Treatment Of Low-risk Prostate Cancer Research Articles

The impact of adding cost information to a conversation aid to support shared decision making about low-risk prostate cancer treatment: Results of a stepped-wedge cluster randomised trial.

Decision aids help patients consider the benefits and drawbacks of care options but rarely include cost information. We assessed the impact of a conversation-based decision aid containing information about low-risk prostate cancer management options and their relative costs. We conducted a stepped-wedge cluster randomised trial in outpatient urology practices within a US-based academic medical center. We randomised five clinicians to four intervention sequences and enroled patients newly diagnosed with low-risk prostate cancer. Primary patient-reported outcomes collected postvisit included the frequency of cost conversations and referrals to address costs. Other patient-reported outcomes included: decisional conflict postvisit and at 3 months, decision regret at 3 months, shared decision-making postvisit, financial toxicity postvisit and at 3 months. Clinicians reported their attitudes about shared decision-making pre- and poststudy, and the intervention's feasibility and acceptability. We used hierarchical regression analysis to assess patient outcomes. The clinician was included as a random effect; fixed effects included education, employment, telehealth versus in-person visit, visit date, and enrolment period. Between April 2020 and March 2022, we screened 513 patients, contacted 217 eligible patients, and enroled 117/217 (54%) (51 in usual care, 66 in the intervention group). In adjusted analyses, the intervention was not associated with cost conversations (β = .82, p = .27), referrals to cost-related resources (β = -0.36, p = .81), shared decision-making (β = -0.79, p = .32), decisional conflict postvisit (β = -0.34, p= .70), or at follow-up (β = -2.19, p = .16), decision regret at follow-up (β = -9.76, p = .11), or financial toxicity postvisit (β = -1.32, p = .63) or at follow-up (β = -2.41, p = .23). Most clinicians and patients had positive attitudes about the intervention and shared decision-making. In exploratory unadjusted analyses, patients in the intervention group experienced more transient indecision (p < .02) suggesting increased deliberation between visit and follow-up. Despite enthusiasm from clinicians, the intervention was not significantly associated with hypothesised outcomes, though we were unable to robustly test outcomes due to recruitment challenges. Recruitment at the start of the COVID-19 pandemic impacted eligibility, sample size/power, study procedures, and increased telehealth visits and financial worry, independent of the intervention. Future work should explore ways to support shared decision-making, cost conversations, and choice deliberation with a larger sample. Such work could involve additional members of the care team, and consider the detail, quality, and timing of addressing these issues. Patients and clinicians were engaged as stakeholder advisors meeting monthly throughout the duration of the project to advise on the study design, measures selected, data interpretation, and dissemination of study findings.

Stereotactic focal radiotherapy as an alternative treatment for low-risk prostate cancer: Results of a single-arm monocenter Phase-II trial.

Since radical treatments in low risk prostate cancer do not improve overall survival in comparison to active surveillance, preserving quality of life (QOL) remains the key objective. Active surveillance of indolent prostate cancer avoids curative treatment side-effects but necessitates repeated biopsies. Focal stereotactic body radiation therapy (focal SBRT) may be an alternative. This non-randomized Phase-II trial examined the feasibility and safety of focal SBRT for low and favorable intermediate-risk prostate cancer. Patients were recruited in 2016-2019 if they had: localized CAPRA ≤ 3 prostate adenocarcinoma; an isolated PIRADS≥4 macroscopic tumor on MRI; WHO Performance Status 0-1; and no major urinary symptoms. 36.25 Gy (80% isodose prescription) were delivered in 5 fractions every other day. Primary outcome was delay between focal SBRT and salvage-treatment initiation. Secondary outcomes were: acute/late genitourinary/rectal toxicity; biological, clinical and MRI local control; and change in QOL measures. Over a median follow-up of 36 months, salvage prostatectomy in the 24 eligible patients was never required. Three-year biochemical progression-free survival was 96%. The single biochemical recurrence was a small (2-mm) Gleason 6 (3 + 3) lesion in the non-irradiated lobe. All 19 patients with ≥1 post-treatment MRI evaluations demonstrated complete radiological response. Acute/late grade ≥3 toxicities did not occur: all acute toxicities were grade-1 genitourinary (38% patients), grade-2 genitourinary (8%), or grade-1 rectal (13%) toxicities. There was one (4%) late grade-1 genitourinary toxicity. QOL was unchanged at last follow-up, as shown by IPSS (2.86 to 3.29, p>0.05), U-QOL (0.71 to 0.67, p>0.05), and IIEF5 (the 14 initially potent patients maintained potency (IIEF5 > 16)). Focal SBRT is feasible, well-tolerated, and preserves QOL. This innovative robotized approach challenges active surveillance.

