JUNE 2019 | FUTUREOFPERSONALHEALTH.COM
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PROSTATE AND UROLOGICAL HEALTH
Harry Lennix
Why it’s especially important for African American men to get screened for prostate cancer
This test is giving prostate cancer patients a newfound confidence
Learn why having options for prostate cancer treatment is a huge advantage
The Biggest Developments in Precision Medicine We sat down with Brian Alexander, practicing physician and chief medical officer at Foundation Medicine, to talk about the current state of cancer care.
Prostate Cancer Treatment Has Come a Long Way in a Short Time Men diagnosed with prostate cancer have more effective and safer treatment options than ever before.
How is Foundation Medicine advancing the field of precision medicine in cancer care? Cancer is a complex disease of the genome, and from my experience treating patients and leading Foundation Medicine’s research and development team, I believe the more we understand cancer on a molecular level, the faster we can transform cancer care for patients. I’m excited to come to work every day because, at Foundation Medicine, we’re uniquely positioned to lead a paradigm shift in the collective understanding of cancer. What developments in precision medicine are most exciting to you? The more we learn about cancer genomics, the more we’re realizing cancer is increasingly defined by genomic signatures of cancer growth, not the tissue of origin. This is evidenced by the fact we continue to see approvals of pan-tumor therapies that oncologists can prescribe based on a tumor’s genomic signature regardless of tissue of origin. Foundation Medicine continues to explore the role of pan-tumor biomarkers, such as MSI and NTRK, which can be detected by our tests and are now associated with FDA-approved therapies. Additionally, we have led the research in advancing the clinical utility of tumor mutational burden as a predictive genomic biomarker for response to immunotherapy. Read the full interview online at FutureofPersonalHealth.com.
Jonathan W. Simons, M.D., President and CEO, Prostate Cancer Foundation f you are diagnosed with prostate cancer, rest easy — the chances of long-term survival are better than they have ever been. Even some men with widely metastatic cancer have achieved long-term remission — something we only dreamed of 20 years ago. The 10-year survival rate in the United States is over 98 percent. How has this changed? Let’s start with diagnosis. Better detection Twenty years ago, the prostate-specific antigen (PSA) test was still fairly new — so new that doctors didn’t know what a “safe” number was. The very first cutoff number for PSA was four. Many men with aggressive prostate cancer have a lower PSA. Now, we not only know what levels PSA should be
for a man in his 40s and every decade afterward, but we have different ways of looking at PSA, including free PSA and other biomarker tests to help rule out benign prostatic enlargement. Better treatments Surgery is better than ever, with fewer side effects. A minimally invasive robotic prostatectomy didn’t exist 20 years ago. Surgeons also know much more today about how to preserve potency and urinary continence. Twenty years ago, there were no drugs like Viagra to help men with erectile dysfunction after surgery or radiation. Unlike today, there was no biofeedback to help men learn bladder control and no good, effective surgical help for men who had persistent trouble with urinary continence. Also, radiation has gotten so much more precise, it has matched the “gold standard” of surgery. Radiation used to be under-powered and was delivered unevenly. Now, it is delivered at higher strength with greater precision, and radiation oncologists are much better at protecting normal tissue
in the rectum and other areas adjacent to the cancer. Better understanding Hormonal therapy was not very effective; worse, estrogen (not even used to treat prostate cancer today) carried major risks of heart attack and stroke. Now, hormonal therapy, or androgen deprivation therapy, is combined with androgen-blocking drugs (including abiraterone, enzalutamide, and apalutamide) to delay the time to progression significantly — sometimes for decades. Today, taxotere is proving to be an effective chemotherapy, which previously didn’t exist. We also didn’t really know the significance of family history. We knew that prostate cancer ran in some families, but we didn’t have any identified genes to test. Today, we know that even if prostate cancer doesn’t run in your family, but other cancer does, you might be at higher risk of getting prostate cancer, and you need to start getting screened in your 40s. These are bright days for treatment of prostate cancer — there has never been more hope. n
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The Test Helping Prostate Cancer Patients Avoid Unnecessarily Aggressive Treatment With Con�ıdence
Dan P. used the Oncotype DX Genomic Prostate Score® test to help guide his prostate cancer treatment decision.
