A lot has been written about the need to identify better biomarkers to both assist in the initial diagnosis of prostate cancer and then to help determine which cancers are potentially dangerous from those that are actually indolent. Finding these markers is vital, I too have written about the great need for them.

However, in the middle of this conversation and the ensuing controversy about PSA screening that has resulted from our failure to develop adequate biomarkers, we have lost sight of the other very important concern, the lack of biomarkers for men with advanced prostate cancer. Honestly, the controversy over PSA screening has so over shadowed the prostate cancer debate, the concern about advanced disease has just melted away.

“There is a need for identification of accurate and simple-to-use prognostic factors for men with prostate cancer that has spread beyond the prostate, so that patients and their doctors can determine which treatment regimen makes the most sense for their situation,” said Andrew Armstrong, M.D., a medical oncologist at Duke and lead investigator on a study looking to identify these biomarkers. “Our study was aimed at developing accurate predictors which may be used to assist in clinical decision-making and also in planning clinical trials for men whose disease has stopped responding to hormone therapy.”

Dr. Armstrong’s study has identified four risk factors that help predict how long men may survive with metastatic prostate cancer. These risk factors could help doctors choose more effective treatments, including the timing of their use.

The researchers examined the records of more than a thousand men who participated in a study that eventually led to the FDA’s approval of the chemotherapeutic drug docetaxel (Taxotere). This study was completed in 2004. Dr. Armstrong’s study identified four independent risk factors that predicted whether a patient’s PSA levels — which indicate the presence or absence of cancer — went down in response to treatment, Armstrong said. The factors included the presence of significant cancer-related pain; anemia (low blood counts); the extent of cancer spread to other organs; and progression of cancer in bone.

“Using these predictors, we were able to assign patients to risk groups of good — indicating an average survival of about two years; intermediate — with survival of about 1.5 years — and poor, with survival of less than a year,” Armstrong said. “By knowing a patient’s prognosis and expected responses to chemotherapy, we are better able to discuss and determine whether a more or less aggressive treatment plan might be advisable.”

Researchers will present their findings on a poster at the 2009 American Society of Clinical Oncology meeting in Orlando, on Sunday, May 31. The study was funded by the Duke University Comprehensive Cancer Center.

I can only hope that this is a beginning of our trying to understand advanced prostate cancer. Without a better grasp of the disease, we will continue to treat men arbitrarily, not knowing what might help and how aggressively to treat.

We need to discuss what men should be treated, in other words, are there men who will not receive any survival benefit from treatment, but might have their quality of life further degraded without any upside? This is a tough conversation, but a vital one.

Joel T Nowak MA, MSW