«The accent in the diagnosis of prostate cancer is clearly shifting down to the age of 60, which, by the way, corresponds to world trends. We move not only in the chronology of the patient’s age, but also in the so-called natural history of the disease. » With dr. hab. Artur Antoniewicz, national consultant in the field of urology, we are talking about cancer, which does not have to be a verdict.
- In each stage of prostate cancer, the prognosis is incomparably better than it was until recently
- In many cases, prostate cancer can be cured with surgery or radiation
- Even with advanced cancer, it is possible to prevent recurrence or postpone the progression
- In the case of a mildly aggressive neoplasm, some patients do not need treatment
- What is the treatment of prostate cancer in Poland like and what progress has been made in this area in recent years – says the national consultant in the field of urology, Dr. hab. Artur Antoniewicz, med
- More information can be found on the Onet homepage.
Medonet: What is the treatment regimen for this cancer?
Dr hab. n. med. Artur Antoniewicz, expert in the field of urology: In many cases, prostate cancer can be cured with surgery or radiation. In some patients, in the case of a mildly aggressive neoplasm, no treatment is needed; close urological supervision and PSA monitoring are sufficient. Typically, even with advanced cancer, it is possible to negotiate, prevent recurrence, or postpone progression. In some cases, when metastatic disease does not respond to hormonal treatment, we are still helpless, although here too we can observe an extension of life and an improvement in its comfort.
It has been said for years that Polish men do not regularly check themselves as prostate cancer prophylaxis. Who or what is referring them to your office: wife, elevated PSA or disturbing urinary symptoms?
In fact, there is no rule for this. Certainly, there are more and more men who undergo regular urological control after the age of 50. The partners often accompany them – either personally or passively, i.e. they order men to visit a urologist and often hold them accountable for the instructions made. They say: I go to the gynecologist and you to the urologist. Importantly, if the examination is favorable, i.e. no abnormalities are detected, men never feel a loss of time or money. On the contrary, they leave the urologist “winged” convinced that they are healthy and valuable. They are ready to face everyday problems and just enjoy life. It is very important to them.
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Cancer has no characteristic symptoms, hence a small percentage of patients present for this reason. The main group are men with increasing PSA levels. Thus, the prostate cancer diagnosis pathway begins with the growing popularity of the PSA test, as well as the growing awareness of male health. This is good news, showing that trends from Europe are reaching us as well. Following the recommendations of the European Society of Urology, we begin to investigate and understand that cancer that is detected early is a treatable cancer.
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Prostate cancer is associated by many with the “old men disease” – how old are your patients?
Definitely less and less. I also get the impression that the former 70-80-year-olds are sick less frequently. In other words, the accent of prostate cancer diagnosis is clearly shifting down to the age of 60, which, by the way, corresponds to global trends. We move not only in the chronology of the patient’s age, but also in the so-called natural history of the disease.
Even 20 years ago, prostate cancer was diagnosed mainly in the stage of advanced metastatic neoplasm, currently in the early stage of development, when the cancer is confined to the prostate gland. The trend I am talking about is so strong that if we take into account, for example, genetic tests, we are able to predict the likelihood of cancer in a given patient long before the cancer actually occurs. It is a complete change in the way we think about diagnosing and treating cancer.
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In the case of prostate cancer, the first element of diagnosis is the PSA test. I heard the opinion that it is not the total PSA that really matters, but the free PSA …
This is true, but it is not easy to transfer all scientific knowledge to clinical practice overnight. In recent years, scientific evidence has been established that justifies the calculation of the ratio of free PSA to total PSA. The value of about 20 percent. and more are considered safe in the context of prostate cancer. In my practice, I use the fPSA / PSA ratio in all situations where I consider the total PSA value questionable, especially when other clinical parameters indicate the risk of prostate cancer, e.g. prostate cancer, in the immediate family. The lower this index, the more consistent I am and I always perform a prostate biopsy.
Sometimes I additionally perform the so-called liquid prostate biopsy, i.e. Select MDx molecular test after prostate massage. I have evidence of the effectiveness of such a procedure in the form of a positive biopsy result (sometimes performed several times) confirming the presence of cancer in many cases of this type. Then radical treatment can be started.
- How is a prostate biopsy done?
The next step is therefore a biopsy, what is its availability under the National Health Fund?
In Poland, about 44 thousand. prostate biopsy procedures financed from the state budget. This is usually a transrectal biopsy under the guidance of transrectal ultrasound. However, the problem is the availability of a modern fusion biopsy, i.e. a special type of biopsy that requires the fusion of the magnetic resonance image with the image of transrectal ultrasound using dedicated equipment. It is performed through the percutaneous (percutaneous) route.
I am convinced that this modern study should become an element of the guaranteed benefits package, but limited to its use in accordance with the guidelines of the European Association of Urology (EAU). The main indications are patients whose first biopsy was negative, but the clinical premises for looking for cancer still persist, as well as those patients whose finger examination does not show any changes, and the mpMRI indicates the presence of PIRADS 4 or 5 foci. it is a skill for the modern urologist to choose the type of biopsy responsibly. There are several of them and the type of biopsy should be adjusted to each patient individually.
