There are actions that break the taboo and make more men start getting tested. The chances of effective treatment depend largely on the ability to use the most effective therapy at each stage. In advanced prostate cancer, we still often delay modern hormone therapy, says Prof. Piotr Chłosta, head of the Urology Clinic of the Jagiellonian University Medical College.
Katarzyna Pinkosz, Wprost: Movember breaks the taboo: prostate cancer is widely discussed in November. Especially since the KultURO festival is still going on in Krakow, during which there is a lot of talk, among others: about urological cancers. Are the effects already visible: men are starting to go to urologists and get examined more often?
Prof. Piotr Chłosta: Both international campaigns (e.g. Movember, when men are encouraged to undergo preventive tests for male cancers) and the KultURO festival – which used to be part of the International Urology Week, but is now an independent event – show that it is worth getting tested. The Kulturo Festival “plays” from September until the end of 2023, you can get access to Krakow hospitals for tests and free urological consultations without a referral. Thanks to such actions, the image of a urologist is also being demystified. Today, he is already the “best friend” of men and women in the health context, and a visit to him is not stigmatizing. Being healthy is becoming more and more fashionable, because we live not only for ourselves, but also for our loved ones. If the cancer is detected early, complete recovery is possible and minimally invasive and minimally mutilating treatment methods can be used. And it’s worth being fit. Any preventive action that aims to detect cancer earlier deserves the highest respect. Especially since we need to be prepared for the prostate cancer epidemic.
Why this prostate cancer epidemic?
It is an age-related disease, and the average age of our society – as in the whole of Europe – is systematically increasing. In 2009, almost one million new cases of prostate cancer were diagnosed worldwide and 250,000 deaths, and it is estimated that in 2030 we will have 1 million 700 thousand. new cases of prostate cancer and over half a million deaths. This means an increase in new cases by 70% and deaths by over 50%. Half a million new cases are diagnosed every year in Europe.
The positive thing is that the ratio of the number of cases to the number of deaths is more favorable than in the case of other urological cancers. Prostate cancer can be cured today, and if cure is not possible, it can often be treated for many years.
We know more and more about the biology of this cancer; we also know that in some cases it is family-related. There are certain gene mutations, e.g. in the BRCA1 and BRCA2 genes, leading to disorders of the DNA repair mechanism. We also know more and more about the impact of risk factors – such as excess body weight, smoking, excessive alcohol consumption.
Why is it so important that a urologist is the number 1 doctor in the case of prostate cancer? And is this already happening in Poland?
It’s like that all over the world. The urologist has all the diagnostic tools to confirm (or exclude) the presence of cancer; both non-invasive and invasive methods. The urologist can suggest the patient to choose the best therapy – regardless of whether it is radical treatment (aimed at cure – using various methods) or aimed at keeping the cancer in check. The urologist will also recognize at the earliest the situation when it is necessary to implement systemic treatment: hormonal or modern hormonal treatment, when there is a risk of progression or when the disease is already diagnosed in the metastatic stage. A urologist is responsible for his patient from the very beginning of treatment.
Recently, joint recommendations of the Polish Society of Urology and the Polish Society of Clinical Oncology have been developed. What changed?
Guidelines for the treatment of prostate cancer, bladder cancer and kidney cancer are the result of joint work of PTU and PTOK. They concern the management of various stages of prostate cancer. They are consistent with global recommendations and at the same time take into account treatment options in Poland. These recommendations in the hands of urologists, clinical oncologists, radiotherapists and family doctors will be a guide on how to proceed in this disease – about which we know more and more: its biology and sometimes complicated course.
It is worth emphasizing that currently in Poland the treatment options – both radical, modern supportive treatment and palliative treatment – do not differ from those in other EU countries when it comes to access to medicines. In Poland, however, there are certain limitations caused by drug programs, especially in the case of modern hormonal drugs.
What are these limitations?
The goal of treatment is to obtain the best possible results and delay the progression of the disease. Appropriate monitoring and interdisciplinary cooperation are necessary so that patients can receive the best treatment at the earliest possible stage of the disease. This also applies to patients who are at risk of metastatic disease, e.g. at the stage of castration sensitivity.
Until recently, the standard treatment for patients with metastases but sensitive to hormone therapy was monotherapy with first-line hormonal drugs (pharmacological androgen deprivation – ADT). Such treatment was supplemented with chemotherapy in the case of disease spread. However, the results of recent studies have proven that the combination of new hormonal drugs – with ADT or chemotherapy – results in a significant improvement in the effectiveness of treatment – both in terms of progression-free survival and overall survival. This was reflected in the updated Polish guidelines of PTU and PTOK.
The provisions of the drug program do not yet allow for such treatment? Should they be updated faster, in line with changing guidelines?
Recently, it has been possible to add modern hormonal treatment to hormonal therapy in the case of metastatic, hormone-sensitive prostate cancer as part of a drug program. In March 2023, the prostate cancer drug program was updated – patients received new treatment options, including: at the metastatic stage, sensitive to hormonal treatment. Another positive change is that abiraterone acetate has been moved to the chemotherapy catalog. However, it is worth remembering that when planning treatment, the possibility of systemic treatment should first be considered as part of the drug program, and therapies within the chemotherapy catalog should be left for subsequent lines of treatment, because their use at an earlier stage (in accordance with the provisions of the program) excludes the patient from being included in the treatment program. treatment with modern hormonal drugs as part of a drug program.
However, the use of modern hormonal drugs as part of a drug program in patients with metastatic, castration-sensitive prostate cancer is limited by prescriptions that are difficult to interpret.
It would be good to simplify the criteria for including patients in the drug program so as not to exclude patients who could benefit from modern treatment. It is necessary, for example, to document contraindications to chemotherapy, which is not recommended for patients in selected groups in the guidelines of the Polish Urological Society and the Polish Society of Clinical Oncology.
I believe that the different biology of different forms of prostate cancer should require an interdisciplinary approach and, above all, personalized treatment for each patient according to his or her needs.
Treatment options have improved greatly but are not yet in line with the latest recommendations?
I believe that the first thing the new Ministry of Health should do is abolish drug programs. It is worth seeing what treatment is like in other countries, where more patients have faster access to these modern drugs. They have better treatment results – this is shown by a number of studies conducted by the most important urological and oncological institutions in the world.
I always say that there is no need to force open doors and that it is worth being where others have been for a long time. Especially if we see that it works and the benefits of good treatment will accrue to patients and their families.