DR LOVE: When you look into your crystal ball, what do you see for prostate cancer clinical research five years from now?

DR D’AMICO: I think in five years we’ll have information on the impact of chemotherapy in earlier disease. There will be other chemotherapies at that point, which will have been proven in advanced disease, and we’ll be getting ready to move those up and test those next in earlier-stage disease.

Concomitant with that, we’ll have the answer as to whether PSA screening decreases mortality. My hope is that it will, particularly in high-risk subsets. Once that answer comes on board, the way we look at prostate biopsy will change — what level of PSA is the trigger point for biopsy, how PSA velocity plays into it, etc. As a result, prostate biopsies may only be directed at those people with the kind of cancers we need to diagnose and treat.

The other thing is genomics and proteomics. Investigators are trying to use these techniques to determine when to biopsy and when to treat and to determine who needs their prostate taken out versus other local or systemic therapies. These tools also may help us identify which patients in the metastatic setting are on the favorable and unfavorable ends of the curve. I think proteomics and genomics will become part of the patient selection process for future clinical trials.

And the final thing is, I’m very happy to see that in the last five years, patients have become more actively involved at different levels, from support groups to lobby groups. Patients have assisted with the design of trials and have encouraged participation. People like Michael Milken have also facilitated financial support for prostate cancer research. The patients’ voice here — just like it was in breast cancer — is so important to keep research dollars coming and to obtain input on the important questions of men afflicted with the disease. All of this is a plus for where we’re heading.

We discuss patients in real time, face to face, and have the ability to really come up with a uniform plan and recommendation. Presenting the spectrum of options to patients and giving them the good things and bad things about different approaches is where we’re at right now in prostate cancer today. We also wanted to create a setting that would serve as an educational conduit not only for the patient and their family but also for the trainees at our center — residents and fellows in radiation oncology, urology and medical oncology.

After each clinic, we have a conference where pathology is reviewed and we discuss the patients’ management, including suitability for protocols. We’ve written several papers and given a number of presentations about this clinic, and generally, patient satisfaction is extraordinarily high. It’s a lot of effort, but when we go home at the end of the day, we feel we have not only done a service for the patient and their family, but also optimized our ability to learn more about the disease.

— Leonard G Gomella, MD

Historically, prostate cancer patients were predominantly managed by my urologic colleagues, who for many years, were a group of surgeons somewhat unique, in that they managed all of urologic disease, including medical aspects.

That paradigm began to change in the late 80s and early 90s, with the recognition that medical oncology had an important role. Of course, there was also an evolving role of radiation therapy over the years. Traditionally, much of urologic research in cancer was surgical based and institution based; ie, “I have 2,000 cases and these are our outcomes. This is what we do.”

As the NCI’s National Prostate Cancer Project came on line — driven in part by urology — there was the introduction of the randomized clinical trial, as with the NSABP with breast and colon cancer in that same era; however, when you delay the trial process for several decades, it takes time to catch up.

Most patients who enter clinical trials come from the community setting, where interdisciplinary urologic oncology management is not the standard. There are certainly some communities in which it works very well, but there are others in which it doesn’t work well at all.

We need to have young urologists entering clinical practice, who are well aware of the interdisciplinary nature of management and can help us evolve therapy of this group of diseases — prostate, bladder, renal and testes cancer — in an interdisciplinary way, and hopefully reproduce the model of our colleagues in breast and colon cancer, where interdisciplinary management results in clinical trials that get done relatively quickly.

Fortunately, we now have major academic urology thought leaders who are taking a leadership role in all of these areas. So, the problem from that end has clearly been fixed. But it takes time, and it’s incumbent upon the urologist — the captain of the ship — to say, for example, to his or her patient, “You have high-risk disease, which will ultimately require the skill sets of a number of my colleagues. I’m going to refer you to a medical oncologist. He or she is not likely to need to do anything now, but I would like you to get to know each other, have a discussion about your disease from another perspective and obtain a sense of what’s out there and what might be coming.”

For example, in our interdisciplinary program at the Cleveland Clinic — patients with biochemical failure are seen by a GU medical oncologist from the start, and that works well. Having done that, the patient has a relationship with two doctors and moves forward. There’s no reason for that paradigm not to work.

Every year, urology residents finish at our shop and other places, and they are well-trained individuals who understand the interdisciplinary nature of the disease. When they get into the community, they will work and act differently. So, it’s a problem that will be fixed, but transitioning to the fix is taking time.

— Robert Dreicer, MD