It’s always a great feeling to be able to deliver positive news, especially when it comes to cancer. On a national level, deaths from all cancers reached a new low in 2018—down 27% from what it was a quarter century ago. This dramatic announcement as 2019 begins is the result of 25 years of progress!
With particular regard to prostate cancer (PCa), all of us at Sperling Prostate Center view 2018 as a year of deepening rather than revolutionizing. Of course, there were dramatic developments such as Artificial Intelligence and Theranostics that are ushering in radical clinical change. On balance however, 2018’s ongoing evolution in detection, diagnosis and treatment technologies has strengthened our existing directions in controlling and even preventing PCa.
Below are some of the highlights we feel especially good about during 2018. Click through the links to read more about everything discussed here!
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Detection – Biomarkers and imaging updates
The classic PCa biomarker has been Prostate Specific Antigen (PSA). Although it is not specific just for prostate cancer, over a 20-year period the simple PSA blood test became an early warning sign that saved the lives of countless men. However, it came with a price: overdetection and overtreatment. Many of those men ended up with urinary and sexual problems, some of them permanent. When the US Preventive Services Task force issued the controversial warning against widespread screening, men’s health went through a worrisome period during which not enough men were screened with the result of a uptick in diagnosing more dangerous PCa. Now in 2018 the pendulum has swung back. Numerous papers were published encouraging screening but with the addition of multiparametric MRI (mpMRI) before rushing to biopsy.
We also saw the application of more PSA variants (total PSA, free PSA, isoPSA etc.). Again, depending on test results, integrating mpMRI was recommended before a needle biopsy. As these developments gathered force last year, the use of conventional randomized TRUS biopsy as the sole response to PSA testing began to diminish.
Diagnosing Prostate Cancer
Speaking of TRUS biopsy, another positive trend over the last 12 months has been the increased use of MRI-guided targeted biopsy instead. Published statistics confirm that real-time, in-bore MRI guided biopsies offer more accurate diagnosis of significant PCa (disease that possibly needs a rapid treatment response). NOTE: Do not confuse in-bore targeted biopsy with fusion-guided biopsy, which is often mistakenly called “MRI-guided biopsy” without further explanation. Fusion guidance is quickly being taken up by urology practices but it is NOT as accurate as real-time MRI guidance by an experienced radiologist!
When it comes to diagnosing PCa cells, 2018 saw improved use of the PI-RADS scoring system (Prostate Imaging-Reporting and Data System) implemented by radiologists using mpMRI. Suspected lesions (tumors) seen on mpMRI scans are assigned a score from 1 to 5, where 5 is the most aggressive. Studies have shown that PI-RADS correlates strongly with PCa biopsies or post-surgery prostate specimens. There is also a new Gleason grading system that parallels PI-RADS in its use of a 1-5 scale, rather than the conventional system of summing two numbers. Although adopted in 2016 by the World Health Organization (WHO), it wasn’t until 2018 that it has become more widely used. 2018 research papers report that the new grading system correlates better with prostatectomy outcomes.
Genomics and molecular analysis have been much more widely implemented during the past 12 months, taking our understanding of PCa its molecular and genetic mutation markers deeper. Research continues to confirm the value of the latest available tests based on tissue samples from biopsy—and even blood and urine tests in development—for identifying potentially life-threatening cell lines and planning treatment accordingly.
2018 brought diagnostic help from a surprising breakthrough source: Artificial Intelligence (AI) and Deep Learning. Clinical tests during the past year have already shown that computer programs (and computers equipped with special cameras) can be created to detect PCa on MRI scans and diagnose PCa from tissue samples faster and more accurately than us mere mortals.
Treating Prostate Cancer
MRI-guided Focal Laser Ablation (FLA) as a prostate cancer treatment pioneered by Dr. Sperling has become a recognized treatment choice for appropriate patients. Growing urologic and radiologic acceptance of MRI-guided focal laser ablation (FLA) culminated in a 2018 Delphi consensus project to standardize international guidelines for FLA. A panel of worldwide experts went through a number of rounds of questionnaires designed to establish the greatest common agreement on topics such as qualifications for focal therapy, details of the FLA procedures, best monitoring and follow-up practices, etc. The process wrapped up in 2018, and the resulting paper is scheduled for publication in 2019. We look forward to a productive standardization that will shape research studies and clinical practice. We are proud that Dr. Sperling was one of the global experts who participated in the process.
Another PCa treatment trend that crested in 2018 is broader use of Active Surveillance for men with early stage, low-risk PCa. This signals recognition that treatment for insignificant PCa can safely be deferred as long as monitoring is excellent. Until recent years, most protocols for following patients on AS included an annual TRUS biopsy, at least for the first few years, as well as PSA tests at regular intervals. This was not successful. Many patients avoided the re-biopsy process due to its risks and unpleasantness, with the result that changes in their PCa were detected too late for a favorable treatment window. All that is changing. Progress during 2018 reinforced the crucial role that mpMRI plays during surveillance, especially with eliminating unnecessary repeat biopsies. This increases patient confidence in AS as a safe choice, and ensures a much higher rate of compliance with follow-up protocols.
2018 likewise strengthened developments in different types of immunotherapies for advanced cases of prostate cancer. Immunotherapy means activating and engaging the body’s natural defense mechanisms. A breakthrough study this past year demonstrated the effectiveness of a new drug, pembromizulab, against prostate cancer cells carrying a specific genetic defect. It’s easy to predict that progress in immunotherapies will gain much more ground in the years to come.
One more treatment area deserves mention. It is called personalized medicine, precision medicine, or theranostics—terms we’re sure to hear more often. It is based in genomics and molecular medicine. A theoretical example is that PCa can be attacked one cancer cell at a time by attaching a lethal molecule to a nutrient that the cell will take up. Think of it like the Trojan Horse that delivered warriors disguised as a gift into the heart of Troy, a walled city. Stay tuned for hopeful research.
Understanding about many areas of men’s health profited by studies released in 2018. A big area is Testosterone Replacement Therapy (TRT), which went on a rather wild ride of shifting clinical attitudes about its use for men with PCa. It appears that the dust is settling, now that there is ample evidence that TRT does not increase the risk for developing PCa. Furthermore, thanks to mpMRI, it is possible to track PCa patients (before, during, or after treatment including AS) for prostatic changes.
mpMRI continues to be helpful in the field of men’s pelvic health, particularly for identifying Benign Prostatic Hyperplasia (BPH), chronic inflammation or chronic prostatitis/pelvic pain. We are proud to offer expert imaging, interpretation and consultation for conditions related to men’s pelvic health. Dr. Sperling is also the leading expert in FLA for the relief of urinary symptoms due to BPH.
Prostate Cancer Prevention
The Year in Review would not be complete without acknowledging forward momentum in understanding how to reduce the risk of PCa and ways to prevent it from recurring after treatment. As we have often written on our blog, “What’s good for the heart is good for the prostate.” This includes nutrition and dietary habits, exercise, and new research into pharmaceuticals that have the potential to help us age well. Among the topics that pertain to these areas, over the past few years we have written about issues that became even more high profile in 2018:
- How extra fat contributes to inflammation, a precursor to cancer
- How the Western diet raises PCa risk
- Intermittent fasting
- Four lifestyle factors that lower medical expenses
- Anti-inflammatory drugs may prevent PCa
- A diabetes drug that may prevent PCa and support healthy aging
It was a very good year
All in all, the progress we observed throughout 2018 gives us tremendous optimism. The world of prostate cancer—and more broadly, men’s health—is even better today than it was twelve months ago. We eagerly anticipate the bright clinical future we foresee for 2019 and the years beyond.
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