Prostate cancer is a disease with which one can live

 On the one hand, data from the Lithuanian Health Information Center shows that prostate cancer ranks first in the structure of malignant tumors affecting men. On the other hand, prostate cancer is one of the few cancer localizations where clinically insignificant prostate cancer, in the early stages of the disease, does not necessarily require treatment—just active monitoring. Patients, accustomed to hearing that cancer should be treated as early as possible, often find it difficult to understand this approach by doctors. How should doctors properly treat patients with prostate cancer? How should they determine which patients need treatment and which do not? What new treatments can patients with advanced forms of the disease expect? We discuss all this with Prof. Mindaugas Jievaltas, the head of the Urology Clinic at the Lithuanian University of Health Sciences.

There is a lot of talk about prostate cancer. Can it be said that the disease is diagnosed early and that more and more patients are being cured?

The trend of the last 10-15 years worldwide, in Europe, and in Lithuania is that doctors are diagnosing more and more cases of early-stage prostate cancer. In Lithuania, stages I and II of the disease, by the way, even include stage III as early stages because even these patients can be radically treated, with about 60-70% of cases being detected. In my opinion, the discovery of prostate-specific antigen (PSA) marker has been a breakthrough in diagnostics. Along with early detection of the disease, the early diagnosis program for prostate cancer, which has been implemented in our country for 7 years, has also contributed. This trend pleases the urology community because by detecting prostate cancer much earlier, we can offer patients various effective treatment options. However, there is another issue related to early diagnosis of prostate cancer. Not every case of prostate cancer needs treatment. Therefore, today doctors face the dilemma of distinguishing which patients need treatment from those who only need monitoring. In other words, only aggressive, life-threatening forms of prostate cancer should be treated. The diagnostic challenge lies not in the early detection of prostate cancer but in distinguishing the dangerous form of the disease. This task presents unresolved issues because no clear criteria exist to select patients suffering from an aggressive and life-threatening form of prostate cancer. Experts believe that biological markers should help clearly identify such patients in the near future.Urologists have high hopes for these new diagnostic possibilities.

You mentioned that genetic markers could help select patients and differentiate those who need monitoring from those who need treatment. Please comment on this further.

So far, there are no gene markers that we could apply in practice today, although science is rapidly moving in that direction. Scientists are studying BRCA2, PCA3, and other genes, but it is not yet possible to talk about their usefulness and significance in treating prostate cancer.

Researchers have extensively studied the PCA3 gene, and recommendations mention it, although this genetic marker is currently more used in scientific programs and laboratories rather than in daily medical practice. According to the latest data, identifying the PCA3 gene should help precisely at the diagnostic stage aimed at identifying patients at risk of progressing to aggressive cancer. Quite often, urologists perform a prostate biopsy and do not observe cancerous changes, even though the PSA marker is elevated. With today's diagnostic capabilities, such patients remain at high risk of developing prostate cancer. When PCA3 gene testing becomes part of routine practice, doctors should additionally examine these patients and, based on the expression of this gene, determine which patients are at a much higher risk of not only prostate cancer but aggressive prostate cancer.

The detection of the BRCA2 gene can also be useful when it comes to hereditary cancer, a higher risk of prostate cancer.

Does the early detection program for prostate cancer justify itself, as opinions about it are controversial? Perhaps there is another way to detect early prostate cancer in the world?

Criticism of the early detection program for prostate cancer arises because many clinically insignificant or clinically less significant cancers are diagnosed, which do not need treatment, yet they are treated. Meanwhile, treatment - surgery or radiation therapy - is costly. And what if a person lives just as long even without radical treatment? According to urologists, almost half of all newly diagnosed stage I or II prostate cancer cases could be actively monitored for 5 or 10 years without any treatment. Active monitoring means that the patient should undergo a PSA test more frequently (every 3 or 6 months) and a follow-up prostate biopsy every 2-3 years. This way, about 60-70% of all monitored patients could avoid radical treatment. In other words, these people would live happily and die not from prostate cancer, but from a heart attack, stroke, or other causes.

Such a surveillance tactic is also applied in Lithuania. There are no precise epidemiological data, but I think that about 15% of all newly diagnosed cases of prostate cancer could be left actively monitored. Of course, in the future, the number of these patients should increase.

Are there any innovations in the field of diagnostics, and is positron emission tomography (PET) already used in medical practice?

So far, doctors do not use PET scans in practice to diagnose prostate cancer, although this test also holds a lot of promise. In conducting this test and using various reagents, attempts are made to determine if there are metastases in the regional lymph nodes. Studies have also shown a certain sensitivity and specificity of this test, but for now, doctors do not have it in their arsenal.

Understandably, cancer treatment depends on the stage of the disease, the condition of the human body. Which stage of prostate cancer is most effectively treated, and what methods or treatments are used?

For treating early stages of prostate cancer, surveillance can be recommended, or 2 forms of radical treatment - surgery (radical prostatectomy) and radiation therapy. If a patient is diagnosed with advanced prostate cancer, they are treated with hormone therapy aimed at prolonging survival, but complete recovery is no longer possible. Naturally, the chances of recovery are highest in the early stages of cancer.

Is there an effective treatment for advanced prostate cancer? Please comment on the latest treatment methods for advanced prostate cancer. Are they available to our patients?