What determines the choice of treatment method: surgery or radiation? Apparently there is a conflict between urologists and radiotherapists …
The best solution is an operation, i.e. radical prostatectomy, the purpose of which is to radically remove the gland along with the tumor. Personally, I share the opinion I heard from one of the leading European urologists in the 90s, prof. Guy Vallanciena from the Montsouris Institute in Paris, who qualified for radiotherapy a patient who was unsuitable for surgery or who did not agree to it. This definition is safe for all parties – the phrase “not suitable” means that there are medical reasons that make the surgical risk too great. On the other hand, the term “disagrees” refers to patients who, for religious, philosophical or personal reasons, do not accept the operation itself and its consequences, including the risk of loss of sexual function or the risk of continence disorders.
Contrary to appearances, both of them constitute a very large group and these qualify for radiotherapy. On the other hand, the vast majority of men with organ-limited prostate cancer may be subjected to e.g. robotic radical prostatectomy. In addition to the so-called active observation is the second real revolution in the treatment of prostate cancer. In this way, we eliminate the neoplasm with a minimal risk of loss of continence and a limited risk of loss of potency. The patient recovers faster, the hospitalization time is shortened and the risk of blood transfusion is eliminated. These advantages make this method of treatment popular.
I have no doubt that if fate had touched me with prostate cancer and I had been eligible for radical surgery, I would have had it immediately. However, when observing the fate of patients after radical radiotherapy, I would be rather restrained due to its “conservative” nature and significant side effects. So back to your question, in my opinion “number one” is robotic radical prostatectomy, which closes the era of open and laparoscopic surgery. In Poland, we are at the beginning of this road, but about 1,5 thousand jobs are already being performed. robotic operations every year and this number will increase. Recently, they are also available free of charge in public urology centers, including in Białystok, Siedlce, Warsaw, Szczecin and Gorzów Wielkopolski.
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What is the percentage of all operations?
Currently, approximately 7 radical operations are performed, so the percentage of robotic operations is approximately 22%. In developed countries, this percentage is much higher, reaching even 98%. Polish urology still has a long way to go to catch up with the leaders.
There is a lot of talk about complications of radical prostatectomy, but what awaits patients who choose radiation?
First of all, we observe patients in whom radiotherapy turned out to be ineffective, i.e. those in whom biochemical relapse and / or clinical relapse after radiotherapy is present. This is why I recommend radical radiotherapy in two cases, which I have already mentioned: “when the patient is unsuitable or does not agree” to surgical treatment. It must be emphasized that a huge number of cancer patients, the so-called risk benefits from using both methods. By using a surgical method quickly supplemented with radiotherapy with hormone therapy, in seemingly extremely difficult situations, excellent results can be obtained. The trick, then, is to choose the right method for each individual case.
An important element in the evaluation of radiotherapy should be reliably determined as to the frequency of bladder or radiation bowel side effects. Patients with such problems usually go to a urologist, hence the urologist’s restraint to radiotherapy is understandable. It is known, however, that modern radiotherapy can significantly reduce the percentage of patients who will experience significant side effects and improve the effectiveness of oncological treatment. Technological progress in this matter is also huge.
The latest breakthrough in the treatment of prostate cancer is to be modern antiandrogens. Which patients will benefit most from them?
The drug program B56 was initially dedicated to patients with prostate cancer in the castration-resistant stage, i.e. at the stage of the disease when the cancer is out of hormonal control. It was then that they appeared two main drugs – abiraterone used with prednisolone and enzalatumide. The second form of therapy in these cases is chemotherapy in the form of docetaxel. Along with medical knowledge, there are indications for the use of these drugs before chemotherapy. We now know that patients will benefit from using them earlier, that is at the stage of diagnosis of metastatic disease, which allows us to stay ahead of the CRPC (Castration Resistant Prostate Cancer) stage.
It is important that more and more urology centers implement this drug program, making it more accessible to patients. New drugs in the form of the next generation of antiandrogens (enzalutamide, apalutamide, darolutamide) or radium 223 or lutent are further progress that significantly changes the fate of patients in the final stage of the disease. Pallation ceases to be only a last-resort treatment with a maximum life span of a few months, but becomes a management strategy that delays clinical progression for many months, prolonging survival.
Summarizing our conversation – how would you rate the prognosis of a patient with prostate cancer yesterday and today?
Without a doubt, in each phase of the disease, the prognosis is now incomparably better than it was until recently. In the United States, in the case of organ-confined cancer, the 10-year survival rate is over 80%. This is the value we must strive for. My personal goal as a national consultant as well as a practicing urologist is to take action to move patients in the natural history of the disease to the earliest stages of cancer development – when it is completely treatable. Then the results of treatment in Poland will reach the level of developed countries and many patients will be cured permanently. As a result, the number of patients treated palliatively will decrease and the costs of pharmacotherapy will be significantly reduced. So let me say that the diagnosis of prostate cancer is not a sentence.
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