Miami Cancer Institute Expert Highlights Advances in Prostate Cancer Treatment

For the nearly 250,000 men expected to be diagnosed with prostate cancer this year, advances in both technology and treatment are offering new hope in fighting what the U.S. Centers for Disease Control & Prevention (CDC) says is the leading cause of cancer in men next to non-melanoma skin cancer and one of the leading causes of cancer death among men of all races and Hispanic origin populations.

Adeel Kaiser, M.D., a radiation oncologist with Miami Cancer Institute, part of Baptist Health South Florida, has been at the forefront of several recent studies and says these new therapies will give physicians better, more effective options for treating prostate cancer. And for patients with advanced disease, he says they promise to help lower mortality rates and extend survival times.

As with any other type of cancer, there is no “one size fits all” approach when it comes to treating prostate cancer, says Dr. Kaiser, who has special expertise in the treatment of solid tumor malignancies, including genitourinary and gastrointestinal cancers. “At Miami Cancer Institute, we provide prostate cancer patients with a personalized, integrative strategy for their cancer treatment,” he says.

Prostate cancer patients are grouped according to their risk of succumbing to the disease, says Dr. Kaiser. “A simple blood test can determine the level of prostate-specific antigen (PSA) proteins in the blood, which tells us if something is going on in the prostate,” he says. Once diagnosed, patients are further classified by their combined Gleason score, which Dr. Kaiser says is a useful tool for predicting the behavior of the cancer and determining the best course of treatment. Newer tests that examine gene expressions in prostate cancers are further helping to refine treatment approaches for each individual patient.

Low-risk patients – those with a PSA score of less than 10, and a combined Gleason score of six or lower – can be treated with surgery, radiation or active surveillance according to Dr. Kaiser. “A Gleason score of less than six means your cancer is less aggressive and likely to grow slowly,” he explains. Active surveillance, he adds, involves getting your annual PSA test and periodic biopsies to assess for any changes in the Gleason score of your cancer. MRI scans and gene expression tests are now increasingly employed to help identify patients who will have the best chance of success with active surveillance.

Promising results from metabolic therapy

Obesity, age, family history of prostate cancer, and Caribbean or African-American ancestry are risk factors for prostate cancer. Given the association of obesity and prostate cancer progression, researchers from Canada followed 565 men who had been diagnosed with low-risk prostate cancer and found that those with an elevated Body Mass Index (BMI) were the ones most likely to experience progression of their disease during active surveillance. “In fact, the risk of progression increased by 50 percent for every five BMI points above 25,” added Dr. Kaiser. A normal BMI would be less than 25, he notes, yet the average American has a BMI of 25 to 30.

In another study led by Dr. Kaiser, a dozen men on active surveillance with low-risk prostate cancer were placed on a two-month ketogenic diet intervention. According to Dr. Kaiser, “recent research suggests that fat cells surrounding the prostate may promote tumor cell migration out of the prostate, so we wanted to see if weight loss had any effect on disease progression.” The study is now completed with data analysis underway.

Complementing radiation with hormonal therapy

Intermediate-risk patients have a PSA score of 10-20 or a combined Gleason score of seven, which means the cancer is likely to grow but may not spread quickly. These patients are typically treated with surgery and radiation, says Dr. Kaiser – possibly in conjunction with hormonal therapy.

“The male hormone testosterone can influence cancer progression for those who’ve already been diagnosed with prostate cancer,” he says. “So for certain intermediate-risk patients we incorporate a short four-to-six-month course of hormonal therapy with patients who choose to undergo radiation. Surgery is also a great option.”

For high-risk prostate cancer patients with a PSA of more than 20 or a combined Gleason score of eight to 10, which would indicate an aggressive tumor, Dr. Kaiser says the treatment options include surgery alone or radiation with 18 to 24 months of hormonal therapy .

Enhanced imaging technology aids treatment

Miami Cancer Institute is one of the only cancer centers in the world to offer all of the most advanced radiation therapy modalities under one roof, according to Dr. Kaiser, including proton therapy and also magnetic resonance (MR) image-guided radiation therapy using the MR Linac, a linear accelerator that allows the physician to precisely target the tumor.

“This enables us to deliver higher doses of radiation to the tumor with extreme precision, while sparing healthy surrounding tissue,” Dr. Kaiser notes. “This translates to fewer and milder side effects for the patient and better outcomes overall.” Another imaging advance is Prostate Specific Membrane Antigen (PSMA) imaging, which he says is more effective in identifying tumors. “Compared to conventional CT imaging, PSMA-based imaging is better at identifying prostate cancers, and permits more precise targeting of radiation therapy,” he says.

New treatments for metastatic prostate cancer

Another study Dr. Kaiser has been involved in holds promise for patients in whom the cancer has metastasized outside of the prostate wall and spread to other parts of the body. Systemic treatments such as chemotherapy are typically used to control metastatic prostate cancer that has migrated outside the prostate. However, new research shows that in select patients focal therapy, such as that provided by stereotactic ablative radiotherapy (SABR), can destroy these errant tumors with minimal side effects. “With SABR, we can actually target metastases where they occur and they disappear,” Dr. Kaiser says.

Finally, Dr. Kaiser reports an exciting development with just-published results from a Phase 3 clinical trial studying the use of Lutetium-177-PSMA infusion therapy for metastatic prostate cancer patients that are no longer responsive to hormonal therapies. The study found that overall survival increased as much as 35 percent, from 11 months to 15 months, when Lutetium-177-PSMA therapy was added to standard-of-care treatments. “This is a very significant improvement to current standard therapies,” says Dr. Kaiser.

Dr. Kaiser adds that Miami Cancer Institute will be offering Lutetium-177-PSMA therapy as soon as it is approved by the U.S. Food & Drug Administration (FDA) for patients with hormone-resistant prostate cancer. “We will also be opening a clinical trial for the use of up-front Lutetium-177-PSMA with standard therapies for hormone-sensitive prostate cancer cases,” says Dr. Kaiser.