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A simple test can clarify prostate cancer prognoses, o�fering men more focused treatment options. Prostate cancer is one of the most common cancers afflicting men; nearly 175,000 men will be diagnosed with prostate cancer this year alone. In the past, this has inspired doctors to take an aggressive approach to treatment by default. “The majority of men that have prostate cancer have lower risk prostate cancer,” says Rick Baehner, M.D., chief medi-
cal officer at Genomic Health, a diagnostic company addressing both the overtreatment and optimal treatment of cancer with genomic-based tests. “They will die with their cancer — not from their disease. Unfortunately, the vast majority will choose to have a prostatectomy for fear of their cancer being potentially more aggressive.” “There are a lot of misconceptions about the disease,” says Wendy Poage, MHA, president of the Prostate Conditions Education Council (PCEC). “Prostate cancer does not only impact older men; and there is a significant life-saving benefit to screening and early detection, especially for at-risk men.” PCEC reaches more than 400
million people each year with information about prostate cancer and men’s health, and provides free and low cost PSA tests throughout the country. To learn more, visit www. prostateconditions.org or call 1 (866) 4-Prost8. More focus The most common screening test for prostate cancer is the prostate-specific antigen (PSA) test. “Most men are sent to a urologist because of an elevated PSA,” says Richard C. Sarle, M.D., a urologist with Sparrow Medical Group Urology. “They get a biopsy, and they get a diagnosis of prostate cancer. Then the urologist will place the patient into a risk category. Treatment options are based on that risk.”
The difference in approach between highrisk and low-risk patients is stark. “If someone’s diagnosed with low-risk disease, the mortality from prostate cancer at 10 years is probably less than 1-2 percent,” says Sarle. “The problem that we’ve had historically is that the initial risk assessment has been fundamentally flawed. If we put them in the wrong category, we end up making incorrect decisions, and that’s where Genomic Health’s GPS test has come into the mix.” The Oncotype DX Genomic Prostate Score® (GPSTM) is a genomic test offering an extremely accurate prediction of the level of risk involved with prostate cancer. “The GPS test looks at 17 genes and their expression,” explains Baehner. “Those levels tell us whether or not that is an aggressive or non-aggressive tumor, so the patient can be selected for monitoring — known as active surveillance — if it’s not aggressive.” “What’s special about the GPS test is that the result is representative of the entire prostate,” says Po a g e. “W i t h a biopsy, the patient often worries about if a more aggressive cancer was missed — they’re worried about what might be hiding. The GPS test gives patients and doctors more information to help make a decision — and at a minimum it confirms the decision to treat with active therapy versus active surveillance.” This has greatly reduced over-treatment of
low-risk cancers. “Twenty years ago, almost everyone with prostate cancer — 98 percent of patients — were treated in some way,” says Sarle. “Today, that number is getting closer and closer to 50 percent. For a large number of low-risk patients, their decision is to enter active surveillance.” Empowering urologists and patients Avoiding over-treatment has a real impact on a patient’s quality of life, and can also avoid the often-unpleasant side effects of most prostate cancer treatments. “There may be side effects to treatment,” notes Poage. “There’s a risk of impotence and incontinence, but it’s a decreasing risk as the tools and surgeries and techniques that we have get better. Probably the biggest misconception I hear is that if you have cancer it needs to be removed. We remind patients and their families that just because you get diagnosed doesn’t mean you need to get treated. Monitoring the cancer is often a great option, and that’s where tests like the GPS score make a big difference.” In the end, the Oncotype DX® GPS test is making treatment easier and more effective. “This is an extremely exciting time of moving from onesize-fits-all to an era of personalized medicine,” says Baehner. “Targeted therapies, better molecular tools, and, ultimately, better outcomes for physicians and patients.” n Jeff Somers MEDIAPLANET • 3
What Men Should Know About Erectile Dysfunction It wasn’t that long ago that erectile dysfunction spelled doom in the bedroom for many men and their partners. There was a general view that men and their partners in their 60s, 70s, and beyond did not need to — or, in some views, shouldn’t — engage in an active sex life.
Then sildenafil — or Viagra, “The Little Blue Pill” — came along in the 1990s, soon to be followed by tadalafil and vardenafil. These landmark medicines ushered in a new era for older men in the treatment of ED. It’s estimated more than 2 million prescriptions for Viagra, or its generic, will be filled in the United States this year.
The facts about ED and treatment Traditionally, ED was thought to only occur in older men. But in reality, about 5 percent of men develop ED in their 40s. While the physiology is complex, at its core, ED is caused by a lack of increased blood flow to the penis in response to sexual stimuli. This increased blood flow is what creates an erection.
