Personalization and efficiency in prostate cancer care

Prostate cancer continues to be among the top two cancers affecting men worldwide, but patients have been benefitting from notable progress in recent years. Diagnostic accuracy and the availability of more personalized treatment options have improved significantly. The introduction of advanced imaging and integrated diagnostic tools has enhanced clinicians’ understanding of the disease, leading to more precise and efficient therapy options for patients.

Collaboration across oncology service lines

To discuss the latest advances across prostate cancer service lines, GE HealthCare brought together leading experts in the field of prostate cancer care. Dr. Mukesh Harisinghani, Radiologist and Professor of Radiology at Harvard Medical School at Mass General Hospital in Boston, Massachusetts, and Dr. Paulo Pfitzinger, Urologist and Head of Prostate Cancer Diagnostics at the Ludwig Maximilians University Hospital Munich, Germany, participated in the discussion, which was moderated by Dr. Ilya Gipp, Global Clinical Leader in Oncology at GE HealthCare.

Participants highlighted the continued importance of prostate cancer awareness, the necessity for precise and timely detection, as well as overcoming the challenges of overdiagnosis on one hand and undertreatment on the other. The dialogue centered around best imaging practices, biopsy techniques, advanced staging, and the collaborative efforts that lead to optimal treatment decisions for prostate cancer patients.

Fine-tuning prostate cancer diagnosis with the precision of MR imaging

Selection of high-risk patients typically begins for patients at age 50 with blood testing detecting elevated prostate-specific antigen (PSA), then followed by digital rectal exam (DRE) and ultrasound examinations. With significantly elevated PSA and/or suspicious prostate lesion findings, biopsies are ordered.^[1] However, PSA levels are sometimes elevated when no cancer is present, which may lead to biopsies that are unnecessary.

Multiparametric magnetic resonance imaging (MRI) is the method that allows clinicians to score the likelihood of malignancy in prostate lesions. Its use, according to a study, has spared one in four men from an unnecessary biopsy, which is invasive and can lead to complications.^[2]

The wider use of multiparametric MRI as one of the most precise imaging procedures available for the investigation of suspected abnormalities of the prostate and better access for patients was a central topic of the discussion. Dr. Pfitzinger presented data showing a substantial reduction in the need for biopsies with the implementation of MRI in the diagnostic pathway for prostate cancer. This 20-30 percent reduction is attributed to the ability of advanced imaging to identify and characterize suspicious lesions more accurately.

Dr. Harisinghani addressed the cost implications of MRI. He emphasized the need to balance the expense of the procedure with its downstream benefits.

“If you have a test that, by itself, is on an expensive piece of equipment and is expensive to perform, but at the end of the day, the information you garnish dramatically reduces the downstream cost of care, then that can be justified,” Dr. Harisinghani said.

“As a radiologist myself,” added Dr. Gipp, “I like to look at the data that comes in. If it can ultimately serve the patient on a broader scale, and if we can prevent other risks and adverse effects rather than just weighing the standalone expense, I think the cost can be balanced and justified as well. That’s very important.”

Overcoming the challenges of overdiagnosis in prostate cancer care

Addressing the challenge of overdiagnosis, Dr. Pfitzinger acknowledged historical concerns but highlighted positive changes that have taken place over the past decade. He emphasized the importance of active surveillance as a form of curative treatment and the need for a bilateral dialogue between radiologists and urologists to optimize patient management decisions.  

Although more efficient detection of prostate cancers via better risk assessment and screening eases the burden of advanced aggressive disease and is reducing mortality, the chances for overdiagnosis resulting in overtreatment of the disease increase. This can lead to lowered quality of life for patients who may suffer adverse effects associated with treatment that may not have been completely necessary.^[3] Unfortunately, the frequency of recommending a surveillance strategy in the United States remains low; however, alternative strategies to improve precision diagnosis through fusion biopsy with ultrasound have been suggested.^[4]

“Sometimes,” explained Dr. Pfitzinger, “a prostate cancer found at an early stage might be the one that never needs to be radically treated. We know that when prostate cancer is over diagnosed, the care course is quite burdensome, not only for the patient but for the healthcare system as well. And data has been published about watchful waiting, and I want to emphasize that, active surveillance is a form of curative treatment. It is our effort, not only as urologists but as clinicians involved in this diagnostic workup, that we try to eradicate the diagnosis of ‘prostate cancer’ for clinically insignificant cancers.”

