, helps determine the best course of treatment.” However, new research done by Bivalacqua, Debasish Sundi, M.D., and colleagues suggests that not all high-risk prostate cancer is the same. This work was published in the May 2014 issue of the journal, Prostate.
“Some men with high-risk disease are cured with treatment such as radical prostatectomy, while other men in the same high-risk category, even after undergoing aggressive treatment, will experience a rapid recurrence of their cancer,” says Bivalacqua, Director of Urologic Oncology, and “this issue can present a dilemma to patients and their urologists trying to formulate an optimal treatment plan.”
With the hope of fine -tuning the highrisk category and predicting which men have the most aggressive cancer, Sundi and Bivalacqua designed a study of men with high-risk prostate cancer who underwent radical prostatectomy. “We wondered if we could determine which ones are most likely to experience early cancer recurrence,” says Sundi. (Early recurrence is defined in this s tudy as having a detectable PSA of 0.2 ng/ml or greater within the first year after treatment.) “We needed to use precise pre-treatment predictors,” Bivalacqua explains, “because by the time pathologic data are available, the men with the most aggressive cancers may potentially have missed their window to try a more intense, multimodal treatment approach.”
Sundi, Chief Resident of Urology and lead author on the paper, says, “we found that men meeting a certain set of criteria were the most likely to experience early biochemical recurrence. Furthermore, these same men were at a more than threefold higher risk of having the cancer spread to distant sites, and dying from their cancer,” than other high-risk men. Clearly, says Bivalacqua, “there are significant differences even within this single group of ‘high-risk.’” Men at highest risk of early recurrence of cancer were found to have either primary Gleason pattern 5 present on any biopsy core; or four or more biopsy cores containing Gleason pattern 4, primary or secondary. (In a Gleason score such as 3+4, the primary pattern is the first number, 3, and the secondary pattern is the second number, 4.)
“The fact there is such variation in the clinical outcomes of men with high-risk prostate cancer suggests that we should not treat everyone the same,” Bivalacqua adds. This study suggests that “high-risk men who meet early-recurrence criteria, whom we would predict to have much more aggressive cancers, should be offered more aggressive treatments up front.” For example, to maximize their chances of cure, these men might strongly consider enrolling in a clinical trial of neoadjuvant therapy before surgery. “Patients should be aware of precisely how aggressive their prostate cancer might be. It affects the optimal treatment strategy, which might involve a multidisciplinary approach.”