ED is caused by myriad complex, interlaced psychological and physiological conditions, and a substantial percentage of ED is related to medical conditions that harm blood vessels, including those in the penis. Treatment of ED is often linked with treatment of underlying health conditions like diabetes, hypertension, arteriosclerosis, depression, and low testosterone. Healthcare providers work with patients to bring these conditions under better control to manage ED. When ED is found to be mainly psychological, medications like Viagra may need to be paired with behavioral health treatment. If sexual intimacy has been absent for awhile, men and their partners may need to reinvigorate intimate relations slowly over time. It’s important that men don’t think of erectile dysfunction as the end of the road for their sex lives — treatments exist. n Dr. Salvatore J. Giorgianni, Pharm.D., Science Advisor, Men’s Health Network
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A Better Way to Talk About — and Treat — Erectile Dysfunction Erectile dysfunction (ED) is a lot more common than you might think; studies show that ED affects approximately 10 percent of men per decade of life — i.e., 20 percent of men in their 20s, 30 percent of men in their 30s; and yet, you’d never know it, because of the stigma associated with ED. SPONSORED
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Men are afraid to talk about sexual performance because it risks humiliation,” says Paul R. Nelson, LMHC, CCMA, SE, a sexuality educator and founder of FrankTalk.org, the first non-commercial online community for men with sexual dysfunctions. “Talking about it, making it a topic of conversation without shame is going to take a shift in the culture.”
Very personal Nelson’s passion for the subject is personal, stemming from his own experience with sexual dysfunction after prostate cancer surgery. “Men tend to be emotionally isolated — guys do not have intimate male relationships with other men where they can tell them anything,” Nelson says. “Men have to realize that it’s just a medical condition. It’s not a reflection on anybody or anything.” What makes that shift in thinking so important is that ED can be the fi rst sign of serious health issues. It’s the fi rst place oncoming health problems like diabetes or heart disease show up.”
The takeaway is simple. “If it’s bad for your penis, it’s bad for your heart, and vice versa. Obesity, alcohol, drug abuse, steroid abuse — anything that’s bad for your heart is going to show up in your penis first.” New tools While Viagra is likely the only ED drug men have heard of, it’s often not the best choice. “Fifty percent of men who get a prescription for Viagra never refill it,” Nelson notes, “because they couldn’t tolerate it — or it didn’t work for them.” Men shouldn’t settle for the first-generation oral ED medication if they’re not a good fit. There is a second-generation
option that may improve the situation as far as Nelson is concerned. “STENDRA is an FDA-approved second-generation oral erectile dysfunction drug. When the time is right, you can pop the pill, even after moderate alcohol consumption and dinner. Then, you’re ready for intimacy in as early as 15 minutes, enjoying a more natural rhythm of intimacy with a favorable tolerability profile.” There is still a low side effect incidence rate; tell your doctor about all medications you are taking, especially nitrates or alpha blockers. (See important safety on the following page). This is a crucial difference, Nelson states: “With Viagra and Cialis, a lot of guys stop taking them because of a significant side effect or delay in onset; not realizing they have another option to try. In fact, STENDRA was studied and clinically proven to work on a patient’s terms. For those patients: don’t give up! Ask your doctor about STENDRA.” For Nelson, this is a game changer for men dealing with ED. STENDRA offers some unique attributes that are worth a try, including selectivity, predictability, and helping to restore natural intimacy. Stop performing, start playing Nelson plans to keep working to change the conversation around ED. “My big thing with everyone is, ‘stop performing, start playing,’” he says. “That’s my slogan. When it comes to sex, everyone’s performing. The voice is screaming in the back of every guy’s head that he’s not doing it right.” As the conversation around ED evolves, so are the tools on hand to combat it. If you’re suffering any sort of erectile dysfunction, talk to your doctor today. n Jeff Somers MEDIAPLANET • 5
Patient Information STENDRA® (sten-druh) (avanafil) Tablet Read this Patient Information before you start taking STENDRA and each time you get a refill. There may be new information. This information does not take the place of talking with your healthcare provider about your medical condition or your treatment. What is the most important information I should know about STENDRA? STENDRA can cause your blood pressure to drop suddenly to an unsafe level if it is taken with certain other medicines. Do not take STENDRA if you take any medicines called “nitrates.” Nitrates are used to treat chest pain (angina). A sudden drop in blood pressure can cause you to feel dizzy, faint, or have a heart attack or stroke. Do not take STENDRA if you take medicines called guanylate cyclase stimulators which include: • riociguat (Adempas®) a medicine that treats pulmonary arterial hypertension and chronic-thromboembolic pulmonary hypertension Ask your healthcare provider or pharmacist if any of your medicines are nitrates or guanylate cyclase stimulators, such as riociguat. Tell all your healthcare providers that you take STENDRA. If you need emergency medical care for a heart problem, it will be important for your healthcare provider to know when you last took STENDRA. Stop sexual activity and get medical help right away if you get symptoms such as chest pain, dizziness, or nausea during sex. Sexual activity can put an extra strain on your heart, especially if your heart is already weak from a heart attack or heart disease. What is STENDRA? STENDRA is a prescription medicine used to treat erectile dysfunction (ED). STENDRA is not for use in women or children. It is not known if STENDRA is safe and effective in women or children under 18 years of age. Who should not take STENDRA? Do not take STENDRA if you: • take medicines called “nitrates” • use street drugs called “poppers” such as amyl nitrate and butyl nitrate • are allergic to avanafil or any of the ingredients in STENDRA. See the end of this leaflet for a complete list of ingredients in STENDRA.