Developing biopsy strategies for prostate cancer patients

A 2021 German study reported the established treatments for localized prostate cancer with curative intent are radical prostatectomy, percutaneous radiotherapy, and brachytherapy, with active surveillance as an alternative option for patients with low-risk disease.^[5] The research team that published the data emphasized that the eventual selection of treatment is determined by tumor stage, risk group, comorbidities, and patient preference after conferring with the patient’s care team.

When PSA levels are elevated, patients often get sent for an ultrasound-guided biopsy for verification of a prostate cancer diagnosis. Discussion participants felt strongly that biopsies should be targeted and not randomized regarding locations of sampling. The speakers acknowledged the evolving landscape of prostate cancer diagnostics, with advancements in imaging technologies and biopsy tools, as well as the potential to omit biopsies.

“We’ve seen studies showing that after implementing the MRI into the diagnostic workup pathway of the patient,” explained Dr. Pfitzinger, “they were able to demonstrate avoid biopsies in 20-30% of patients and that the targeted biopsy of lesions with higher likelihood of malignancy have led to an increase in clinically significant, based on pathology data, prostate cancer detection. So performing a randomized biopsy after only an elevated PSA test without additional validation such as positive DRE or ultrasound finding clearly belongs in the past.”

In addition to traditional biopsy methods, clinicians can select from a range of available targeted biopsies, which take advantage of the combined power of imaging and interventional technology. Innovative fusion technology enables greater accuracy in targeting via real-time ultrasound-guided biopsies paired with images obtained with multiparametric MRI and can be used in both transrectal and transperineal prostate biopsies.

“Looking ahead,” Dr. Pfitzinger highlighted, “the shift towards transperineal prostate biopsy is a safer and more effective alternative to transrectal biopsy.” He discussed the rise in incidents of multi-resistant bacteria infections associated with transrectal biopsy and the potential of transperineal biopsy to minimize infection rates.

Engaging the patient in prostate cancer treatment decisions

Patient engagement is vitally important for the best health outcomes, and patients should be a part of treatment options discussions.

“The role of the patient is probably the most important,” explained Dr. Pfitzinger. “Ultimately, as Dr. Harisinghani said earlier, the word cancer has a different effect on every individual. Just hearing the word [cancer] and maybe explaining to them they are the perfect candidate for active surveillance will never be something convincing to the patient. They want to get rid of it right away. Better yesterday than today. We should take this into account, as the patient plays an important role in the decision-making.”

“Clearly, the way these patients should be approached,” Dr. Harisinghani added, “is in a multidisciplinary setting, where all relevant and evidence-based data can be presented to them. In the best possible scenario, there is one point of contact. In other words, the patient doesn’t have to talk to a surgeon, then talk to a radiation oncologist and hear two different or, sometimes, competing options. They’re given one single approach and the level of evidence to support that. “At the end of it, I think the decision lies with the patient.” Dr. Pfitzinger said.

Future directions in precision care of prostate cancer

The discussion participants highlighted the critical role of collaboration, technical advancements, and evolving diagnostic strategies in improving prostate cancer care. The emphasis on personalized approaches, the precision of MRI, and the potential shift in biopsy selection underscored the commitment to enhancing patient outcomes in the highly dynamic field of oncology. As prostate cancer care continues to evolve, these insights pave the way for future advancements to optimize diagnostics and treatment.

RELATED CONTENT

• View the webinar, now on-demand: Personalization of prostate cancer care and efficiency in patient management.
• For information on MR in prostate cancer, click here
• For information on Ultrasound visualization in fusion biopsy, click here

DISCLAIMERS

The referenced presentation represents the clinical practice and views of Dr. Mukesh Harisinghani of Massachusetts General Hospital and Harvard Medical School, and Dr. med. Paulo Pfitzinger of Ludwig-Maximilians-Universität Munich, Germany. 

Factors that should be considered by clinicians include cleared and approved product labeling and guidelines provided by medically sourced organizations. 

Dr. Mukesh Harisinghani specializes in abdominal MRI and receives financial support from GE HealthCare. Dr. med. Paulo Pfitzinger specializes in Urology and receives financial support from GE HealthCare.  

Not all products or features discussed are available in all geographies. Check with your local GE HealthCare representative for availability in your country or region.

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