National Conference on Prostate Cancer 2005
Exploring New Pathways – Sharing the Journey
June 16-19, 2005 – Thursday through Sunday
Omni Shoreham Hotel
Thursday – June 16
PSA and Other Markers
Jonathan McDermed, PharmD
PSA is the most important tumor marker test for prostate cancer detection, prognosis assessment and treatment monitoring. However, tumor markers other than PSA can be abnormal in certain forms of prostate cancer and should also be followed. In addition, men receiving therapy for their cancer should have other blood tests performed at intervals to monitor for possible onset of drug-related adverse effects. This 30-minute presentation will briefly review PSA and other relevant tumor markers for prostate cancer management and explain why other types of blood tests are important for monitoring specific drug treatments.
Pathology – Defining the Nature of the Disease
David Bostwick, MD
The Gleason score has long been the standard for evaluating prostate cancer biology. The revolution of genomic and proteomic testing has spawned a variety of new diagnostic and therapeutic biomarkers. The most promising available new marker for early detection of prostate cancer is the uPM-3 test, a simple urine-based assay that is much more accurate than serum PSA. The use of alpha-methyl-coA-acetyl-racemase has become standard practice in tissue diagnosis. These and other markers will be discussed as models for improving prostate cancer patient management.
PC 101- Diagnosis and Staging of Prostate Cancer
Charles Myers, MD
In this talk, we will cover the major aspects of prostate cancer. This will include a discussion of what differentiates dangerous prostate cancer that needs aggressive treatment from prostate cancer that grows and spreads slowly and can be treated with treatments that are not toxic or damaging. For patients that need aggressive treatment, we will review some of the issues that govern the decision to go for surgery vs radiation therapy. We will also talk about when it may be useful to add hormonal therapy to surgery or radiation therapy. This talk will provide you with the framework to understand subsequent talks about the different diagnostic procedures and treatment options.
Friday – June 17
Arthur Lurvey, MD
In this session we will review many websites that have extensive information about prostate cancer for the professional clinician and for the interested patient. Many are free (with some registration requirements) and all provide up to date information usually from textbooks and peer reviewed journals. Included are sites from the National Library of Medicine, national collection of guidelines, and nationally registered clinical trials.
Color Ultrasound with Doppler for Prostate Cancer Diagnosis and Staging
Duke Bahn, MD
1. Understand the basic prostate anatomy
2. Ultrasound findings of prostate cancer.
3. Benefits of color-Doppler ultrasound.
4. Importance of targeted and staging biopsy
5. Future developments.
Status & Strategy in the Successful Treatment of Prostate Cancer
Stephen Strum, MD
In the year 2005, men diagnosed with PC still are not being evaluated using a strategic methodology. Despite multiple publications on: the critical nature of the Gleason score, the value of accurate clinical staging and the importance of employing combined variable analysis (nomograms, algorithms & neural nets), more than 90% of men newly diagnosed with prostate cancer do not undergo such analyses. Instead, most men in the USA and worldwide have a bone scan & CT scan and then are asked to decide on a “definitive” form of therapy. The latter approach has been shown in multiple papers to grossly understage PC due to the lack of sensitivity of both bone and CT scanning. In this presentation, a logical and strategic approach to the evaluation of men with PC is presented. Such an approach—based on tens of thousands of human outcomes in the evaluation of PC—provides to patients and physicians alike, an evolved manner to evaluate the patient’s biologic findings & make further recommendations to optimize a successful outcome.
