In Italy, prostate cancer is still the most common among men. It accounts for 18% of all cancers diagnosed and in 2020 there were more than 36,000 new cases. Despite the degree of incidence, however, in recent years a reduction of 15.6% in the mortality rate has been estimated, thanks above all to the improvement of diagnostic techniques, the development of new targeted therapies and the ability to perform personalized investigations, predict the evolution of the disease and adapt the treatment strategy to the patient. To take stock of Medscape is Guillaume Ploussardurologist and oncologist at La Croix du Sud Clinic in Toulouse, France, and director of the prostate cancer subcommittee of the French Association of Urology (AFU).
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Precision diagnosis with MRI and targeted biopsies
Today we are able to obtain very precise magnetic resonance imaging (MRI) images and the ability of radiologists to interpret such images has improved. “This – explains Ploussard on MedScape – has made us better at identifying severe tumors on the one hand, and those that do not require treatment on the other”. But not only: MRI imaging is recommended in cases of suspected prostate cancer because it provides precise indications on the size and extent of the affected tissue, two fundamental parameters for determining the target area for targeted biopsy, the necessary examination for diagnosis. A spatial distribution of the disease is thus obtained. However, systematic biopsies are always added to targeted biopsies, which consist of taking a dozen samples. It is estimated that this procedure can identify 5 to 10% of cancers that would go unnoticed with a targeted biopsy. The improvement in imaging techniques has reduced overdiagnoses and has also changed the follow-up path of those who do not have to undergo therapy but undergo active monitoring. In this case, in the past, biopsies were performed every year or 2 years, while today they are not performed if the tumor appears stable on MRI.
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The genetic test
Another tool that has proved fundamental in recent years both for personalizing patients’ treatments and for assessing the risk of getting sick for a healthy person is genetic testing. Thanks to genetic analysis, in fact, we are able to identify mutations and defects that on the one hand predispose to the disease and on the other make the disease more sensitive to certain treatments, such as PARP inhibitors. About 5 percent of prostate cancer cases are due to inherited genetic mutations in the Brca 1 and 2 and Hoxb13 genes, the expert says. For this reason, patients with a family history of prostate cancer are advised to undergo tests for genetic mutations: in a partly Italian study published earlier this year, it was observed that men carrying a mutation in the Brca2 have more than double the risk of non-carriers of developing prostate cancer before the age of 80. “The departments of oncogenetics – stresses Ploussard – are overloaded with work, but they are adapting to this increase in demand”. But what path to early diagnosis should these people follow? “For those over 40 years old and present with one of these mutations – says the oncologist – the strategy for early diagnosis includes the prostate specific antigen test (PSA) and digital rectal examination, to be repeated on an annual basis or every 2 years “. As for the PSA for the general population, however, a clarification must be made: now there is no longer talk of prostate cancer screening, but of an early diagnosis adapted to individual risk, to be carried out in well-informed men.
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Latest generation hormonal therapies
For metastatic cancer, hormone therapies aim to reduce the level of testosterone, the male hormone that stimulates the growth of cancer cells. “In recent years, many steps have been made in the development of next-generation hormone therapies, capable of directly attacking cancer cells,” continues Ploussard. These treatments are essentially androgen receptor inhibitors, which work by preventing cancer cells from using specific metabolites that promote their growth. Also for patients with advanced castration-resistant prostate cancer (i.e. resistant to the elimination of male hormones through surgery or hormone therapy) there are new third-line therapies that have shown their effectiveness. We are talking about both chemotherapies, both radionuclides and Parp inhibitors such as olaparib, for those with the BRCA 1/2 genetic mutation.
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The new radiopharmaceuticals
Among the therapies of the future, there are certainly radiopharmaceuticals. These are radioactive isotopes linked to molecules capable of recognizing cancer cells. Once administered, these isotopes serve both to detect metastases and to target them, releasing radiation in a targeted manner. “For the time being, radionuclide therapy has not been approved, and its use is limited to a few centers,” says Ploussard. “But approval for the treatment of castration-resistant metastatic cancer is expected shortly and other studies are underway to evaluate the use of the treatment in the early stages of the disease. The results are very encouraging ”.
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Quality of life goal
The side effects of prostate cancer – and treatments – often alter or compromise the quality of life of patients, sometimes affecting urinary and sexual function. Today, the quality of life is a parameter that is taken much more into consideration and treatments have evolved accordingly. There have been improvements in surgery thanks to the increasing use of robotics and the development of more precise radiation therapy, which plays an important role in prostate cancer, although little is said about it. These advances, facilitated by improvements in MRI, have clearly reduced cases of urinary and erectile dysfunction, Ploussard concludes. But although less frequent, these complications must still be kept in mind when discussing possible therapies with the patient.
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