– Prostate cancer has become a chronic disease. I have patients who, ten years after diagnosis, function normally, work and enjoy life. With dr hab. n. med. Tomasz Borkowski, we talk about the progress in the treatment of prostate cancer.
Doctor, statistics show that while the incidence of prostate cancer is growing all over Europe, the mortality only here … Is it so bad?
We are lagging behind Europe and America, but not the rest of the world. Due to the increase in life expectancy, prostate cancer, the main risk factor of which is age, is a modern epidemic. Just look at the numbers – since 2016, even lung cancer has surpassed the inglorious classification of the most commonly diagnosed cancers. However, when it comes to mortality, it is a mortality that does not apply to those diagnosed today, but to those diagnosed 15, 10, 5 years ago. So some things change positively and some things stay as they were.
Let’s start with the positives …
The message that it is worth betting on prophylaxis is becoming more and more common awareness. This is in line with the line of the European Association of Urology (EAU), which promotes the first PSA determinations between 40 and 50 years of age. And the sooner cancers are diagnosed, the easier it is generally to cure them.
And the bad news?
A lot of work still awaits us if we compare Polish and American data on the stage of the cancer at which it is diagnosed. In the United States, prostate cancer diagnosed with disseminated disease accounts for only about 5 percent. However, in our country, it is between 10 and 20 percent, or four times more, which naturally translates into prognosis. The second bad news is the lower availability of drugs that prolong survival in advanced or very advanced stages of cancer.
What treatment options are offered to patients? Scalpel or rays?
Whenever possible, we start with active observation. Until twenty years ago, the locus and kill approach was indeed the dominant approach, but we have now learned that in some patients with low-risk prostate cancer, a tumor with a small volume, low malignancy (Gleason 6), restricted to the prostate, and low PSA, active surveillance is a possible management option. In some Scandinavian countries, 75 percent. low-risk cancer patients choose observation rather than aggressive treatment. On the other hand, the more aggressive a neoplasm, the higher its malignancy, and the greater the mass of neoplasms, even with low malignancies, the more appropriate aggressive treatment is. In this case, we have a choice of radical prostatectomy or radiotherapy, as well as methods less recognized by scientific urological societies in the world, such as focal therapy or HIFU.
What about advanced and disseminated cancers?
Until recently, the standard of treatment in disseminated neoplasms was self-hormone therapy, i.e. castration achieved in a pharmacological or surgical manner, involving bilateral removal of the testicles. However, as a result of very well-designed randomized controlled trials, it turned out that patients gain much greater benefits if we add chemotherapy to hormone therapy, i.e. treatment with docetaxel. This combination extends their survival by an average of 13 months, and in some cases of more advanced tumors even longer.
In addition, in this group of patients, we can use modern hormone therapies in conjunction with castration, i.e. drugs known as ARTA, aimed at the androgen receptor pathway, such as: abiraterone, apalutamide, enzalutamide. Considering the comfort of admission, especially in patients who are unwilling or unable to undergo chemotherapy due to their health condition, they are beneficial. Unfortunately, they are also very expensive and while they are available in most countries in the world, we have a long way to reimburse them.
The last treatment option reserved for patients with the so-called Oligometostatic prostate cancer, i.e. one whose main tumor is located in the prostate, with few bone metastases, is a combination treatment consisting of radiotherapy to the prostate area and additionally hormone therapy.
Patient organizations have been trying to reimburse the modern anti-androgen drugs you mentioned for a long time. How much do they extend the survival time of the sick?
It depends at what stage of the disease they are applied. Basically, the sooner modern therapies are implemented, the longer the patients’ survival time is, but also cancers are treated at an earlier, less advanced stage. In some cases, the increase in survival is several months and in some patients it is several years. In recently published studies in a group of patients with non-metastatic castration-resistant prostate cancer, the inclusion of modern hormone therapies reduces patient mortality by about 30%. The improvement in overall survival, time to progression, time to treatment is impressive and in my opinion patients should be able to access such therapies as soon as possible.
Are there any significant differences in the group of modern antiandrogens?
Basically no, they have a very good side effect profile and for most people it doesn’t matter which one you use. However, for patients with cardiac conditions, enzalutamide is the better choice. Conversely, for patients with a history of seizures or those who report severe asthenia, enzalutamide may be less beneficial.
Is there a chance that modern anti-androgen drugs will be added to the list of reimbursed drugs in the near future?
I am not the best addressee of your question. I can only say that it should be like this, especially since very expensive drugs are reimbursed, which extend survival by only 1,5 or 2 months. However, the problem is their price – hormone therapy itself is expensive, and the addition of these drugs causes many times higher costs. Here we come to the question: How much is human life worth? And there is no wise answer to it. This dilemma is best dealt with by the English who have appropriate algorithms and if a given therapy is too expensive, they say: sorry, but we cannot afford it. However, if the therapy meets the relevant criteria, it is reimbursed. Therefore, it would be reasonable to adopt clear criteria regarding the effectiveness of action, disease-free survival or the profile of side effects, which would define what drug can be reimbursed and what can not.
Can it be said that thanks to new treatment options, prostate cancer is becoming a chronic disease?
Yes, because it takes an average of 10 years to develop the first clinical symptoms of the disease, and many patients survive with prostate cancer a dozen or so years, even if the cancer is locally advanced or has lymph node metastasis at the time of detection. I have patients who, at the time of diagnosis, had metastatic neoplasms, went through the whole path of treatment options – from surgical treatment, through radiation therapy, one, second and third type hormone therapy, chemotherapy, to clinical trials in which they received drugs that later became new standard. They function, work and enjoy life normally.
At one of the PTU congresses, a film was even presented, the protagonist of which was a patient with bone metastases, which made it impossible for him to walk. After hormone therapy, Lazarus almost got out of bed and finally, what we can call the malice of fate, he survived his doctor. So there are patients with advanced disseminated tumors who survive more than 10 years, although the median survival of those treated with testosterone-lowering hormone drugs alone is 42 months.
Do you want to check if you are at risk of developing prostate cancer? Prostate cancer – genetic testing is available by mail order on Medonet Market. The blood sample should be taken by yourself and then sent to Medgen in Warsaw. After 3-5 weeks, the results will be available.