ProstaScint with CT, MRI, PET
D. Bruce Sodee, MD
Three complementary nuclear imaging modalities can be used to stage prostate cancer, each of which has specific applications and potential pitfalls. The most widely used of these is bone scintigraphy, which is the standard method of identifying skeletal cancer, the most frequent site of prostate cancer metastasis. The morbidity of prostate cancer escalates markedly when skeletal metastasis occurs; thus early detection of bone metastasis is critical to initiating optimum therapeutic or palliative treatment. Another nuclear imaging modality that can be applied to prostate cancer is positron-emission tomography [PET], which is a means to directly monitor metabolic activity, a universal marker of carcinogenesis that can be used to identify both primary prostate cancer as well as metastases to lymphatic and skeletal sites. The third modality and the focus of this talk is single photon emission computed tomography [SPECT] imaging of capromab pendetide or ProstaScint. This is a monoclonal antibody that targets prostate-specific membrane antigen [PSMA]. PSMA is a trans-membrane glycoprotein that has been thoroughly characterized due to its serving as a marker for prostate and other cancers. Accurate interpretation of SPECT-derived ProstaScint images requires considerable reader expertise, but many of the problems associated with ProstaScint imaging can be alleviated by fusing the ProstaScint images on anatomic images obtained from other modalities such as CT or MR. Our efforts in optimizing ProstaScint/CT imaging and applying it in staging prostate cancer in >600 patients will be discussed.
Lymph Node Staging Using Magnetic Nanoparticles
Mukesh G. Harisinghani, MD
Detecting the extent of local or regional lymph node metastases affects the therapy and prognosis in most malignancies. Current cross-sectional imaging modalities like CT and MRI have a reported sensitivity of around 50 % (mean 36%, variation 0-100%) for determining which lymph nodes harbor metastases. This poor performance stems from reliance on size criteria for differentiating benign from malignant lymph nodes. MRI enhanced with nanoparticles (Combidex) allows accurate analysis of lymph nodes independent of size and location. This new technique termed "Lymphotrophic Nanoparticle enhanced MRI (LNMRI)" has shown promise in accurate nodal staging for various types of primary cancers.
Arthur Lurvey, MD
In this session we will discuss all the services Medicare covers for patients with prostate disease, how to locate coverage rules, how to locate local Medicare Contractors and their Medical Directors, and how to challenge any adverse payment situation.
To Treat or Not To Treat: Difficult Choices for Men with Prostate Cancer
H. Ballentine Carter, MD
Today with PSA screening, 2 of 3 prostate cancers detected are considered to be low to moderate risk and are detected on average 10 years earlier than without PSA screening. Because of this earlier detection and the long protracted course of low risk prostate cancer, many men today are ideal candidates for expectant management with careful monitoring and the plan for curative intervention if there is evidence of disease progression. For younger men and those with potentially life threatening cancer, radical prostatectomy is an ideal management that results in a high probability of long term freedom of disease.
Robotic Prostatectomy w/ 3D Video
Ashutosh Tewari, MD, M.Ch.
This talk will utilize a 3-D video to illustrate the technique of nerve sparing and cancer control in men undergoing robotic prostatectomy for the management of prostate cancer. It will present a review of world data on this technique and share newer advances in preoperative planning to individualize the robotic surgery.
Graphs will be shown to illustrate various end points such as pain, blood loss, cancer control, catheter duration, recovery of sexual and urinary functions.
Cryoablation Therapy for Prostate Cancer
Duke Bahn, MD
1. Fundamental biology of tissue death with cryoablation.
2. Patient selection criteria.
3. Details of cryo procedure.
4. 7 year data on primary cryo and salvage cryo.
5. Quality of life issue related with cryoablation.
6. New developments.
IMRT & Brachytherapy
Michael Dattoli, MD
The presentation will be focused on:
1. A “state of the art” review of Brachytherapy and IMRT including combination treatment.
2. Comparing Radical Prostatectomy to Brachytherapy for Localized Prostate Cancer
3. Time allowing, Dr. Dattoli will present and refute “Common Brachytherapy Myths.”
Saturday – June 18
Charles Myers, MD
Hormonal therapy is commonly used as a treatment for prostate cancer, but many physicians and patients under estimate its effectiveness. This talk will provide you with a better idea of how effective hormonal therapy in your case. We will also review the evidence supporting the use of intermittent hormonal therapy. Finally, we will cover the second-line hormonal therapy approaches that have proved most effective.
Overview of Androgen Independent Prostate Cancer Therapy
Oliver Sartor, MD
Hormone-refractory prostate cancer is simply defined as a testosterone of less than 50 ng/dL and evidence of disease progression. Disease progression may occur as a consequence of increases in PSA (most commonly), progression by radiographic criteria (such as bone scan), progression on physical exam (prostate or lymph nodes), or progression in terms of symptoms (most commonly bone pain). Despite the fact that an individual may have failed either medical or surgical androgen deprivation therapies, a wide range of sensitivity to secondary hormonal manipulations still occurs.
