The Current and Future State of Prostate Cancer Care
November 16, 2021
University Hospitals experts share insights into latest developments and what new technologies are coming
Innovations in Urology | Fall 2021
Lee Ponsky, MD, Chairman of the Department of Urology and Director, University Hospitals Urology Institute, gathered a panel of experts to discuss the current and future landscape of prostate cancer, the second-deadliest cancer in men. The National Cancer Institute estimates that almost 250,000 men will be diagnosed with prostate cancer in 2021 — and 34,000 will die. Below are comments and insights from their recent discussion.
Pictured Left to right: Lee Ponsky, MD, Anant Madabhushi, PhD, Daniel Spratt, MD, Leonardo Kayat Bittencourt, MD, Jonathan Shoag, MD, and Jorge Garcia, MD.Lee Ponsky, MD :: This discussion reflects one of the core strengths of prostate cancer care at University Hospitals. We work as a multidisciplinary team, with the overall goal of providing the best possible care to each patient. Let’s start with screening for prostate cancer, especially for those men in populations where there are significant health disparities. There’s been a lot of controversy about whether we should even do Prostate Specific Antigen (PSA) tests, and then when and how often.
Jonathan Shoag, MD, University Hospitals Urology Institute and Assistant Professor of Urology at Case Western Reserve University School of Medicine and member of the Case Comprehensive Cancer Center :: I think prostate screening is incredibly important. It does prevent prostate cancer mortality. The controversy around screening arose out of misinterpretation of the data. I believe all men should have a baseline PSA test in their forties or early 50s, particularly African-American men who are at higher risk for prostate cancer morbidity and mortality.
Jorge A. Garcia, MD, FACP, Division Chief, Solid Tumor Oncology, and George & Edith Richman Distinguished Scientist Chair at University Hospitals Seidman Cancer Center, and Professor at the School of Medicine :: One of the challenges we face in North America is the concept of PSA screening. I think we need to reframe it as prostate cancer screening. The PSA test is part of it, but we also need to think about individual patients and their risk factors, family history, age, comorbidities and life expectancy to help define each patient’s risk of having prostate cancer. Future screening would then be based on the initial PSA level.
Dr. Ponsky :: I would like to see prostate screening follow the model of colonoscopy. You look at the risk factors for each patient, do a baseline screening and then tell patients when they should be screened again. It might be three years; it might be 10 years.
Shifting from screening to diagnosis, transrectal biopsy has been the industry standard for diagnosing prostate cancer and is what most urologists have been trained to do. What about transperineal biopsy?
Dr. Shoag :: While convenient for urologists, transrectal biopsies have about a 7 percent risk of infection and a 1 to 2 percent risk of serious, potentially life-threatening infection. Transperineal biopsy, which goes through the skin instead of the rectum, decreases the morbidity of biopsies substantially for patients. Men can choose to have it done with local anesthesia, or with anesthesia like colonoscopy.
Dr. Ponsky :: Another advantage of being seen at University Hospitals is that men who have an elevated PSA don’t necessarily need to go straight to biopsy. Our imaging and radiology specialists also play an important role in screening and diagnosis.
Dan Spratt, MD, Chair, Department of Radiation Oncology, UH Cleveland Medical Center and Clinical Professor at the School of Medicine. :: Yes, we can use MRI to screen smarter for prostate cancer. MRI helps distinguish between healthy and diseased tissue. We’ve published data showing we can actually get close to diagnosing prostate cancer just with MRI. If a patient still needs a biopsy, MRI helps the urologists more accurately target the suspected lesion with fewer samples.
UH has really pioneered routine MRIs for prostate screening and is only one of a handful of medical centers in the country offering gantry MRI. We’ve also determined that routine pre-biopsy MRIs are cost effective, contrary to previous perceptions that they’re too expensive.
Dr. Ponsky :: Case Western Reserve University and University Hospitals were the first to offer magnetic resonance fingerprinting (MRF) and are leading the way for other institutions. This new technology is non-invasive and uses a pattern-matching algorithm that allows us to efficiently measure multiple tissue properties at the same time and compare them to a ‘dictionary’ of all possible signals. It may even help us estimate the aggressiveness of the cancer.
Dr. Spratt :: University Hospitals is also using prostate specific membrane antigen (PSMA) PET scans, which is the most sensitive imaging, to check for PSMA+ cancer in the body. Late last year, the FDA approved two drugs for PET imaging of PSMA+ lesions in men with prostate cancer.
Dr. Ponsky :: Artificial Intelligence (AI) is changing the face of healthcare by automating repetitive, time-consuming tasks and delivering more information to healthcare providers. How are we using it in prostate cancer care?
Leonardo Kayat Bittencourt, MD, Radiology-Abdominal Imaging, University Hospitals Cleveland Medical Center :: AI is bringing new tools for radiologists, replacing many of our menial tasks and allowing us to focus on the core job of curating imaging information to drive risk stratification and treatment selection.
AI identifies areas of concern on a prostate biopsy, which then helps us make a more accurate diagnosis and select the best course of treatment. Just this past September, the FDA approved Paige Prostate, the first AI-related software to help pathologists identify areas most likely to have cancer.
Anant Madabhushi, PhD, Professor in the Department of Radiation Oncology at the School of Medicine, and Member of the Cancer Imaging Program at the Case Comprehensive Cancer Center. :: Yes, AI is another tool in our arsenal to help with informing enriching decisions. For example, we’re trying to get the machine to recognize what is a pattern for Gleason 3+3 or 3+4,or 4+3, versus BPH, versus atrophy versus inflammation.
Dr. Ponsky :: University Hospitals Seidman Cancer Center brings together all of our areas of expertise to provide the most advanced and personalized diagnostic and treatment options to men with prostate cancer to restore quality of life and preserve urinary and sexual function. We have been able to offer same-day diagnostics, so men have answers immediately.
At the core of all we do is the patient. We want them to be informed, to hear all the options our multidisciplinary prostate cancer team can offer. We want patients and their physicians to know that even when they are not directly in front of us, we are collaborating behind the scenes to provide the most comprehensive care to each patient.
Dr. Garcia :: With all the recent advances in technology and other innovations, we are changing the landscape for prostate cancer. We’re improving radiographic progression-free survival and overall quality of life for these men.