What should I tell my healthcare provider before taking STENDRA? Before you take STENDRA, tell your healthcare provider if you: • have or have had heart problems such as a heart attack, irregular heartbeat, angina, or heart failure • have had heart surgery within the last 6 months • have had a stroke • have low blood pressure, or high blood pressure that is not controlled • have a deformed penis shape • have had an erection that lasted for more than 4 hours • have problems with your blood cells such as sickle cell anemia, multiple myeloma, or leukemia • have retinitis pigmentosa, a rare genetic (runs in families) eye disease • have ever had severe vision loss, including an eye problem called non-arteritic anterior ischemic optic neuropathy (NAION) • have bleeding problems • have or have had stomach ulcers • have liver problems • have kidney problems or are having kidney dialysis • have any other medical conditions Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. STENDRA may affect the way other medicines work, and other medicines may affect the way STENDRA works causing side effects. Especially tell your healthcare provider if you take any of the following: • medicines called nitrates (see What is the most important information I should know about STENDRA?) • medicines called guanylate cyclose stimulators, such a riociguat (see What is the most important information Ishould know about STENDRA?) • medicines called HIV protease inhibitors, such as ritonavir (Norvir), indinavir (Crixivan), saquinavir (Fortavase orInvirase) or atazanir (Reyataz) • some types of oral antifungal medicines, such as ketoconazole (Nizoral), and itraconozale (Sporonox) • some types of antibiotics, such as clarithromycin (Biaxin), telithromycin (Ketek), or erythromycin • medicines called alpha blockers. These include Hytrin (terazosin), Flomax (tamsulosin HCl), Cardura (doxazosin), Minipress (prazosin HCl), Uroxatral (alfuzosin HCl), Jalyn (dutasteride and tamsulosin HCl), or Rapaflo (silodosin). Alpha-blockers are sometimes prescribed for prostate problems or high blood
pressure. In some patients, the use of STENDRA with alpha-blockers can lead to a drop in blood pressure or to fainting. • other medicines that treat high blood pressure • other medicines or treatments for ED Ask your healthcare provider or pharmacist for a list of these medicines, if you are not sure. Know the medicines you take. Keep a list of them to show to your healthcare provider and pharmacist when you get a new medicine. How should I take STENDRA? • Take STENDRA exactly as your healthcare provider tells you to take it. • Your healthcare provider will tell you how much STENDRA to take and when to take it. • Take STENDRA 100 mg or 200 mg as early as approximately 15 minutes before sexual activity. • Take STENDRA 50 mg as early as approximately 30 minutes before sexual activity • Do not take STENDRA more than 1 time a day. • Your healthcare provider may change your dose if needed. • You should take the lowest dose of STENDRA that works for you. You and your healthcare provider should decide about the lowest dose of STENDRA that works for you. • STENDRA may be taken with or without food. • Do not drink too much alcohol when taking STENDRA (for example, 3 glasses of wine, or 3 shots of whiskey). Drinking too much alcohol when taking STENDRA can increase your chances of getting a headache or getting dizzy, increasing your heart rate, or lowering your blood pressure. What are the possible side effects of STENDRA? The most common side effects of STENDRA are: • headache • flushing • stuffy or runny nose • sore throat • back pain STENDRA may uncommonly cause: • an erection that will not go away (priapism). If you have an erection that lasts more than 4 hours, get medical help right away. • sudden vision loss in 1 or both eyes. Sudden vision loss in 1 or both eyes can be a sign of a serious eye problem called non-arteritic anterior ischemic optic neuropathy (NAION). It is uncertain whether PDE5 inhibitors directly cause vision loss. Stop taking STENDRA and call
your healthcare provider right away if you have sudden vision loss in 1 or both eyes. • sudden hearing decrease or hearing loss. Some people may also have ringing in their ears (tinnitus) or dizziness. Tell your healthcare provider if you have any side effect that bothers you or does not go away. These are not all the possible side effects of STENDRA. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store STENDRA? • Store STENDRA at 68°F to 77°F (20°C to 25°C). • Keep STENDRA out of the light. Keep STENDRA and all medicines out of the reach of children General information about the safe and effective use of STENDRA. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use STENDRA for a condition for which it was not prescribed. Do not give STENDRA to other people, even if they have the same symptoms that you have. It may harm them. This Patient Information leaflet summarizes the most important information about STENDRA. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about STENDRA that is written for health professionals. For more information, go to www.STENDRA.com or call 1-844-458-4887. What are the ingredients in STENDRA? Active ingredient: avanafil Inactive ingredients: mannitol, fumaric acid, hydroxypropylcellulose, low substituted hydroxypropylcellulose, calcium carbonate, magnesium stearate, and ferric oxide yellow This Patient Information has been approved by the U.S. Food and Drug Administration.
