Answers to Frequently Asked Questions About Prostate Cancer Risk, Treatment

Navigating a prostate cancer diagnosis involves understanding a range of factors, including one’s individual risk profile and the various treatment options available.

Several elements contribute to determining risk for cancer recurrence or progression, including Gleason score (which grades the aggressiveness of the cancer cells), the stage of the cancer, prostate-specific antigen (PSA) level (the amount of a protein produced by the prostate gland, found in the bloodstream) at diagnosis and after treatment, and certain genetic markers. With these pieces of information, patients are then categorized as low, intermediate or high risk, which in turn, helps guide treatment decisions and follow-up strategies.

Fortunately, there are multiple effective treatment options for prostate cancer, and the best choice for patients is typically based on individual risk, the stage and grade of the prostate cancer, overall health, and personal preferences. Treatment options for prostate cancer include active surveillance, surgery, radiation therapy, hormone therapy, focal therapy and chemotherapy.

In tandem with CURE’s Educated Patient Prostate Cancer Summit, Dr. Kelly Stratton answered common queries related to risk assessment, treatment options and managing advanced prostate cancer. Stratton, who served as the summit chair, is an assistant professor of urologic oncology in the OU Department of Urology and serves as an adjunct assistant professor of medical oncology at the OU Health Stephenson Cancer Center, in Oklahoma City.

Understanding Your Risk

Question: Can my PSA level indicate if the cancer has spread, or metastasized?

Answer: PSA is a test that helps us understand the risk of prostate cancer. It depends on where you are in spectrum of treatment to determine how a PSA may impact your risk of metastatic cancer.

Question: At what PSA level is external beam radiation therapy (EBRT) typically recommended?

Answer: PSA levels can correspond with prostate cancer risk by including prostate cancer grade. When PSA is high, it can be associated with high-risk disease. When PSA is low, it may or may not be associated with low-0risk disease. EBRT is usually used for intermediate and high-risk prostate cancer. For low-risk prostate cancer, we generally use active surveillance.

Question: Is focal therapy an option for low-risk prostate cancer (Gleason 3+3)?

Answer: Most people with low-risk prostate cancer are recommended active surveillance. In the United States we generally do not use focal therapy for low-risk disease. There may be very specific instances where focal therapy could be an option. A study outside the US found that certain focal therapy may prevent the need for additional treatment, but from our perspective that did not offer enough benefit to support the use of focal therapy in that situation.

Question: What types of imaging are used in prostate cancer?

Answer: There are several options. Most people will have a prostate MRI at some point. There is also PSMA PET that can be used for imaging. Traditionally we used CT scan and bone scan, which is often called conventional imaging.

Question: Could hip pain with certain movements be a sign of cancer spread?

Answer: Pain in the hip can be caused by many different issues. For some men, it is caused by orthopedic joint disease. However, it can be caused by prostate cancer spread. We often do imaging to determine the cause.

Understanding Your Treatment Options

Question: What is the overall survival (OS) associated with Erleada (apalutamide)? What are my options if prostate cancer has spread?

Answer: Erleada has been shown to improve survival in men with advanced prostate cancer. It depends on where you are in the treatment spectrum. Many people do good on Erleada and may be on treatment for a long duration.

Question: What does it mean if OS is five months in prostate cancer clinical trials?

Answer: Often when we say that survival was improved by five months, we mean that survival was extended on average five months longer than the comparison. While that seems like a short time, it may mean much longer for any one particular patient. This can be confusing, but the key is that the suggested treatment is better than the alternative.

Question: Why is active surveillance not often discussed as a treatment option for prostate cancer?

Answer: Prostate Cancer treatment has changed over the past several decades. Current guidelines recommend active surveillance for patients with low-risk prostate cancer. The use of active surveillance is gradually increasing as doctors have grown to understand the negative impact of over treatment in low-risk patients.

Question: Why do patients with BRCA1/2 mutations sometimes respond better to new therapies?

Answer: The patients with BRCA mutations do better with the specific PARP treatment because those treatments exploit the venerability of the genetic alteration.

Question: Are there studies comparing estrogen-based androgen deprivation therapy (ADT) to traditional ADT regarding heart disease risk factors like cholesterol and body mass index (BMI)?

Answer: The PATCH study suggested that transdermal estrogen therapy may improve lipid profiles and potentially reduce BMI. However, long-term studies are necessary to confirm these benefits in patients undergoing ADT for prostate cancer.

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