Abstract 3383: Circular RNAs as non-invasive diagnostic biomarkers for prostate cancer

Abstract Prostate cancer is one of the most common cancers in men. The disease is largely indolent in nature and treatment of low-risk prostate cancer is not always necessary. However, a fraction of the patients will progress to aggressive disease which accounts for most of the cancer related mortality. Detection methods accurately differentiating between high- and low-risk patients for lethal prostate cancer is a critical need and currently, prostate biopsies and subsequent histopathology and molecular profiling are the most definitive way to differentiate between these two patient populations. But biopsies are invasive procedures associated with significant morbidity. Hence, there exists a critical need to develop non-invasive and highly sensitive diagnostic biomarkers to avoid unnecessary biopsies. Here, we propose to develop a novel biomarker panel which constitutes of a class of RNA molecules called circular RNA (circRNA) to be detected in liquid biopsies. Circular RNAs are covalently closed RNA structures, which are resistant to degradation by exoribonucleases because of the absence of free termini in their nucleotide chain. Due to their increased stability compared to their linear counterparts, circRNAs are ideal candidates for biomarkers, especially in non-invasive liquid biopsies. Using MiOncoCirc, a circRNA compendium from &amp;gt;2,000 primary and metastatic cancer tissues representing 40 cancer types, we first identified 9 circRNAs that are specifically expressed in prostate adenocarcinoma (PRAD) compared to all other cancer types. Next, we examined if these candidates are differentially expressed between PRAD and normal prostate tissues. Based on higher levels of expression which were statistically significant in the PRAD compared to normal prostate tissues, we promoted 4 circRNAs to our biomarker panel. In addition, our panel also includes 2 circRNAs that we predicted to arise from PRAD specific lncRNAs. To study the expression of the novel 6-circRNA biomarker expression in high-risk prostate cancer patients we developed a capture-based RNA sequencing assay. For the initial round we used this assay to test our pilot post-DRE patient urine sample EDRN cohort and detected expression of the prostate cancer-specific circRNAs in a subset of these post-DRE urine samples. We are in the process of expanding our test cohort which will also contain additional clinical annotations such as Gleason score. Post cohort assembly we intend to run our 6-circRNA capture assay on these samples to determine whether the expression levels of candidate circRNAs are correlated with disease stage and other clinical parameters. Our results will facilitate the rapid development of a diagnostic test using non-invasive urine samples for the early detection of high-risk prostate cancer. Citation Format: Palak Shah, Pushpinder Bawa, Lanbo Xiao, Yelena Kleyman, Josh Vo, Saravana M. Dhanasekaran, Jason Brown, Nicolette Loeding, Alexander Koons, Javed Siddiqui, Xuhong Cao, Arul M. Chinnaiyan. Circular RNAs as non-invasive diagnostic biomarkers for prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3383.

The evolving landscape of practice pattern and survival outcomes in the management of localized low-risk prostate cancer.