©Metuchen Pharmaceuticals LLC. All rights reserved. US Patent Number: 6,656,935 and 7,501,409 STENDRA® is a registered trademark of Metuchen Pharmaceuticals, LLC All other trademarks are the property of their respective owners. Manufactured by: Sanofi Winthrope Industrie, Ambares, France 332F007 / 332F008 ©June 2019 STEN-MET-45
Having Conversations About Men’s Health Over a Pint Misinformation reversed years of progress in getting men to receive prostate cancer screenings. This charity is bringing awareness back to an important men’s health issue. Early diagnosis is the key to successfully treating prostate cancer, but men have been alarmed by reports that screening can lead to overtreatment. Ignorance is not bliss when it comes to men’s health. I’m a prostate cancer survivor and I shouldn’t be. In 2007, a work colleague battling the disease urged his male friends to get screened. I had just turned 47 years old, had no symptoms and no known family history of prostate cancer, but my friend was fighting against a disease he knew would eventually take his life. His simple request was that I ask for a prostate-specific antigen (PSA) test during my next physical.
I did not know what a PSA test was, but the simple blood test was quick, easy, and a lifesaver. A biopsy followed my test results and confirmed I had prostate cancer. In April 2008, I had successful prostate cancer surgery. That’s when I became an unlikely men’s health advocate, but it was not long before an obscure federal agency suggested men were making a mistake by opting for a PSA screening. Pints for Prostates Shortly after my surgery, with the help of family and friends, I started a 501(c)3 charity called Pints for Prostates. I had a career in marketing and had been writing about beer since 1980, when I was a junior at Syracuse University. My gut told me the universal language of beer was a great way to reach guys who typically
PHOTO: COURTESY OF PINTS FOR PROSTATE
of data from earlier studies, reversed itself and found PSA testing had indeed helped reduce the prostate cancer death rate.
