At the 2012 Genitourinary Cancers Symposium ASCO conference, Dr. Philip Kantoff (Dana-Farber Cancer Institute, Harvard Medical School Boston, MA) suggested taking a personalized approach to the individualized treatment plan for all men suffering from advanced prostate cancer.
Dr. Kantoff said, “Few patients with advanced prostate cancer are currently cured with ADT (but anecdotally, long-term survival is found from docetaxel). Studies show immunotherapy can prolong survival. Curing men with CRPC using new agents in sequence or combination offers a realistic opportunity for men with early disease, intermediate- and high-risk local prostate cancer. Timing is critical to move from level 1 evidence to randomized studies to specifically understand the impact of ADT. But we also have to ask whether there is something different about CRPC patients (pre-dox and post-dox), and yes, post-dox patients are less likely to respond to other agents. Post-dox patients are more advanced and therefore respond more poorly to most therapies.”
He also said, “In addition, it is time to reassess the CRPC statement (of which Dr. Kantoff helped create). Recognizing the rise in PSA still appears to be reasonable; however, with reevaluation of the SERUM T levels. Imaging (currently done via bone scans and CT) requires major evaluation as overall improvement is needed in functional imaging. “
“For the non-mCRPC patient, no therapy currently improves survival. Observation is reasonable for those with slow PSAV and clinicians should consider secondary hormonal therapy.”
“In mCRPC pre-chemo, our focus should be bone protection. While novel agents are on the horizon, we still do not have a definitive or optimal schedule for delivery. In all cases, the physician is sensitive to the individual treatment of the patient, based on convenience – which impacts compliance. Side effects differ. There is a cost-benefit ratio, and as physicians, we need to understand the co-pays and payer parameters”.
He added that it is necessary to understand disease progression.” We typically divide our patients into two groups: symptomatic and asymptomatic and then determine if the patient should be enrolled in a particular RCT. CRPC is clearly not one disease. Gene analysis is proving CRPC has many facets. Which clinical phenotypes will respond better or worse and what is the best way to stratify patients into effective treatment subsets? Likewise, a consideration should be made for the elderly patient as to when to apply cytotoxics (toxic drugs) which may be poorly tolerated. “
In summary, his important points were:
1- Treatment of prostate cancer, including advanced prostate cancer must become individualized. Castrate resistant prostate cancer is not one disease, so our treatments must differ from man to man.
2- Treatment modalities can and do extend survival time, but they rarely cure advanced prostate cancer.
3- Men who are still pre-chemotherapy tend to respond better to other treatments than those who are post-chemotherapy.
4- Men who are castrate resistant and metastatic while still pre-chemotherapy need to have their treatments focused on bone protection.
Joel T Nowak, M.A., M.S.W.