– I believe that we are in for a serious discussion about whether or not we should actively search for prostate cancer in the asymptomatic male population. The more so that we currently have new diagnostic methods, i.e. multiparameter magnetic resonance imaging, which allows us to very precisely assess the presence of clinically significant prostate cancer. With the oncologist prof. extra Paweł Wiechno, MD, PhD, we talk about the need for changes in the care of patients with prostate cancer.
Professor, many experts admit that Polish oncology collapsed during the COVID-19 pandemic – do you observe the effects of the “freezing” of the health care system in your office?
Unfortunately, yes – the effects of the pandemic translate into the fact that patients report in higher stages of cancer. We have hard data that the number of imaging tests performed has decreased in recent years. There were also fewer cases of malignant neoplasms. Which does not mean that the COVID-19 pandemic had a protective effect. It’s just that those patients who should go to a specialist: urologist, oncologist, stayed at home.
We know that prostate cancer is tricky – it can take years to develop without any symptoms. How many Poles learn that it is “HE” at an advanced stage of the disease?
It is difficult to define, therefore we use the number of registered cases and deaths. Unfortunately, prostate cancer is the second most malignant neoplasm in terms of mortality in men in Poland and Europe. This is bad news, considering that early diagnosis of prostate cancer translates into giving the patient the option of a permanent cure. However, when I look after a patient with a generalized disease, I know that I can treat my patient effectively, even for years, but I am not able to cure him of the neoplastic disease. In short, it is very important to recognize prostate cancer early, which proves to be difficult.
What changes have been made in the care and treatment of prostate cancer patients in the first half of the new year?
New drug programs have emerged to treat patients with non-metastatic castration-resistant prostate cancer. This is a situation where metastases are not yet visible in imaging tests, while the growing PSA concentration shows that the cancer is escaping the first hormonal treatment, which consists in lowering testosterone levels. The use of new anti-androgens in such patients significantly improves the prognosis, delays the time to the appearance of distant metastases and translates into a longer overall survival.
How much time does the patient gain?
We already have data from randomized clinical trials for three reimbursable molecules – apalutamide, darolutamide and enzalutamide. Depending on the study, the time to the appearance of metastases without treatment ranged from 14,7 to 18,4 months, while after treatment it was extended to over 36 or even 40 months.
Are there patient groups currently waiting to access modern treatment?
Yes, these are patients with castration sensitive prostate cancer (mHSPC). Today we know that the first treatment should be more intensive, and not only rely on obtaining castration levels of testosterone. We have access to chemotherapy, but we do not have access to modern hormonal drugs.
What areas of systemic prostate cancer care still need to be changed?
The most important problem is an unsolved issue not only in Poland but also in the world, i.e. the dilemma: should we actively seek prostate cancer in asymptomatic men? The analyzes conducted so far have shown that there are many doubts about this. Therefore, the extensive study of PSA in the population of healthy men was abandoned, which resulted in a shift in the number of patients diagnosed at the stage of metastatic disease in Europe and the United States.
Therefore, I believe that we are in for a serious discussion about whether or not we should actively seek prostate cancer in the asymptomatic male population. All the more so because we currently have new diagnostic methods, i.e. multiparameter magnetic resonance imaging (mpMRI), which allows us to very precisely assess the presence of clinically significant prostate cancer, and thus increase the effectiveness of the biopsy or sometimes allow it to be avoided. And one of the primary criticisms of the screening programs was that a great many men are unnecessarily exposed to invasive diagnostics. Another objection to the active search for prostate cancer is that many men were exposed to unnecessary treatment.
Currently, however, we feel much more confident when implementing active observation (AO), i.e. a procedure based on monitoring the advancement of the disease process in selected patients. This allows treatment to be postponed or even avoided. We know this is a strategy that allows us to reduce the risk of treating clinically insignificant cancer. Summarizing, the arguments against the active search for prostate cancer are much less relevant today.
In your opinion, are specific movements necessary in terms of the provisions of the drug program?
Yes, I did intervene in this matter. I believe that ending a drug program due to biochemical progression, that is, a rise in PSA levels, is not a happy record. In all registration studies of modern drugs, therapy was performed until progression in imaging studies, and patients were not excluded on the basis of biochemical progression. Moreover, radiological and scintigraphic evaluation of progression for patients with prostate cancer is quite difficult.
In best medical practice, we follow two scoring systems, while the program stipulations are oversimplified, which can lead to abnormal termination of treatment too early. It is quite complicated, because during active treatment, hitherto invisible metastatic changes in the skeletal system may be revealed, which is an expression of the healing of the lesions, and it is not good for the patient to stop treatment for this reason, because he benefits from it.
Has anything happened with your intervention?
For now, silence.