ignore health messages and avoid doctor’s office visits. Our mission is to visit beer festivals, breweries, and beer bars to educate guys. It’s a simple mission complicated by conflicting messages. In 2009, the U.S. Preventive Services Task Force (USPSTF) issued a startling finding. They recommended against PSA screening, saying two studies indicated little life-saving benefit, suggesting testing caused overdiagnosis of slow-moving cancers that were unlikely to be deadly. This amazed many in the prostate cancer community, since the death rate from the disease had been cut by nearly 40 percent in the two decades since the PSA came into widespread use. USPSTF’s announcement got a lot of media attention, causing many men to avoid screening. It was not until 2017 that USPSTF, based on a new review
Reversing progress Several important milestones have occurred since I was treated and when USPSTF initially suggested PSA tests were problematic. The number of prostate cancer deaths in the United States, which had been declining since the early 1990s, started creeping up in 2016. It’s estimated 31,620 American men will die from prostate cancer in 2019. Prostate cancer is a scary subject for guys. They don’t like to talk about the physical exam and they dread the potential side effects from treatment. Pints for Prostates attempts to remove some of the fear by starting a simple conversation about men’s health. It helps that many of these discussions happen over a pint with other men who have conquered the disease. Our goal is to get guys to take charge of their health by getting an initial screening at 40 — 35 for men with a family history or high-risk groups, like African Americans. Last year, at 17 events across the country, Pints for Prostates provided free men’s health screenings to 1,043 guys — many of whom had not seen a doctor in years. They get their PSA score and data on lipids, glucose, and testosterone, providing warnings on heart disease, diabetes, and other common men’s health issues. Men have a right to know their numbers and make informed health decisions with the help of medical professionals. As we like to say, “Get tested. Live longer. Drink more beer.” You can get more information on Pints for Prostates and upcoming events by visiting www.pintsforprostates.org. n Rick Lyke, Founder, Pints for Prostates MEDIAPLANET • 7
Prostate cancer is the second leading cause of cancer death among men, however, advances in technology are leveling the playing field. Prostate cancer has a wide range of severity, outcomes, and risk factors, but improvements in radiation treatment technology have been critical to better outcomes for prostate patients in recent years. “Less invasive forms of surgery, such as robotic prostatectomy and proton therapy, have been instrumental in improving patient outcomes by reducing post-treatment complications,” said Naren Ramakrishna, M.D., Ph.D, director of neurologic and pediatric radiation oncology at Orlando Health UF Health Cancer Center. Since the early 1900s, X-rays have predominantly been used to treat cancer, but doctors now have another option. “Protons are fundamentally different than X-rays/photons,” Dr. Ramakrishna explained. “They deposit the majority of their dose in a sharp peak within the tumor, and essentially no dose beyond the tumor.” The technology for proton therapy continues to improve using technology like pencil beam scanning, which allows proton doses to be “painted” in layers in a tumor and form even more precise shapes and distributions, according to Dr. Ramakrishna. He noted that morbidity and mortality from prostate cancer have a significant impact on society, and are challenging for men’s health. “Better outcomes in the foreseeable future will require approaches that combine improved technology, such as proton therapy, with our growing understanding of the biology of prostate cancer in the localized and metastatic setting.” Cindy Riley
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Why Getting Screened for Prostate Cancer Is “Life or Death” Actor and director Harry Lennix wants all men, but in particular African American men, to understand the importance of detecting prostate cancer early.
PHOTO: THEO & JULIET PHOTOGRAPHY
These Innovative Technologies Are Improving Prostate Health
lthough the rate of cancer deaths a m o n g African Americans has been declining since 1990, this racial group remains the most likely to be diagnosed with, and die from, cancer, according to the American Cancer Society (ACS). That’s why stage and screen actor and direc-
tor Harry Lennix wants to spread the word about the importance of getting screened for prostate cancer, a disease that has a five-year survival rate of 99 percent when caught early. “I love my brothers and I love my friends,” said Lennix, who was in films like “Man of Steel’” and TV shows including “Billions”
and “The Blacklist.” “These are personal relationships, and I want those people in my life as often and as long as I can have them.” In his nearly 40-year acting career, Lennix has witnessed the toll prostate cancer has taken on his friends, colleagues, and family members with the disease. “It hits pretty close to home, and the science says 1 in every 6 black men are diagnosed with prostate cancer,” he said. Because of the location of the prostate, which is between the penis and the rectum, many men are embarrassed or afraid to have the conversation with their healthcare providers, according to a review published in November 2017 in PLOS One. But Lennix encourages men to overcome any feelings of shame or fears of stigma in service of their health. After all, he said, the conversation about prostate cancer with your healthcare provider isn’t a matter of if — but when. “It’s about putting on your big-boy pants, no matter how uncomfortable it is to talk about it, and going through the processes of trying to avoid it,” he said. “It’s way more preferable to do those things than to actually have to fight this insidious disease.” n Melinda Carter
How Prostate Cancer Treatment Is Changing for the Better Prostate cancer once had limited treatment options, but at many leading treatment centers, a multimodal approach combining the best of several options is changing the dynamic.