There are advancements in treating advanced prostate cancer. The standard treatment for advanced prostate cancer with metastases is androgen deprivation therapy, which aims to stop the natural secretion of testosterone in the testes. We have used this treatment in our practice for 30-40 years, and the doctors who proposed this therapy received the Nobel Prize for treating prostate cancer with antiandrogens. During that time, science has made significant progress, and now new groups of drugs are emerging that still maintain a hormonal effect mechanism. The closest to clinical practice at the moment is abiraterone acetate. Doctors could prescribe it for hormone therapy or for treating castration-resistant prostate cancer when the disease progresses even after chemotherapy. Intensive discussions are currently underway with the State Health Insurance Fund, and perhaps this year, this drug will be reimbursed. By the way, the State Health Insurance Fund considered reimbursing abiraterone acetate last year, and this year, discussions about including it in the list of reimbursable drugs continue. Therefore, patients with severe forms of cancer have hope for more effective treatment, as several completely new groups of drugs with different mechanisms of action are coming to their aid. These are next-generation antiandrogens. Similar drugs with a similar effect are also in the stage of clinical trials, and we hear about them at conferences, for example, about enzalutamide.

What are the latest developments regarding prostate cancer aimed at family doctors? How can they contribute to treating this disease?

Family doctors should be aware of the early diagnosis program for prostate cancer, as they are the ones who should inform their patients about it and suggest they undergo a PSA test. The role of family doctors is very important. It is thanks to them that more cases of early-stage cancer are being detected today.

The news for family doctors is that from this year, they can perform a PSA test for those patients already diagnosed with prostate cancer. This was defined in the order issued by the Minister of Health in April 2013. Previously, they did not have this opportunity. However, the order does not specify how many times a year they can perform the PSA test, but once is certain.

Family doctors often see those patients who are treated by urologists. Therefore, they are the first to notice if a patient's condition worsens, if bone pains appear, or if kidney function deterioration progresses, and in such cases, they should immediately refer the patient for a consultation with a urologist to adjust the treatment.

So family doctors should know the general principles of prostate cancer treatment, symptoms of progression, and timely refer patients for consultation with a urologist.

Are there any plans to update prostate cancer treatment methods in the near future?

Lithuanian urologists use the European Urology Prostate Cancer Guidelines, which have been translated into Lithuanian. The Ministry of Health would like urologists to adapt the guidelines for our country. In my opinion, this work is unnecessary because it is a European document that Lithuanian urologists recognize and successfully use. I don't think there is a need to create Lithuanian mathematics. Furthermore, the European Prostate Cancer Guidelines are reviewed and updated annually, something we couldn't do in Lithuania. A completely different matter is the reimbursement mechanism for prostate cancer treatment. In 2011, we approved an algorithm for the reimbursement of diagnostic and treatment drugs for prostate cancer. It is quite modern, and we use it when deciding on treatment with reimbursable drugs.

What new treatment methods, medications are expected in the future?

The most important news, as I mentioned, is the new generation of antiandrogens - abiraterone acetate, enzalutamide, ipilimumab, etc. We expect cabazitaxel and radium-223, already included in everyday practice in the USA and Europe, to be available in our pharmacies or treatment facilities someday. Another piece of news is the successful testing of a vaccine in the USA designed to treat advanced prostate cancer with bone metastases. It is a special technology that allows doctors to create an individual vaccine tailored to a specific patient and his form of the disease, which effectively slows the progression of the disease. New drugs have been developed to treat bone metastases - denosumab. There is news, especially about drugs for treating advanced prostate cancer. All of this gives hope to doctors as it expands their ability to fight prostate cancer and to patients, allowing even those with severe forms of prostate cancer to live longer and better.

Regarding prostate cancer prevention, the influence of certain foods on the development or inhibition of prostate cancer is mentioned, such as coffee, milk, tomatoes. What is your opinion?

Unfortunately, doctors do not yet fully understand the causes of prostate cancer, making effective prevention difficult. Some known risk factors include age, which influences the development of the disease, but we cannot stop the biological clock. Another risk factor is race; African Americans have a higher risk of developing prostate cancer, but race is not a choice. Heredity also plays a role, as men with a family history of prostate cancer, especially if relatives died from the disease, are 5-8 times more likely to develop it. However, we cannot change genetics either. So, while we understand the risk factors, we cannot alter them.

In my opinion, one preventive measure is early detection of prostate cancer. However, another problem arises here—doctors, upon detecting a less significant prostate cancer that a person can live with for a long time, often start treating it unnecessarily instead of actively monitoring the patient. On the other hand, emotionally, patients find it difficult to accept that they have prostate cancer but do not need treatment yet, leading some to demand treatment.

Regarding foods that could influence prostate cancer, there is no scientific evidence to support this. Unfortunately, the effectiveness of products containing selenium, green tea, or tomatoes in reducing the risk of prostate cancer has not been proven. A recently published review article emphasizes that, due to the lack of precise causes of prostate cancer, we do not have effective preventive measures, especially concerning food products.

However, general cancer prevention recommendations exist and are suitable for avoiding prostate cancer. Major risk factors in oncology—such as smoking and harmful environmental factors—should be avoided.

Thank you for the conversation. Interview with Natalija Voronaja