Next steps after an early-stage prostate cancer diagnosis
We had the honor of hosting Massachusetts General Hospital’s Dr. Xin Gao during a recent “Ask the Expert” webinar. In this educational session, Dr. Gao provided insights on different treatment paths and exciting advancements in prostate cancer care that patients should know about from last year’s American Society of Clinical Oncology (ASCO) meeting. You can watch the full discussion below.
Read on for some of the questions we covered on treatment paths for early-stage prostate cancer, transcribed from the conversation.
The following questions and responses have been lightly edited for grammatical purposes.
1) What are the first steps you should take after receiving a prostate cancer diagnosis?
I think take a deep breath and understand that it’s obviously not news that anybody would hope to receive, but there are many cases of prostate cancer that do extremely well. In terms of the next steps, think about where to get care and what all the treatment options are, or in some cases, management options rather than direct treatment. Talk with specialists who deal with prostate cancer and feel comfortable with the physician you choose to get care from.
2) Are there ways for early-stage prostate cancer patients to avoid surgery?
Surgery is a tried-and-true way to treat prostate cancer. It’s highly effective and has been around for a long time. The main alternative to surgery would be radiation-based treatments and there are various forms that can be discussed. Radiation oncologists, like my good colleagues here at the cancer center, really tailor it to the specific patient and to things like the Gleason score, the PSA, and what the prostate gland and tumor might look like on MRI tests. That would be the main form of alternative therapy.
In some cases, hormonal medications, androgen deprivation therapies or ADTs, are added to the radiation therapy depending on the specifics of the case. I would say radiation, plus or minus hormone therapy, would be the main alternative to surgery. In general, those treatment modalities have been compared head-to-head: surgery versus radiation-based therapy. They’re believed to be equivalent in terms of efficacy, cure rates, and survival; all the main things that patients would care about as they’re thinking about their treatment options. They’re equivalent and they come with different trade-offs and different logistical considerations. Some patients are truly a better fit for surgery rather than radiation-based therapies based on their specific factors and there are other patients who are better suited for radiation-based therapies.
3) When is surgery the right approach?
There are some patients who are just not great candidates for radiation therapy. Modern radiation techniques are quite good at honing in and attacking the prostate cancer and the prostate gland, but you’re inevitably going to expose surrounding tissue to some amount of radiation as well. For the most part, people do quite well. If somebody has a history of certain gastrointestinal conditions like Crohn’s disease, ulcerative colitis, or certain forms of inflammatory bowel disease that are at risk for flaring up with radiation, it’s certainly not a great option. I would say surgery would be better.
In general, we also think more about surgical treatment for younger patients who might be in their 40s or 50s. Part of it is because people tend to bounce back and recover quite well with surgery when they’re younger. Also with radiation therapy, there is a low risk of a secondary cancer that can develop, but it’s a very low risk. Our radiation oncologists usually cite a number well less than 1% in a lifetime. If it happens at all, it’s decades later, but that becomes more relevant if somebody’s in their 40s or 50s rather than in their 70s or 80s.
4) How does hormonal therapy help in treating early-stage prostate cancer? What are the potential side effects when it’s used?
When we talk about hormone therapy, there are various names for it. I tell patients that it’s really anti-hormone therapy, anti-testosterone, anti-androgen, anti-“male hormone” therapies. The other word for it that’s used is androgen deprivation therapy, or ADT, and it’s exactly what it sounds like. They’re medications that deprive the body of androgens and the main androgen in men is testosterone. These medications block the making of testosterone.
Prostate cancer is pretty unique among cancers in that it needs androgens and testosterone to grow, survive, and spread. We know that these medications can help in a variety of different ways for early-stage prostate cancer. Most commonly for early-stage prostate cancer, we use it in combination with radiation therapy. If somebody is choosing surgery, typically androgen deprivation therapy is not given because surgery is just going to remove the cancer and the gland. There have been studies done in the past years that have tried to look at whether antigen deprivation therapy helps with surgical outcomes. In general, it doesn’t seem to help with long-term outcomes like recurrence and those kinds of things, but with radiation therapy, we do think that it helps.
There have been a lot of different prospective randomized clinical trials where half of the patients get radiation alone and half get radiation with hormone therapy. The groups who got hormone therapy tend to do better in terms of cure rates and survival if they had what we would call intermediate-risk or high-risk prostate cancers. For some patients who have low-risk prostate cancer and for certain patients who have favorable intermediate-risk prostate cancer, it doesn’t seem like the hormone therapy did as much. That’s probably because they’re low-risk enough that radiation therapy itself is plenty adequate. Typically, we would not add the hormone treatments for those patients.
Read part two of our webinar recap with Dr. Gao where we discuss metastatic prostate cancer.
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