e17057 Background: The majority of patients with low-risk prostate cancer (LRPC) are candidates for active surveillance (AS) or definitive local treatment, which may include radical prostatectomy (RP), external beam radiotherapy (EBRT), or prostate seed implant (PSI). In the recent edition of the National Comprehensive Cancer Network (NCCN) guidelines, the “preferred” status was removed for AS, which rekindled a debate and interest in the management of LRPC. In this study, we analyzed the treatment pattern and impact of various treatment modalities on the survival of patients with LRPC using a large patient population provided by the National Cancer DataBase (NCDB). Methods: Patients with LRPC, as defined by the NCCN criteria, between 2004 and 2015 from NCDB were analyzed. Patients are categorized by treatment modalities, including RP, EBRT, PSI, and those who received no local therapy (NLT). Only patients with low Charlson-Deyo comorbidity score, 0 or 1 were included to ensure comparability between treatment groups. A multivariable Cox regression model was developed to determine the adjusted odds of patients' survival. The Kaplan Meier survival plots stratified by treatment were generated to establish the median overall survival (OS). The log-rank test was used to determine significance between treatment groups. Cox regression models were used to produce parameter estimates and hazard ratio (HR) for each age group. Results: A total of 195,452 patients with LRPC were identified from 2004 to 2015. There was a significant practice pattern change with increased utilization of NLT over time, from 11.3% in 2004 to 53.5% in 2015, with a turning point in 2009. The utilization was peaked for RP at 41.6% in 2008, EBRT at 24.3% in 2006, and PSI at 35.3% in 2004, but dropped to 17.6%, 18.1%, and 10.8%, respectively, in 2015. Of different treatment modalities, compared to NLT, RP provided a superior OS with a HR of 0.662, p &lt; .0001; PSI also improved OS with an HR of 0.795, p &lt; .0001. However, EBRT did not improve OS and was potentially detrimental, HR = 1.049, p = 0.01. With age-matched subgroup analysis, the survival advantage based on HR of RP relative to NLT favors RP until the age of 74 but diminishes as age increases. In patients younger than 70, NLT provided comparable survival to EBRT or PSI. The survival advantage of EBRT or PSI is only seen in older patients, at age of 75 or older for EBRT and 70 or older for PSI. Conclusions: There has been a significant treatment pattern change between 2004 and 2015. AS, as represented by the NLT in this study, has become the dominant choice of treatment for LRPC. However, of different treatment modalities, both RP and PSI improve OS. The patients managed with AS had comparable OS to those who received EBRT. The survival benefit of RP is mostly seen in younger patients. Only older patients benefit from PSI or EBRT. This study is limited by its retrospective nature and inherent bias in NCDB.

Patient Decision-Making Factors in Aggressive Treatment of Low-Risk Prostate Cancer.

BackgroundActive surveillance (AS) is underutilized for low-risk prostate cancer. This study examines decision-making factors associated with AS vs aggressive treatment in a population-based cohort of low-risk patients.MethodsNewly diagnosed patients (n = 599) were enrolled through the North Carolina Central Cancer Registry from 2011 to 2013 and surveyed regarding 5 factors that may impact treatment decision making: perceived cancer aggressiveness, aggressiveness of treatment intent, most important goal (eg, cure, quality of life), primary information source, and primary decision maker. We examined the association between treatment decision-making factors with patient choice for AS vs aggressive treatment using multivariable logistic regression analysis.ResultsThis is a sociodemographically diverse cohort reflective of the population-based design, with 37.6% overall (47.6% among very low-risk patients) choosing AS. Aggressive treatment intent (odds ratio [OR] = 7.09, 95% confidence interval [CI] = 4.57 to 11.01), perceived cancer aggressiveness (OR = 4.93, 95% CI = 2.71 to 8.97), most important goal (cure vs other, OR = 1.72, 95% CI = 1.12 to 2.63), and primary information source (personal and family vs physician, OR = 1.76, 95% CI = 1.10 to 2.82) were associated with aggressive treatment. Overall, 88.4% of patients (92.2% among very low-risk) who indicated an intent to treat the cancer “not very aggressively” chose AS.ConclusionsThese data from the patient’s perspective shed new light on potentially modifiable factors that can help further increase AS uptake among low-risk patients. Helping more low-risk patients feel comfortable with a “not very aggressive” treatment approach may be especially important, which can be facilitated through patient education interventions to improve the understanding of the cancer diagnosis and AS having a curative intent.

Monitoring Proves Better Than Active Treatment for Low-Risk Prostate Cancer

Monitoring Proves Better Than Active Treatment for Low-Risk Prostate Cancer

Twenty-year trends in prostate cancer stage and grade migration in a large contemporary german radical prostatectomy cohort.

