Paris, France – The treatment of prostate cancer has advanced significantly in recent years. Advances in MRI imaging have undeniably contributed to changes, both in diagnostics, for example through the possibility of targeted biopsies, and in the therapeutic approach. The advent of new treatments (new generation hormonal therapy, vectored internal radiotherapy, etc.) has also made it possible to improve the prognosis of patients with metastatic forms.
To take stock of these advances, we interviewed them dr Guillaume Ploussard (Clinique de La Croix du Sud, Toulouse), Urologist, Surgeon, Oncologist, Head of the Prostate Cancer SubcommitteeFrench Society of Urology (AFU).
German edition of Medscape: The treatment of prostate cancer has evolved significantly, both diagnostically and therapeutically. What do you think is the most significant advancement in recent years?
dr Guillaume Ploussard: The evolution to personalize treatments. Today, thanks to the improvement in imaging techniques and the contribution of genomics, it is possible to better categorize a cancer, predict the evolution of the disease and adapt the therapeutic management accordingly for each patient.
These advances in MRI are leading to better differentiation of the major types of cancer
The detection of prostate cancer by MRI has become more efficient by obtaining more precise images, but also by improving the training of radiologists in interpreting the images. These advances in MRI are leading to better differentiation of the major types of cancer, avoiding treatment of patients who do not need it.
Genetic testing now makes it possible to better define risk and treat it more precisely. In particular, they are used to characterize tumors and to validate the administration of certain treatments such as PARP inhibitors in metastatic cancer.
Oncogenetics has also become more important in the prevention of prostate cancer. How did she change the practice?
Genetic testing now makes it possible to better define risk and treat it more precisely.
dr Plousard: Both patients and doctors are aware of the importance of genetics in the risk of developing prostate cancer. It is estimated that less than 5% of prostate cancer cases are linked to genetic mutations. Oncogenetic counseling has been integrated into the treatment for almost four years. It is recommended to look for mutations in the BRCA1, BRCA2 or HOXB13 genes associated with a high risk of developing an aggressive form of cancer in patients with a family history.
In the presence of mutations, a prevention strategy is implemented through early detection of prostate cancer from the age of 40 with annual or biennial renewed PSA determination and rectal examination. With increasing demand, oncogenetic services are stretched, but the sector is adapting.
If mutations are present, a prevention strategy is implemented from the age of 40 through early detection of prostate cancer
What about the PSA screening strategy, long decried because of the risk of overdiagnosis and overtreatment?
dr Plousard: We no longer speak of screening, which implies a systematic and organized assessment of the risk of cancer, but of early detection of prostate cancer adapted to the individual risk. This must be done on voluntary and well-informed patients.
The AFU still considers early detection by means of PSA determination to be interesting for men aged 50 to 75 with a life expectancy of more than ten years and from the age of 45 in the case of family risks. At this point, the recommendations have not changed. With PSA < 1ng/mL, the assay can be repeated every three to four years, depending on the risk profile. This threshold is not included in the recommendations but can be considered as a reference.
Imaging has also changed diagnostics and biopsy practice in particular. Why is this change important?
dr Plousard: The better performance of prostate MRI allows for more accurate localization of lesions, estimation of their size and extent, leading to definition of a target zone for biopsy samples.
MRI is now recommended as a first-line treatment for suspected prostate cancer to identify a possible target prior to biopsy
MRI is now recommended as a first-line treatment for suspected prostate cancer to identify a possible target prior to biopsy. Through its targeted implementation, the biopsy contributes to a better assessment of the disease and consequently to the establishment of a more appropriate treatment. A spatial distribution of the disease in the prostate is obtained, which, for example, limits the functional impact of a surgical treatment without affecting the results at the oncological level.
However, targeted biopsy still complements systematic biopsies [12 prélèvements sur l’ensemble de la prostate, ndr] to ensure no cancerous lesion is missed. Systematic biopsy can still detect 5 to 10% of cancer cases that would go unnoticed with a targeted biopsy.
Have these changes in practice also changed the methods of active surveillance of low-risk cancers?
dr Plousard: In response to the overdiagnosis of minor forms of cancer, active surveillance has been introduced to avoid overtreatment. With these advances, overdiagnosis has been significantly reduced. MRI scanning has also been integrated into the follow-up of patients oriented toward active surveillance to avoid follow-up biopsies when lesions appear stable. In the past, biopsies were performed every one to two years.
In the presence of a suspicious area on the MRI, it is advisable to repeat the imaging study every year to assess its evolution. In the absence of a suspicious lesion, imaging could be done every two years. Today, active surveillance is significantly less characterized by the performance of invasive examinations, which represents an advance in terms of quality of life for patients.
In terms of treatments, we have seen the arrival of the latest generation of hormone therapies in the treatment of metastatic cancer. What contribution do these new treatments make?
The treatment of metastatic forms of prostate cancer has evolved significantly in recent years.
dr Plousard: The treatment of metastatic forms of prostate cancer has developed significantly in recent years and has led to a significant increase in the life expectancy of patients. In fact, the most important change concerns the introduction of new-generation hormonal therapies (abiraterone, enzalutamide, apalutamide, darolutamide, etc.), which offer an anticancer effect directly at the tumor cell level.
These treatments are essentially androgen receptor blockers. They work by preventing tumor cells from performing certain metabolite conversions that promote their growth, while antiandrogens limit the stimulatory effects of androgens by reducing their concentration in the blood.
In case of castration resistance, we also have third line treatments like olaparib (Lynparza®), an anti-PARP indicated in patients with BRCA1/2 mutation, chemotherapy or vectored internal radiotherapy to save years of extra life.
The use of vectored internal radiation therapy is new and appears very promising. Can we hope to expand the indications for this targeted treatment?
dr Plousard: Vectored internal radiotherapy has not yet been approved for the market. Its use is restricted to certain centers in Early Access. Marketing approval for the treatment of metastatic castration-resistant cancer should be available very soon. Further studies are being conducted to assess treatment at earlier stages of the disease.
The antibodies are linked to a radioactive molecule that directly irradiates the tumor cells. So the tolerability profile is good.
This radiation therapy has the advantage of targeting cancer cells through the use of antibodies that target prostate-specific membrane antigen (PSMA). The antibodies are linked to a radioactive molecule that directly irradiates the tumor cells. So the tolerability profile is good. The results are very encouraging and we can hope for an increase in the earlier stages of the disease.
Finally, have the changes in treatment reduced the effects of the treatments on patients’ urinary and erectile functions?
dr Plousard: These side effects are more taken into account and we have indeed seen progress on this point as treatments have evolved, particularly thanks to the improvement in surgery through robotization and the move towards more precise radiotherapy. In surgery, technical improvements today make it easier to preserve the neurovascular strip surrounding the prostate, which is responsible for maintaining erectile function. The urinary function is also better preserved.
This change in management, facilitated by the improvement in MRI scans, has clearly made it possible to reduce urinary and erectile dysfunction.
This change in management, facilitated by the improvement in MRI scans, has clearly made it possible to reduce urinary and erectile dysfunction. Although they occur less frequently, these complications are still an important part of the treatment of prostate cancer. But when they do occur, we also know how to treat them better.
Prostate Cancer: Advances in imaging and oncogenetics have changed the game. Heloise Chochois
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Photo credits front page: Héloïse Chochois
Photo credit: DR
Photo credits in the text: Héloïse Chochois
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