More life after advanced prostate cancer

The approach to prostate cancer is a success story. Nine out of ten cases are detected in the early stages and overall survival at five years is already over 90%, a percentage that is still unusual in other cancers. Early diagnosis and defeat of the tumor go hand in hand. Javier Puente, director of the Oncology Institute of the San Carlos Clinical Hospital in Madrid, outlines the ideal prognosis for those affected and for the professionals who treat them: “They are potentially curable tumors with localized treatments such as surgery or radiotherapy.”

From the age of 50 the probability of suffering from prostate cancer increases. For this reason, the start of the screening programs that have given such good results in recent decades was set at that age. Periodic control consists of a digital rectal examination and the determination of PSA levels through a blood test. PSA is a protein produced by the prostate whose levels rise when the gland presents some pathology.

In some patients, it is recommended to advance the start of periodic check-ups to 45 years of age. The reason is that, in addition to age, there are factors that increase the risk of suffering from a tumor, the main one being first-degree family history. Men who have a father or brother who have had prostate cancer are more likely to develop it.

Other inherited tumor syndromes that may be linked to a genetic alteration also increase the risk. The best known is the BRCA gene, linked to prostate and breast tumors, among others. There are other genetic mutations in the HPC, PTEN, MAD1L1, CHECK2, etc. genes. “In these patients, the PSA threshold is lowered by which we say that there is a suspicion of having a tumor. The PSA level is determined by having a family history, being a carrier of a genetic alteration and by age”, points out Estefanía Linares, urologist at the Hospital la Paz in Madrid and the Lyx Urology Institute in Madrid.

Healthy men who are known to be carriers of a mutation should be followed up more closely. “In these cases, digital rectal examination is very important because it is possible that the patient has a tumor and the PSA has not yet risen enough to indicate it,” points out Dr. Linares.

prostate cancer is feeds of male hormones, of testosterone, and one of the strategies to deal with it is starve to the tumour. “The first thing we do when we face an aggressive tumor is to eliminate food through treatments that inhibit that production or prevent it from reaching the receptor for male hormones in prostate cells,” explains Enrique Grande, head of Medical Oncology at MD Anderson Cancer Center. Hence the term “chemical castration”. But in a percentage of patients, around 20% of those diagnosed at an early stage, problems arise over time. “The tumor, as it becomes aggressive, becomes resistant to this therapy and gives rise to a situation that we call castration resistance,” adds Dr. Grande.

Until a few years ago, therapeutic options for prostate cancer patients who had developed metastases were very limited, but a better understanding of the biology of the disease has made it possible to develop targeted therapies against genetic alterations in the tumour. “We are doing precision medicine, personalized therapy. We have treatments not for a disease in general but for the molecular alterations that this type of tumor presents in a specific patient. This is an important milestone in prostate cancer”, points out Enrique Grande.

One of the challenges in the treatment of advanced prostate cancer is to identify patients who have mutated specific genes related to DNA repair. The alteration may be hereditary or may have been produced by the tumor in its evolution. In both cases, targeted therapy can be used, but the first thing is to detect the mutations. This is one of the areas where the most progress has been made in recent years, as Javier Puente points out: “We already have some tests to be able to identify with high sensitivity and specificity both mutations via the germline (family) and those caused by the virus itself. tumor”.

The therapeutic window that targeted therapies have opened has multiplied the survival of advanced prostate cancer by at least two, according to specialists. The communication campaign of the Spanish Society of Medical Oncology (SEOM) In Oncology each ADVANCE is written in capital letters makes full sense in the most common tumor in men (35,764 new cases last year).

When determining the treatment of a patient with castration-resistant prostate cancer, specialists do not seek a single objective, but several. It is about living more, but not only that. Hence, the therapy is adapted to each patient, because what may be acceptable for one may not be for another. Dr. Grande asks the question that every patient in this situation has to answer: What is the patient willing to sacrifice for the effectiveness of the treatment? In this balance, the protagonist is the patient because, unfortunately, in advanced prostate cancer, oncology still cannot offer a cure.

Of course, there is much more life ahead for any patient who suffers from it because we are unraveling its mysteries. “Now we know more about the molecular alterations responsible for the growth and aggressiveness of tumors, specifically the genes that are responsible for DNA repair, and we can act pharmacologically to prevent their action,” says the MD Anderson specialist. .

The challenge of getting informed patients

Due to its incidence, prostate cancer in men is the equivalent of breast cancer in women. However, much more is said about the second than about the first, partly because men tend to assume a more passive role in relation to the tumour, both specialists and patient associations point out. Marcos Martínez, manager of the Spanish Group of Cancer Patients (GEPAC), points out that “a well-informed patient is capable of taking control of his illness and adopting shared decisions with professionals”. Marcos knows the importance of this implication as a patient (his prostate was removed three years ago and he has overcome the disease) and for his link to the associative movement, which is key in caring for those affected.

At GEPAC they have a support program coordinated by a team of psycho-oncologists “that offers emotional care to both the patient and their partner and deals with everything that can influence the patient’s quality of life, such as nutrition, physical exercise or sexuality”, says Marcos Martínez. Addressing all the implications of cancer with a multidisciplinary team, inside and outside the hospital, gives the patient the leading role that corresponds to him, strengthens the relationship with professionals and improves therapeutic adherence and recovery. From GEPAC they explain that the role of the professionals who can deal with prostate cancer (urologists, oncologists and radiation oncologists) is fundamental and so are many other professionals, such as the physiotherapist, who help the patient to strengthen the pelvic floor and thus avoid urine leakage after an operation. Ultimately, it is about saving life and preserving its quality.

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