A trend towards inverse stage migration in prostate cancer (PCa) was reported. However, previous analyses did not take into account potential differences in sampling strategies (number of biopsy cores), which might have confounded these reports. Within our single-institutional database we identified PCa patients treated with radical prostatectomy (RP) between 2000 and 2020 (n = 21,646). We calculated the estimated annual percentage change (EAPC) for D'Amico risk groups, biopsy Gleason Grade Group (GGG), PSA and cT stage as well as postoperative RP GGG and pT stage relying on log linear regression methodology. Subsequently, we repeated the analyses after adjustment for number of cores obtained at biopsy. Absolute rates of D'Amico low risk decreased (-30.1%), while intermediate and high risk increased (+21.2% and +9.0%, respectively). Rates of GGG I decreased (-50.0%), while GGG II-V increased, with the largest increase in GGG II (+22.5%). This trend, albeit less pronounced, was also recorded after adjusted EAPC analyses (p < .05). Specifically, EAPC values for D'Amico low vs intermediate vs high risk were -1.07%, +0.37%, +0.45%, respectively, and EAPC values for GGG ranged between -0.71% (GGG I) and +0.80% (GGG IV). Finally, an increase in ≥cT2 (EAPC: +3.16%) was displayed (all p < .001). These trends were confirmed in EAPC calculations in RP GGG and pT stages (p < .001). Our findings confirm the trend towards less frequent treatment of low risk PCa and more frequent treatment of high risk PCa, also after adjustment for number of biopsy cores.

PCN159 Prediction of Low-VALUE Cancer Care Among Older Men with Low-Risk Prostate Cancer: A Machine Learning Approach

Older men with incident prostate cancer are vulnerable to low-value prostate cancer treatment. Despite evidence-based support for conservative management (i.e., non-treatment), approximately 2 in 3 Medicare beneficiaries receive treatment for low-risk prostate cancer. Patients with multimorbidity who experience care fragmentation are vulnerable to departures from evidence-based medicine. A comprehensive analysis of clinical and non-clinical factors, such as life expectancy and care fragmentation, that may drive low-value prostate cancer treatment is lacking. Use machine learning (ML) to identify leading predictors of cancer treatment within 12 months of diagnosis among older men with low-risk prostate cancer. Novel predictors included validated prostate-cancer specific life expectancy and care fragmentation. In this retrospective cohort study we linked Surveillance, Epidemiology, and End Results cancer Registry (SEER), Medicare Claims, Census, and Area Health Resource files and included older men with incident low-risk prostate cancer from 2009 to 2014 (n=13,870). We used claims data to identify treatment (Yes/No) in the first 12 months after diagnosis. We used the XGboost algorithm and Shapley additive explanations (SHAP) to rank feature importance in treatment prediction. In our study cohort (n=13,870), 66.9% of older adults received cancer treatment. Age, multimorbidity, care fragmentation, social support, and social determinants were leading predictors of cancer treatment (Accuracy=0.70, Precision=0.71, Recall=.92, Precision-Recall Area Under the Curve = 0.78). Relationships of college education, income, and care fragmentation on low-value cancer treatment were nonlinear and complex. Life expectancy was a weak predictor of prostate cancer treatment. Our results suggest that non-clinical factors such as social determinants, care fragmentation, and social support are the most important predictors of treatment among older men diagnosed with low-risk prostate cancer. Despite a critical role in evidence-based treatment recommendations, life expectancy had limited impact on treatment selection.

Focal Therapy Is a Viable Treatment for Low-Risk Prostate Cancer.

Focal therapy has been introduced as a novel treatment option for clinically localized prostate cancer. However, defining its role in the clinical space is still debated, especially with regards to identifying eligible candidates who will stand to benefit from treatment. Active surveillance (AS) is established as the preferred treatment for low-risk prostate cancer, with the goal of identifying those experiencing risk re-classification for curative intervention if it occurs. AS has been shown to be inferior to whole-gland treatments in to preventing progression or metastases. As a result, the field has sought solutions outside of the dichotomous options currently presented to men with low-risk cancer. Finally, the acceptance of preservation of sexual/urinary function and the avoidance of definitive therapy as valid endpoints has forced providers to think outside of survival alone as meaningful measures of success. It is here that focal therapy has emerged as a prospective replacement to AS or definitive treatment in carefully selected men. Combined with available risk stratification tools, focal ablation may afford patients durable oncological benefit while maintaining quality of life even in low-risk cancers.

Primary Care Providers' Perceptions About Participating in Low-Risk Prostate Cancer Treatment Decisions.

Primary care provider's (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. Cross-sectional, national survey. For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14-4.17) and with higher volume of prostate cancer patients (> 15 vs. 6-10 in past year) (OR 2.16; 95% CI 1.02-4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82-5.32), discussing worry (OR 2.12; 95% CI 1.28-3.51), and reviewing benefits (OR 3.13; 95% CI 1.89-5.16) and risks (OR 3.20; 95% CI 1.91-5.36). The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.

