Today, when you read this, an average of nearly 500 men in the U.S. will leave their doctor’s office newly diagnosed with prostate cancer.
And today that same cancer will kill an average of 85 men.
Those sobering 2019 American Cancer Society statistics highlight the ongoing burden of prostate cancer in the U.S., said Pete Nelson, MD, as he kicked off Saturday’s eighth annual symposium of the Institute for Prostate Cancer Research, a joint program of Fred Hutchinson Cancer Research Center and UW Medicine.
Deaths from prostate cancer are declining, and that should be celebrated. But one in nine American men will be diagnosed in their lifetime. The IPCR annual symposium is how Fred Hutch and UW Medicine helps patients and their families keep on top of the latest developments in prostate cancer. Here are a few key takeaways.
(Editor’s note: Presentations from the event will be posted to YouTube. This article will be updated when they’re live.)
‘You really are what you eat’
Marian Neuhouser, PhD, RD, a Fred Hutch nutritional epidemiologist, stressed the importance of a healthy diet in helping to lower the risk of cancer, including prostate cancer.
“You really are what you eat,” she said. “When your nutrient input gets out of balance, cancer-related pathways in your body start to get active.”
Current research shows that no single food has all the nutrients we need. So a healthy diet is a varied one high in fruits, vegetables, whole grains and lean proteins, and low in added sugars, excess sodium and saturated fat.
Balance is key. Be skeptical of popular diets like Keto or paleo regimens that restrict entire food groups, she said. “If it sounds too good to be true, it probably is.”
Patients already diagnosed with cancer of course want to know: Will eating well help me? Neuhouser highlighted data suggesting that a high-quality diet can reduce cancer mortality. “Better diet will improve outcomes,” she said.
And plan on getting all those necessary nutrients through food — not supplements, added Dr. Jeannette Schenk, a researcher in Neuhouser’s lab. Supplements are not a substitute for a healthful and balanced diet, and in some cases can cause harm. More than half of adults in the U.S. use dietary supplements, spending more than $30 billion each year. Those numbers are even higher among cancer patients.
The American Institute for Cancer Research’s recommendations are clear, she pointed out: Do not use supplements for cancer prevention.
If you do take supplements, talk to your doctor, she said. Some supplements can interact with certain medications. And examine the label to ensure you’re taking quality supplements. If you see the logos for Consumer Labs, U.S. Pharmacopeia, or NSF (National Sanitation Foundation), the supplements in the bottle adhere to certain manufacturing practices.
Know your genes (but not through a mail-order kit)
The seeds of prostate cancer might be written in some men’s genes, said Heather Cheng, MD, PhD, a Fred Hutch and UW researcher. But so could the potential for better treatments and better risk awareness for their family members.
Cheng is co-director of the GENTleMEN study, which offers free, clinical-level genetic testing to men with advanced prostate cancer to see if they’ve inherited alterations in genes linked to this disease.
Some mutations can have significant treatment implications, Cheng said. A small but important percentage of men with prostate cancer have mutations in key genes that are involved in repairing damage to DNA. These genes — including BRCA1 and BRCA2 — are often recognized as being important for breast and ovarian cancer risk. But they also affect the risk of prostate cancer for the men who carry them. And many of these mutations may make prostate cancers particularly vulnerable to certain therapies such as PARP inhibitors and platinum chemotherapy.
Having one of these rare but important gene mutations may also tell a patient’s family members something about their own cancer risk, Cheng said. Siblings and children have a 50% chance of inheriting the same DNA-repair gene mutation, and there may be important lifesaving options to reduce risk and detect cancers early. That’s why men with a strong family history of cancer or certain types of especially aggressive prostate cancers should talk to their doctor and/or a genetic counselor about screening for these mutations, she said.
“A big take-home from today should be to know and share your family history of cancer,” Cheng said.
But when it comes to knowing your genes, please don’t rely on recreational DNA testing to inform medical decisions, she added. “It is a myth that these tests are adequate,” she said. “Recreational genetic testing should never replace medically appropriate clinical genetic testing.”
Tailored treatments for more patients
It’s the Holy Grail of oncology: delivering the right therapy to the right patient at the right time. University of Washington’s Bruce Montgomery, MD, who co-directs the GENTleMEN study with Cheng, updated attendees on the field’s progress toward that dream.
Precision medicine starts with sensitive tests that can identify what’s going on in a patient’s tumor, and then guide diagnosis and treatment. And the root of what’s going on in cancer is DNA damage.
Many genes are involved in preventing and repairing damaged DNA, and any one of them is a potential target to treat cancer, Montgomery said. Today, about a third of prostate cancer patients have certain genetic mutations that can be targeted with existing drugs. They include alterations in the BRCA1/2 and CDK12 genes, for example, and cancer cells that are genetically unstable. Drugs like PARP and checkpoint inhibitors have been remarkably successful in treating prostate cancer patients who have those mutations, Montgomery said.
