Jonathan W. Simons, M.D.
President and CEO, Prostate Cancer Foundation
If you are diagnosed with prostate cancer today, rest easy; the chances of long-term survival and being cured 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.
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, and this sadly proved to be way too high.
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 (BPH).
PSA biopsies used to be like shooting in the dark with too few bullets. Twenty years ago, urologists took just a few tiny samples of prostate tissue — maybe a half-dozen. Now, they take 14 and are much better at sampling tissue from throughout the entire prostate.
Even better, MRI is now able to show cancers that couldn’t be seen 20 years ago, and MRI-guided biopsies make sure the needle gets to suspicious-looking regions of the prostate where cancer might be lurking.
We also know that prostate cancer presents differently in African American men — it tends to start in the apex of the prostate; the hardest area to reach with a biopsy needle.
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, either, 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.
However, many men don’t even need to be treated right away, or maybe at all. Men who have low-grade, low-volume prostate cancer (accounting for 40 percent of men diagnosed with early prostate cancer) can be safely monitored in active surveillance.
Today, the “window of curability” is much wider. Before, men diagnosed with locally advanced or metastatic cancer did not receive treatment to their primary tumor.
We are now treating oligometastasis (a few tiny spots of cancer outside the prostate) with spot radiation, and in an increasing number of men with advanced cancer, we are treating the primary tumor as well. This is because we now know that removing the primary tumor hinders the cancer’s ability to metastasize, sometimes for many years.
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 (ADT), is combined with androgen-blocking drugs (including abiraterone, enzalutamide, and apalutamide) to delay the time to progression significantly — sometimes for decades. Today, ADT combined with 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 — breast, ovarian, pancreatic, colon, etc. — does, you might be at higher risk of getting prostate cancer, and you need to start getting screened in your 40s.
There used to be no genetic tests, but today we can look at tissue, blood, and saliva to learn many things about the genes involved in prostate cancer. This is tremendously important because, while there was no precision treatment back then, there is now.
Men with certain genetic mutations, such as BRCA1/2, are responding exceptionally well to entirely new classes of drugs — checkpoint-inhibiting immunotherapy, platinum chemotherapy, and PARP inhibitors.
Another entirely new category of imaging and treatment, PSMA-targeting PET scans and radionuclides, is creating even more exceptional responders. For the first time ever, we are seeing some men being cured of metastatic prostate cancer.
These are bright days for treatment of prostate cancer — there has never been more hope.
Jonathan W. Simons, M.D., President and CEO, Prostate Cancer Foundation, [email protected]