Treatment of low-risk prostate cancer: a\xa0retrospective study with 477\xa0patients comparing external beam radiotherapy and I-125 seeds brachytherapy in terms of biochemical control and late side effects

PurposeThe goal of our study was comparison of external beam radiotherapy (EBRT) and I‑125 seeds brachytherapy in terms of biochemical control and development of late gastrointestinal and genitourinary side effects.Patients and methods477 low-risk prostate cancer patients treated between 2000 and 2019 at our department using either I‑125 seeds brachytherapy or EBRT with a dose of 74 or 78 Gy were reviewed for our analysis. 213 patients were treated with EBRT and 264 with seeds.ResultsPatients were followed up yearly with a median follow-up of 70 (3–192) months. The biochemical no evidence of disease (bNED) rates after 5 years were 95% for both EBRT and seeds, and after 10 years 87% for EBRT and 94% for seeds using the Phoenix criteria, although no significant difference was observed. Concerning gastrointestinal side effects, EBRT showed significantly higher rates of RTOG grade ≥2 toxicity compared to seeds, but at no point in follow-up more than 15% of all patients. On the other hand, genitourinary side effects were significantly more prevalent in patients treated with seeds, with 40% RTOG grade ≥2 toxicity 12 months after treatment. Nevertheless, both types of side effects decreased over time.ConclusionBoth EBRT and seeds provide excellent biochemical control with bNED rates after 10 years of about 90%. In terms of side effects, patients treated with seeds show higher grades of genitourinary side effects, while patients treated with EBRT show higher grades of gastrointestinal side effects.

Erectile function after WST11 vascular-targeted photodynamic therapy for low-risk prostate cancer treatment.

Vascular-targeted photodynamic therapy (VTP) using padeliporfin is currently assessed as a low-risk prostate cancer (LRPCa) treatment. The aim of this study was to assess erectile function outcomes of VTP for LRPCa treatment. We prospectively included all patients treated with VTP for LRPCa. The primary endpoint was the post-treatment International Index of Erectile Function score (IIEF5 score) evolution (at 6 months, 12 months, and then every year for 5 years). Secondary endpoints were the need of erectile dysfunction (ED) treatment and its efficacy. Eighty-two men were included. The median follow-up was 68 (range: 6–89) months. There was a 3-point significant decrease in the median IIEF5 score between baseline and at 6 months post-VTP (23 [range: 1–25] vs 20 [range: 1–25], P = 0.005). There was a 1-point decrease at 1 year and 2 years post-VTP compared to baseline (22 [range: 2–25] and 22 [range: 0–25], P < 0.005). There was no significant difference at 3, 4, and 5 years compared to baseline. Twenty-seven (32.9%) patients received ED treatment: phosphodiesterase type-5 inhibitors (PDEI5; n = 18), intracavernous injections (ICI; n = 9), and intra-urethral gel (n = 1). The median IIEF5 score statistically significantly increased after ED treatment (7 [range: 0–24] vs 21 [range: 1–25], P < 0.001). ED treatment was efficient for 75% of the patients. There was no statistically significant difference between IIEF5 score at baseline and after ED treatment (P = 0.443). Forty-six patients were totally potent before VTP and among them, 13 needed ED treatment post-VTP with a success rate of 69.2%. VTP induced minimal changes in erectile function with a 3-point and a 1-point reduction in the IIEF5 score at 6 months and at 1 year, respectively. When required, ED treatment was efficient.

Contemporary trends in treatment for low-risk prostate cancer.