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rostate cancer is the second-most common and second-most deadly cancer afflicting men in the United States, with 1 in 9 men diagnosed with the disease at some point in his life. However, the survival rate for prostate cancer can be very good — with the right treatment. “The vast majority of prostate cancers are slow growing,” points out Marcio Fagundes, M.D., medical director of radiation oncology at Baptist Health’s Miami Cancer Institute. “That means a patient has days, weeks, and sometimes a few months to make a decision.” A multimodal approach Making that decision involves maximizing your options. “It’s very important to seek care at a facility that has all the possi-
ble or available resources,” says Dr. Fagundes. “For example, in our center we have every single modality in radiotherapy. So we can select the best modality, as opposed to offering only the technology that we have — because we have all of them.” Th i s c o m p r e h e n s i ve approach to treatment options extends to the surgical realm as well. “Advanced robotic systems can do a robotic prostatectomy and also maintain the quality of life,” notes Murugesan Manoharan, M.D., chief of urologic oncology surgery at Miami Cancer Institute. “We also have other newer technologies available, such as hydrotherapy and cryotherapy.” Having different treatment modalities allows them to be combined in what’s known as a multimodal approach. “Prostate cancer is quite a wide range of disease,” explains Dr. Manoharan. “In the past, we either offered surgical removal of the prostate or we offered radiation and hormones, and none of these treatments on their own provided the best cure rate. Today we can combine the best of the treatments to make every attempt to cure the patient.”
The cutting edge The multimodal approach is further augmented by adoption of cutting-edge treatments, including the aforementioned robotic systems; new diagnostic blood tests; MRI fusion biopsies, which are a targeted and more precise biopsy; newer scans like the Axumin PET/CT and the PSMA PET scan, which are very sensitive to cancer; and new radiation therapies, like stereotactic body radiotherapy (SBRT), and intensity-modulated radiation therapy (IMRT). One important new weapon is proton therapy. “A proton is a particle,” explains Dr. Fagundes. “Unlike X-rays, which go through the body and imprint an image on film, they’re heavy. They go in and they abruptly stop in the body at a controlled depth. And that’s where most of the radiation energy is deposited. Thus we can minimize the exposure of normal organs and minimize side effects.” Quality of life Minimizing side effects that impact a patient’s quality of life is vital. Now practicing at Baptist Health, Dr. Fagundes
was the pioneer user of rectal spacer in the United States, also known as SpaceOAR (OAR stands for organ at risk), in the treatment of prostate cancer with proton therapy, which was only approved by the FDA a few years ago. “When you use high doses of radiation to the prostate,” he explains, “there is a small risk you could irritate the rectum. SpaceOAR is a liquid that is injected between the prostate in the rectum that displaces the rectum away from the prostate enough to lower the dose of radiation on the rectum by about 10 times, essentially eliminating the risk of any serious rectal irritation.” Both doctors agree that these new technologies and the multimodal approach benefits patients. “Cancer treatment should be personal and individualized,” says Dr. Manoharan. “We want to provide total care, a combined approach to do what is best for the patient. And this is possible because we have everything under one roof. We can choose whatever is best for the patient.” n
Jeff Somers MEDIAPLANET • 9
What Men Can Do to Detect and Treat BPH It’s common for men over 50 to have prostate complaints, but how do you know if urinary symptoms signal the presence of prostate cancer or are caused by a benign enlargement of the prostate gland, or benign prostatic hyperplasia (BPH)? etermining whether prostate problems are being caused by prostate cancer or BPH is a dilemma many older men face. While prostate cancer is usually silent — it doesn’t cause symptoms — it can cause urinary symptoms similar to BPH, including difficulty starting a urine stream, a feeling that the bladder has not fully emptied, a sudden urge to pass urine, increased frequency of urination (especially at night), and a weak urine stream. Fortunately, BPH does not appear to increase the risk of developing prostate cancer. The best evidence for this comes from an analysis of a very large study sponsored by the National Cancer Institute (NCI) — the Prostate Cancer Prevention Trial (PCPT). As the name suggests, this was a cancer-prevention study, not a BPH study. However, 10 •
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during the course of the prevention trial, prostate biopsies were performed in many men who would not otherwise have had a prostate biopsy, providing a unique opportunity to assess rates of prostate cancer in men with and without urinary symptoms. This analysis revealed that men with urinary symptoms were no more likely to have prostate cancer than those without symptoms. Types of treatment If prostate symptoms from BPH are interfering with your daily activities, you may benefit from medical treatment. Two different types of drugs have been FDA-approved for the treatment of symptomatic BPH: alpha-blockers, which facilitate the flow of urine by relaxing smooth muscle within the prostate; and 5-alpha-reductase inhibitors (5-ARIs), such as finasteride and dutasteride,
which block the conversion of testosterone to the more potent dihydrotestosterone within the prostate, thus decreasing the size of the gland. These drugs, which can be used either alone or in combination, are highly effective for symptomatic BPH and have gone a long way toward eliminating the need for surgical intervention (a procedure known as a “TURP,” or transurethral resection of the prostate) to treat BPH. Evaluating the data The main finding of the PCPT was that finasteride substantially decreased the overall risk of prostate cancer. However, due to a small but statistically significant increase in higher-grade (potentially more aggressive) prostate cancers among the men who received finasteride, this drug was not approved for prostate cancer prevention.