But those success stories don’t involve the vast majority of patients. “The ICPR is all about finding something for the other 70%,” Montgomery said. He highlighted several trials underway nationwide that are exploring genetic signatures for “BRCAness” in prostate cancer that might be targeted. Other potential targets include pathways that are activated when a gene called PTEN is lost, and a marker called prostate-specific membrane antigen (PSMA), which can be precisely targeted with a radioactive compound called lutetium.
Montgomery stressed the importance of research and clinical trials in the fight against prostate cancer.
“We can only make progress through research,” Montgomery said. “Participation on any level is important for the men who have prostate cancer now and the men who will have prostate cancer in the future.”
‘Immunotherapy is revolutionizing treatment’
John Lee, MD, PhD, who studies the molecular, cellular and genetic causes of advanced prostate cancer, discussed ongoing efforts to harness the immune system to better recognize and fight cancer. The three immunotherapy approaches that are furthest along in development for prostate cancer patients: an approved T cell-stimulating vaccine, checkpoint inhibitor drugs and cell therapy.
In 2010 the U.S. Food and Drug Administration approved a therapeutic vaccine called Provenge for treating men with advanced prostate cancer. The vaccine turns on T cells to fight cancer cells and has been shown to extend the life of patients. Meanwhile, drugs known as checkpoint inhibitors are helping the immune system defeat cancer in a subset of patients with metastatic prostate cancer.
A bit further from the clinic is adoptive cell therapy, where patients’ immune cells are genetically reprogrammed to attack cancer cells. One version of this tactic is CAR T-cell therapy, where T cells are weaponized with an artificial molecule known as a chimeric antigen receptor, or CAR, that enables immune cells to recognize and kill cancer cells. Some patients with blood cancers have seen astonishing results, but the approach hasn’t had the same success with solid tumors like prostate cancer.
Lee’s research is building CARs that are specific to prostate cancer. It’s early days, he cautioned, “but we’re seeing that with CAR T cells, we can inhibit the growth of prostate cancer in mice. We want to build on these early results and enhance this technology to ultimately bring this to patients and make a huge impact on prostate cancer.”
Imaging advances: Searching and destroying
New technologies for imaging prostate cancer will help doctors detect tumors more effectively and hopefully improve treatment outcomes, said Evan Yu, MD, a medical oncologist who treats patients with prostate cancer at Seattle Cancer Care Alliance, Fred Hutch’s clinical-care partner.
“Today, the field is moving beyond just finding cancer,” Yu said. “We’re finding new targets for new drugs. We’re imaging with agents and bringing something to the cancer cell that can attack it.”
He highlighted several next-generation uses of PET imaging. PET, or positron emission tomography, uses radioactive dyes that are injected into the patient’s vein and then taken up into certain tissues, like prostate cancer cells, and then revealed on scans.
The FDA has approved the use of novel radiotracers like fluciclovine that can detect prostate cancer at very low levels. That sensitivity can better guide treatment, Yu said.
And these more sensitive PET techniques can power the new field of “theranostics,” which combines imaging and targeted treatment.
“We already have fluciclovine PET imaging, but there are other new imaging and treatment modalities that we will soon bring here to our patients in the Northwest,” Yu said.
The state of surveillance
It’s one of the most important questions in prostate cancer research:
How can we tell which seemingly low-risk cancers will become aggressive, and which will remain inactive?
For men in this group, the preferred form of management is active surveillance, said Daniel Lin, MD, of Fred Hutch. Doctors use regular biopsies to check the progress of prostate tumors. If a doctor finds that the cancer is progressing into a more dangerous form, the patient can start treatment. If the tumor is stable (or if there’s no evidence of disease), then he stays on surveillance.
Taking an active surveillance approach protects men from treatment side effects if there’s no cause to treat the cancer ― but not every biopsy reveals useful information, and each one carries risks, including bleeding and infection.
After 10 years of active surveillance, about half of patients will undergo treatment like surgery or radiation. The other half will continue to undergo regular biopsies. Lin highlighted ongoing efforts to identify which men will have their cancers progress — and which can avoid biopsies.
One key tool in that effort: an online biopsy risk calculator for more-personalized medicine in patients undergoing active surveillance. The calculator, which Lin created with other researchers, is designed “to help facilitate shared patient-doctor decisions” about follow-up biopsies based on the likelihood that a given biopsy will yield signs of disease progression, he said.
Ethnic disparities in prostate cancer
African-American men have consistently been diagnosed with prostate cancer at higher rates than white men, and the latest stats continue the trend, noted Yaw Nyame, MD, a fellow in urologic oncology at Fred Hutch and UW.
What’s more troubling is mortality: Black patients are twice as likely to die from prostate cancer as white patients.
Conditions in the places where people live and work — the social determinants of health — drive many of those differences in outcomes, Nyame said. He highlighted research underway at Fred Hutch dedicated into overcoming those disparities.
He added that biology might also play a role; genetic differences exist in tumors from patients of different races and ethnicities, he said.
Still, “we’re in the infancy of understanding that biology,” Nyame said. “How people access care might be more important.”
This article was originally published on May 14, 2019, by Hutch News. It is republished with permission.