The PCRI Conference: Standing in the Gap in a Woeful Medical Situation

MARK SCHOLZ, MD

September is prostate cancer awareness month. Every year the PCRI hosts a three-day educational symposium for patients.  “For patients?”  But people always ask, “What about doctors?”

In the cancer world, prostate cancer is the last bastion of surgeons (urologists).  Surgeons, as it happens, are the primary supervisors of this, the most common type of cancer in men.  Thirty years ago all cancers were managed by surgeons because back then surgery was the only available treatment. While the true cancer specialists of today—medical oncologists—have assumed primary responsibility for every other type of cancer, urologists continue to take primary responsibility of caring for men with prostate cancer.

Therefore surgeons tenaciously hang on to the “way it has always been done,” even though surgery is usually the least effective way to treat prostate cancer. In fact, despite tremendous improvement in other methods of treatment, the reliance on traditional surgery has been on the rise.  The excitement surrounding robotic surgery is probably the reason for the increase. Sadly, numerous scientific studies showing that older surgical techniques work just as well have not changed urologists’ minds.

The theme of this year’s PCRI conference—Quality of Life—naturally emphasizes alternatives to surgery.  Active surveillance, seed implants, IMRT and focal therapy all have survival rates at least as good as surgery, but with far fewer side effects.

This year the conference will feature its very first celebrity—actor Ryan O’Neal.  Mr. O’Neal had such excellent results from his focal therapy that he has volunteered to attend the conference and share his experience.  His story will be featured in the next issue of PCRI Insights which should hit the stands next week.  PCRI Insights is a free quarterly newsletter published by the PCRI.  You can sign up at the PCRI website and have it emailed to you.

Back to the question, “Why patients?”  Basically, Dr. Stephen Strum and I founded the PCRI to educate patients because unlike the surgeons, patients are highly motivated to learn and embrace new options in therapy, especially when the new therapy can convincingly be shown to be equally effective and less toxic.  A patient-orientated approach has proven successful, and the popularity of the conference continues unabated.

So far I have only been commenting on treatment issues related to the newly-diagnosed men with early stage disease. What about men with advanced disease?  Believe it or not urologists are still managing the majority of men with advanced disease, even when metastases are present, and despite the fact that in the last few years  five new products—all of which are proven to prolong life—have been approved for use by the FDA to treat advanced prostate cancer.

Do urologists know how to administer these new treatments?  Are they even aware of them? The complexity of managing advanced prostate cancer has increased exponentially due to the availability of these new treatment options.  The question is: How can urologists, who typically manage prostate cancer in their spare time, keep up with all these new developments when they also have to treat so many other serious issues—kidney stones, urinary incontinence, erectile dysfunction, kidney cancer, bladder cancer, testicular problems, urinary infections—in addition to the time they spend in the operating room  performing various types of surgery?

I would suggest that it is not safe to abdicate your health choices to a urologist. To inform yourself about your options, plan to attend the PCRI Conference on September 6^th, 7^th & 8^th at the LAX Marriott.  Tickets can be purchased on line at PCRI.org.

Research at the PCRI

BY MARK SCHOLZ

As Executive Director for the Prostate Cancer Research Institute, I am often asked about our research focus. The PCRI has given unrestricted grants to various institutions over the years. These institutions are listed on the website at www.PCRI.org.   In addition, since the inception of the PCRI, Dr. Lam, Dr. Strum and I have published at least ten scientific articles relevant to prostate cancer in peer-reviewed journals This blog very briefly summarizes the most useful conclusions that can be drawn from this body of work (the article titles are in italics).

1. Anemia associated with androgen deprivation in patients with prostate cancer receiving combined hormone blockade:  We were the first to report that blocking testosterone can result in anemia, i.e. a drop in red blood cell (RBC) counts. The anemia caused by low testosterone resolves spontaneously when testosterone levels are restored to the normal range. Doctors need to be aware of the cause of this phenomenon or else men are unnecessarily subjected to treatment with iron (which may stimulate prostate cancer growth) or to uncomfortable diagnostic studies such as bone marrow biopsy.

2. Low-Dose Weekly Docetaxel (Taxotere) in Elderly Men with Prostate Cancer:  Rather than giving a standard dose of Taxotere every three weeks, which can be associated with low white blood cell counts, infection and excess fatigue, we evaluated 20 elderly men (average age 78) with a 1/3 dose of Taxotere administered weekly.  We found the anticancer effect to be maintained (twelve of the twenty men in the study had more than a 50% decline in PSA).  However, side effects were reduced: Only three of the patients stopped treatment for reasons of fatigue.  No patients experienced low blood counts or infections.