Follow-up analyses of the PCPT suggested the observed increase in higher-grade prostate cancers was due, at least in part, to the fact fi nasteride increases the sensitivity of PSA for the detection of higher-grade cancers and decreases the size of the gland, making it easier for a biopsy to detect the presence of high-grade cancer. Most recently, an 18-year follow-up study of the PCPT found no increase in prostate cancer deaths among men who had received finasteride in the PCPT, providing additional reassurance that finasteride does not increase the risk of lethal prostate cancer. For these reasons, men requiring medical treatment for BPH might want to talk to their urologist about using a 5-ARI, either alone or in combination with an alpha-blocker, to decrease their prostate cancer risk in addition to addressing their urinary symptoms. Urinary complaints become increasingly common as men age. Fortunately, they are most often due to BPH, a benign condition, rather than to prostate cancer. However, if urinary symptoms are interfering with your daily life, medical intervention may be considered. The information provided here is for informational purposes only and does not constitute, nor is it intended to provide, medical advice to readers of this publication. Individuals should consult with their own medical team for medical advice that best supports their individual situation. For additional information, visit NCI’s website at www.cancer.gov and check out the section on prostate health (www.cancer.gov/types/prostate/understanding-your-prostate-changes) for extensive information on prostate cancer and other conditions. n Howard L. Parnes, M.D., National Cancer Institute
Why Less Is More When It Comes to Treating Prostate Cancer A prostate cancer diagnosis may sound intimidating, but there are a lot of benefits to delaying treatment.
rostate cancer is the most common cancer in men — but most men who get it won’t die from it. That means that not every person diagnosed with prostate cancer should treat it. Keep that in mind, especially if you are told you have low-risk prostate cancer. You may be anxious to have the cancer removed as soon as possible, but treatment comes with significant side effects, so take the time to weigh your options carefully. Studies reveal that many cases of low-risk prostate cancer are overtreated in the United States, leaving men to deal with significant side effects for the rest of their lives. Standard treatments for prostate cancer include surgery to remove the prostate or radiation to destroy the tumor. Both can cause erectile dysfunction and urinary incontinence. Keep an eye on it For most men with low-risk prostate cancer, there is another option — active surveillance, or monitoring the disease carefully instead of starting treatment right away. During active surveillance, your doctor will probably recommend a yearly prostate exam, as well as a blood test every 6-12 months to keep an eye on your level of prostate-specific antigen (PSA). A rising PSA level may mean your cancer is becoming more aggressive. In some cases, an MRI or biopsy might also be performed during active sur-
veillance to provide additional information about the cancer. If at any point these tests indicate your cancer is becoming aggressive, you and your doctor may decide it’s time to begin active treatment. This happens with about 1 in 3 patients. Delaying treatment Research shows it’s safe to delay treatment for low-risk prostate cancer while monitoring the disease. A University of Califor-
nia, San Francisco study of 157 men, who underwent surgery after a period of time on active surveillance, found their survival rates were similar to those who had surgery immediately after they found out they had prostate cancer. An even larger study at Johns Hopkins University involved 1,298 men with prostate cancer. It revealed that 10 years after choosing active surveillance, only 0.1 percent of the men
involved died of cancer and only 0.6 percent had cancer that metastasized, or spread to other parts of the body. Only half the men went on to active treatment after starting out on active surveillance. On average, the time from their diagnosis until they began active treatment was eight-and-a-half years — eight-and-a-half years without having to endure the side effects of treatment. In the National Comprehensive Cancer Network® (NCCN®) Guidelines for Prostate Cancer v1.2010 (published in December 2009), the NCCN® advised that virtually all men with lowrisk prostate cancer should be offered active surveillance as an option, and, in many of those cases, it should be the only treatment recommended. Unfortunately, some physicians do not inform their lowrisk patients about this option, or strongly advise them to move ahead with surgery or radiation. If you are told you have low-risk prostate cancer but your doctor does not mention active surveillance, or discourages you from considering that option, it’s time to get a second opinion. For more information about prostate cancer and its treatment, including active surveillance, visit the NCCN website: nccn.org/patients/guidelines/ prostate. n James Mohler, M.D., Roswell Park Comprehensive Cancer Center, NCCN Guidelines® for Prostate Cancer MEDIAPLANET • 11
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