Expert Discusses the Current Screening Recommendations for Prostate Cancer

Lisa Cordes, PharmD, BCACP, BCOP, oncology clinical pharmacy specialist at the National Institutes of Health, discusses treatment options and telehealth for prostate cancer care.

Q: What are the current screening recommendations for prostate cancer?

The primary screening recommendations for prostate cancer come from the United States Preventive Services Task Force and also the American Cancer Society. The US Preventive Services Task Force recommends that men aged 55 to 69 make an informed and individualized decision regarding PSA-based screening for men aged 70 years and older the task force recommends against PSA-based screening.

The recommendations from the American Cancer Society are a little bit different than those from the taskforce in that the American Cancer Society recommendations, which also take into account factors such as family history and race. The American Cancer Society essentially recommends that men in 3 different categories have the opportunity for an individual decision regarding screening. The first of those groups is men with more than 1 first degree relative who was diagnosed with prostate cancer at an early age, and that's defined as a diagnosis before the age of 65. And for that population, the American Cancer Society recommends patients have the opportunity to make an informed decision regarding screening starting at the age of 40.

The second group is men with just 1 relative first degree relative diagnosed with prostate cancer at an early age and again, that's defined as earlier than 65 years ago, years of age, or an African American man. And for these patients, the American Cancer Society recommends that an informed decision start at the beginning of the age of 45 years old.

All other men with an average risk and with a life expectancy of at least 10 years should have the opportunity of an informed decision for screening starting at the age of 50. The American Cancer Society recommends that men who want to be screened have a PSA test, and also a digital rectal exam may also be part of that screening.

As you can imagine, prostate cancer screening recommendations can be a little bit confusing for our patients. So, it's important that we reform we inform them of the risks and the benefits of the screening so that they can determine whether the PSA based screening is right for them.

Q: What are the current approved approaches for treatment of prostate cancer?

For patients with localized prostate cancer, surgery and radiation continue to be the mainstays of treatment. For patients with more advanced prostate cancer, though, we've seen multiple new therapies approved in the past 10 years that has significantly impacted outcomes in this population. Androgen deprivation therapy and cytotoxic chemotherapy such as docetaxel, so played a key role in this population, but treatments such as targeted therapies, immunotherapies, and radiopharmaceuticals are now part of the treatment landscape.

Some of the novel therapies are only approved in various specific subsets of patients for prostate cancer. For example, radium 2 to 3 is only approved in patients with metastatic disease and bone metastases. The blue cell T is approved for patients with minimal symptoms or asymptomatic metastatic disease. And then we're capturing the proper BCR, a mutated prostate cancer, and there are also multiple newer generation antiandrogens available now, and these include enzalutamide, abiraterone, apalutamide, and darolutamide. These are all orally administered therapies and I have demonstrated improvement in survival when given to patients with advances.

Q: Are there any new drugs in the pipeline of note that show promise in treating prostate cancer?

In prostate cancer research right now, there continues to be a lot of emphasis on optimizing the sequence of administration of FDA approved therapies and also moving these proof therapies earlier in the disease course.

However, there are a number of new therapies in the pipeline as well. The targeted therapies continue to show promise in prostate cancer. There has been a lot of attention on a KT inhibitors as well as agents that target DNA damage repair radiopharmaceuticals targeting Prostate Specific membrane antigen or PSA may have also been developed. For example, a large phase 3 trial recently demonstrated that there was a survival advantage when giving a product called Laetitia 177. PSMA 6.7.

In patients with PSMA positive metastatic prostate cancer, immune checkpoint inhibitors are approved for various types of solid tumors, but for this particular population, they're typically studied in combination with other agents in hopes that that'll improve the efficacy in patients with prostate cancer. And we've seen in recent years a trend towards anti-cancer agents being approved for a very specific subset of patients. And we're likely to see that trend to continue in the future.

Q: What are some opportunities to optimize treatments for prostate cancer?

The community pharmacists can make a substantial impact on medication optimization in patients with prostate cancer. First of all, these anti-cancer therapies are incredibly expensive and pharmacists can play a large role by finding copay programs or patient assistance programs that can help with the financial aspect of it.

Also, some of these oral therapies are only available from specialty pharmacies, and so pharmacists can help navigate that unfamiliar territory with these patients. Also, drug-drug interactions and drug-herbal interactions are a significant challenge. And that's particularly true for our newer antiandrogens.

Many pharmacists can play a key role in alerting prescribers of potential interactions, and either making a recommendation for monitoring or else suggesting an alternate therapy. Examples of some potential interactions include Cytochrome P 450, mediated interactions, and also monitoring and watching out for overlapping toxicities.

This is the case, for example, with medications that lower seizure threshold and concurrent use with apalutamide or enzalutamide. Additionally, close monitoring for adverse events is required for all of these anti-cancer therapies. The community pharmacist is perfectly positioned to help watch for these toxicities and support and make supportive care recommendations, which helps our patients stay on these therapies longer.

Q: What are some strategies for managing prostate cancer care and treatment in the home, and has telehealth advanced to support this opportunity?

Many of the therapies used in prostate cancer are orally administered, but they do still require close follow up, and the management strategy really depends on the individual medication itself.

But at the start of each new therapy, it's really important that we provide these patients with extensive counseling and instructions regarding when to call their oncology team if they're experiencing side effects or if they have questions. We also encourage them very simple yet very effective strategies such as having patients create medication reminders and their phones and keeping a log of their side effects so that we can review them when they come in for their next appointment.

The COVID-19 pandemic has allowed us to really embrace telemedicine and allow for more frequent interactions with our patients between our office visits specifically. For example, reaching out to a patient after starting a new therapy to tack on their compliance and also detect for any new toxicities is extremely important.

Telemedicine allows us to have that convenience for our patients. It helps reduce the spread of COVID-19 while it still allows us to check in on them and ensure they're doing well.