3. Using Splines* to Detect Changes in PSA Doubling Times: We collaborated with two mathematicians from UCLA, Robert Jennrich and Ray Redheffer, to develop a mathematical model for measuring the change in the rate of PSA rise after starting a new therapy.

4. Modified Citrus Pectin (MCP) Increases the Prostate-Specific Antigen Doubling Time in Men with Prostate Cancer: A Phase II Pilot Study:  This study used the statistical methods developed in the previous study to measure PSA doubling times before and after starting MCP. We showed a significant slowing in the rate of PSA rise in seven of the ten men who were administered MCP in the study.

5.  Long-Term Outcome for Men with Androgen Independent Prostate Cancer Treated with Ketoconazole and Hydrocortisone: Ketoconazole was the best treatment for men resistant to Casodex and Lupron before FDA approval of Zytiga and Xtandi. In 2005 we published a report of 78 patients showing PSA suppression for an average of 14.5 months.  Even longer responses occurred when treatment was initiated when men were in the earlier stages of androgen independence.

6. Intermittent Use of Testosterone Inactivating Pharmaceuticals (TIP) Using Finasteride Prolongs the Time Off Period: This study of 101 men treated with intermittent TIP reported a number of interesting findings: The “Holiday Period” after TIP is stopped is doubled [twice as prolonged] when finasteride (Proscar) is employed. Longer holiday periods were also associated with advanced age and lower Gleason score.

7.  Preventing and Treating the Side Effects of Testosterone Inactivating Pharmaceuticals in Men with Prostate Cancer: This article reviewed effective methods to reduce or eliminate common side effects of TIP such as fatigue, weakness, anemia, muscle loss, weight gain, penile atrophy, dry skin, breast enlargement, blood pressure changes, hot flashes, osteoporosis, joint aches and urinary symptoms.

8. Prostate Cancer-Specific Survival and Clinical Progression-Free Survival in Men with Prostate Cancer Treated Intermittently with Testosterone Inactivating Pharmaceuticals: 160 men were treated with TIP and monitored for survival over 10 years. We found that the single most powerful factor for predicting extended survival was to have attained a PSA less than 0.05 within eight months of starting TIP.

9. Primary Intermittent Androgen Deprivation as Initial Therapy for Men with Newly Diagnosed Prostate Cancer: This study was an observational report on 73 men who were eligible to have surgery or radiation but instead elected to initiate TIP. After an average observation period of 12 years, three men died of prostate cancer. Of the remaining 70 men, none developed metastasis. 28 men underwent delayed surgery or radiation. On average, the delayed surgery or radiation occurred 5.5 years after TIP was first initiated.

10. Primary Androgen Deprivation (AD) Followed by Active Surveillance (AS) for Newly Diagnosed Prostate Cancer (PC): A Retrospective Study:   This study evaluated 102 men treated with initial TIP to determine how often a single course of TIP for 12 months resulted in durable remission (defined as more than 7 years).  Durable remission occurred in 94% of men in the Low-Risk category, 47% of men with Intermediate-Risk prostate cancer and only 29% of men with High-Risk disease. There were no prostate cancer deaths.

Conclusion

One consistent theme in our published research is that stand-alone hormonal therapy is a reasonable option for men with Intermediate-Risk category prostate cancer. Men with Low-Risk disease are best managed with initial observation, i.e., without any initial therapy at all.  Men with High-Risk disease should be treated with a combination of TIP plus radiation.

Another important conclusion is that while the side effects of TIP can be managed, they tend to be more notable than the side effects of other popular treatments for Intermediate-Risk prostate cancer such as radioactive seed implants or intensity modulated radiation therapy (IMRT). The main exception being a somewhat lower risk of permanent erectile dysfunction with TIP compared to radiation.

Lastly, the overriding theme of all modern prostate cancer research is that over-enthusiasm for curative treatments that extend life must be tempered by the potential negative impact that treatment can have on quality of life.

* A “spline” is a bent line, i.e. a line with an angle. When rising PSA levels are represented graphically the dots can be connected creating a line.  If there is a change in the rate of rise, an angle in the line occurs.