5082 Background: Active surveillance (AS) is the preferred management of low risk (LR) prostate cancer (PCa) to decrease morbidity associated with overtreatment. We hypothesized management trends would show AS increasing and initial definitive treatment decreasing for men with LR PCa. This study describes contemporary trends in initial treatment for LR PCa using the National Cancer Database (NCDB), which includes ~50% of new PCa diagnoses in the United States per year. Methods: NCDB was queried for all patients with LR localized PCa (2010-2015), defined as non-metastatic PCa with PSA&lt;10 ng/mL, Gleason ≤6 and clinical T1-T2a primary tumor. Staging was assigned using 2018 American Joint Committee on Cancer guidelines. Patients refusing treatment, unable to be treated due to comorbidity or with unknown treatment status were excluded. Men were grouped based on NCDB codes for initial treatment including prostatectomy (PR), radiation (RT), AS and no treatment. Those receiving initial definitive treatment were compared to those who were not using logistic regression. Multivariable analysis was conducted for factors possibly correlating with management choice. Results: Of the 645,932 patients identified, 134,540 met inclusion criteria. Of these patients, 114,183 (84.9%) underwent PR or RT compared to 20,357 (15.1%) that did not. When examined over time, 92.4% of patients underwent initial PR or RT in 2010 vs. 73.9% in 2015 (p&lt;0.001). 90% of patients seen at community cancer centers underwent definitive initial treatment compared to 78% of those seen at academic centers (p&lt;0.001). Conclusions: In this national, hospital-based cohort overall rates of definitive initial treatment for LR PCa remain high, though seem to be decreasing over time. Overtreatment of LR PCa remains a concern and illustrates the relatively slow incorporation of guideline recommendations into clinical practice at the national level. [Table: see text]

474 - Sexual function after WST11 vascular-targeted photodynamic therapy for low-risk prostate cancer treatment

474 - Sexual function after WST11 vascular-targeted photodynamic therapy for low-risk prostate cancer treatment

Current Treatment for Low-Risk Prostate Cancer in China: A National Network Survey.

Objective: To analyze the current treatment for low-risk prostate cancer (LRPC) in China.Methods: A national questionnaire survey titled “A survey of current treatment of LRPC” was designed and released nationally through the network from July 16 to August 3, 2017.Results: A total of 1,116 valid questionnaires were recovered. The percentages of preferred treatment by active surveillance (AS) or radical prostatectomy (RP) were 29.21% and 45.61%, respectively. A correspondence analysis showed that the physician in charge was more inclined to choose AS than RP. Respondents from different institution types, hospitals with different annual numbers of newly admitted patients with prostate cancer, and with different familiarity with the LRPC definition presented a significant difference in the preferred treatments (p < 0.05). Urologists chose AS or not for the following reasons: tumor progression (52.51%), potential medical disputes (42.56%) (i.e., medical disputes from patients or their relatives when urologists choose AS to treat patients with LRPC and the patient has a poor outcome), fear of cancer (41.94%), and surgical risk (39.07%). These reasons were ubiquitous, and there was no significant difference among urologists for these concerns (p > 0.05). Personal skills, surgical risk, and tumor progression were the most common factors that influenced whether AS or RP was preferred (p < 0.05). Concern about the medical disputes brought about by AS was a key factor for not choosing AS (p < 0.05).Conclusions: LRPC is still dominated by RP in China, followed by AS. Personal skills, surgical risk, and concern about tumor progression were the common factors influencing whether AS or RP was preferred. In addition, medical disputes brought by AS are another key factor for not choosing AS. There will be more Chinese data in the future to guide treatment of LRPC.

Development and validation of a polygenic hazard score for aggressive prostate cancer identification

Prostate cancer (PCa) is a major health issue that affects over a million men globally every year (1). Although screening men for PCa using prostate specific antigen (PSA) estimates, over the past three decades, resulted in a significant improvement in quantity and quality of life, two major problems reduce the value of early screening using this method: (I) inaccuracy of test results (i.e., the receipt of false positive results), and (II) unnecessary aggressive treatment for low-risk PCa that could be managed via active surveillance or observation (2).

MTOR inhibitors for treatment of low-risk prostate cancer

Prostate cancer incidence increases with age; along with many other cancers, it could be considered a disease of aging. Prostate cancer screening has led to a significant proportion of men diagnosed with low-grade, low-stage prostate cancer who are now more likely to choose an active surveillance strategy rather than definitive treatments. Definitive treatment, such as surgery and radiation therapy, is useful for high-grade disease; however, because of the low long-term risk of progression of a low-grade disease and side effects of surgery and radiation, these treatments are less commonly used for low-grade disease. While five alpha reductase inhibitors have been shown to reduce the risk of cancer detection on subsequent biopsies for men on active surveillance, no medications have been proven to prevent progression to high-grade disease. mTOR pathways have long been known to influence prostate cancer and are targets in various prostate cancer patient populations. Low-dose mTOR inhibition with rapamycin has shown promise in pre-clinical models of prostate cancer and appear to affect cellular senescence and immunomodulation in the aging population. We hypothesize that low-dose mTOR inhibition could reduce progression of low-grade prostate cancer patients, allowing them to remain on active surveillance.

Opinions on the role of brachytherapy boost in management of high-risk prostate cancer: A survey of North American genitourinary expert radiation oncologists.

373 Background: Three randomized clinical trials have established brachytherapy (BT) boost in combination with external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT) as superior to definitive EBRT and ADT alone in terms of biochemical control (but not overall survival) at the expense of increased toxicity in men with high-risk (HR) prostate cancer (PCa). The current view regarding these two treatment algorithms among North American genitourinary (GU) experts is not known. Methods: A survey was distributed to 88 practicing North American GU physicians serving on decision-making committees of cooperative group research organizations. Questions pertained to opinions regarding BT as monotherapy for low-risk (LR) PCa and BT boost for HR PCa. Responders were asked to self-identify as BT experts vs non-experts. Treatment recommendations were correlated with practice patterns using Fisher’s exact test. Results: Forty-two radiation oncologists completed the survey, of whom 23 (55%) recommend EBRT and ADT alone and 19 (45%) recommend addition of BT boost. Twenty-five participants (60%) identified themselves as BT experts. Nearly 90% of those recommending BT boost were BT experts versus approximately 10% of non-BT experts (p &lt; 0.001). Responders who recommended BT monotherapy as first-choice treatment for LR PCa were more likely to recommend BT boost for HR PCa (p &lt; 0.0001). Conclusions: There is a dramatic polarization in opinions regarding incorporation of BT boost into EBRT+ADT therapy for patients with HR PCa among North American GU radiation oncology experts, who serve on decision-making committees and influence the national treatment guidelines and future clinical trials. Those who identify themselves as BT experts are significantly more likely to recommend BT boost, which may serve as a self-fulfilling prophecy regarding the role of BT in North American clinical practice. These findings are likely to influence the national guidelines and implementation of BT boost in current and future North American PCa clinical studies.

Les traitements focaux : une alternative dans la prise en charge du cancer de la prostate de bas risque ?

Recommended options for low-risk prostate cancer treatment are active surveillance, radical treatments or watchful waiting. Focal therapies are currently assessed for low risk prostate cancer treatment. Focal therapies can be performed in research protocols. Oncologic results of these focal treatments are encouraging and show excellent tolerance with few complications. Radical treatments are still possible after focal therapies failure. Focal therapies are a possible solution to over-treatment issue of low risk prostate cancers.

Vascular Targeted Photodynamic Therapy with Padeliporfin for Low Risk Prostate Cancer Treatment: Midterm Oncologic Outcomes

We assessed the midterm oncologic outcomes of vascular targeted photodynamic therapy with padeliporfin for low risk prostate cancer treatment. We prospectively assessed all patients treated with vascular targeted photodynamic therapy for low risk prostate cancer at our center. Patients were followed every 6 months. All patients underwent prostate biopsies 6 months after treatment or when there was biological or clinical progression. The primary end point was progression-free survival. Secondary end points were absent clinically significant cancer in the treated lobes, radical therapy and the prostate specific antigen rate. Variables were compared with the chi-square, Mann-Whitney or Wilcoxon test. Progression-free survival is reported with Kaplan-Meier curves. A total of 82 men were treated with vascular targeted photodynamic therapy. Median followup was 68 months (range 6 to 89). Median progression-free survival was 86 months (95% CI 82-90). Median prostate specific antigen decreased significantly by 41% 6 months after treatment and it remained stable during followup (p <0.001). A total of 115 lobes were treated and absent clinically significant cancer was achieved in 94 (82%). Of the 82 patients 20 (24%) underwent radical therapy, including radical prostatectomy in 18 and brachytherapy in 2, at a median of 22 months (range 6 to 86). Study limitations include a single arm design, small population size and midterm followup. Padeliporfin vascular targeted photodynamic therapy for low risk prostate cancer achieved an 82% rate of absent clinically significant cancer in treated lobes and 76% of patients avoided radical therapy at a median followup of 68 months. However, longer followup is required to determine long-term outcomes.