A variety of treatment options are currently available for those with hormone-refractory prostate cancer. These treatment options include anti-androgen (casodex, flutamide, nilutamide) withdrawal, anti-androgen administration, adrenal suppressive (e.g. ketoconazole) estrogens (e.g. DES), corticosteroids (e.g., prednisone, dexamethasone), and chemotherapies (e.g. docetaxel). For those with bony metastasis, bisphosphonates and the bone seeking radiopharmaceuticals also represent viable options. At times it is appropriate to combine various classes of therapy.
A variety of other approaches should be considered experimental. Considerable progress has been made in the area of immunologic therapies and more progress in this arena is expected. Other experimental therapies include satraplatin for docetaxel failures and the epothilones. Anti-angiogenic compounds are being explored and additional data is needed before conclusions can be drawn.
In summary a variety of options currently exist for patients with hormone refractory prostate cancer. Prediction of responses to therapy is difficult however in the majority of cases individuals can find therapies that are appropriate for their particular disease. It is important and critical to monitor disease progression carefully and to make certain that changes occur when a therapy is no longer effective.
Mark Scholz, MD
It is widely known that ketoconazole is an effective and convenient medicine for the treatment of men who have prostate cancer that is resistant to Testosterone Inactivating Pharmaceuticals (TIP). Ketoconazole is as effective as TIP but tends to have more side effects and therefore is typically reserved for men who have developed resistance to TIP. Not every man with TIP resistant disease is a candidate for Ketoconazole. This presentation defines TIP resistance and the appropriate categories of individuals who are candidates for ketoconazole treatment. Other effective agents for men with TIP resistance are briefly listed. The results of published studies quantifying the effectiveness of ketoconazole are presented. Drug interactions, side effects, and methods to minimize them are also reviewed.
Chemotherapy Combinations that Work
Howard Scher, MD
In the recent past, the use of chemotherapy for prostate cancer has only provided palliative care. Recent advances, especially using Taxotere (docetaxel), have allowed researchers to identify chemotherapy options that improve both survival and quality of life. This talk will discuss the options that are currently in use and several novel combinations that are in clinical trials.
How Supportive Measures Enhance Outcome in PC Patients
Stephen Strum, MD
The prime directive of what physicians do—or are supposed to be doing—for all patients is to preserve, as well as augment, the quality of life. In this regard, the fine-tuning represented by supportive care measures becomes a necessary ingredient for the successful management of all patients. Supportive care is any ingredient that improves the therapeutic index (TI), which is defined as the ratio of “treatment benefit” to “treatment adverse effects”. Therefore, anything done to enhance the patient’s welfare during the timeline from the preventative phase to the terminal phase is considered supportive care. For the PC patient, supportive care ranges from minimizing the discomfort or pain of a DRE to the gamut of protecting against the adverse effects of chemotherapy. This presentation will share many of the supportive care approaches so important to the PC patient that have become an established protocol for a medical oncologist specializing in PC for over 22 years.
Charles Myers, MD
Immunotherapy of prostate cancer has become an active area if investigation with multiple candidate vaccines in clinical testing. While we await the arrival of FDA-approved vaccines, are there alternatives? Leukine is an FDA-approved drug used to stimulate bone marrow recovery after bone marrow transplantation. In January 2003, Eric Small published a critical paper showing that this compound could slow the progression of advanced prostate cancer. This talk will review the evidence that Leukine can suppress prostate cancer as well as other cancers, such as lymphoma, melanoma and breast cancer. Our experience suggests that this drug can be used to arrest or slow the progression of prostate cancer in many patients while causing few side effects.
Treating and Preventing Bone Metastasis
Mark Scholz, MD
Prostate cancer has a predilection for spreading to bone. This tendency is common to a variety of cancers such as breast cancer and lung cancer. What is unique about prostate cancer is that unlike breast or lung cancer, prostate cancer does not easily spread to other organs such as lung, brain, or liver. Thus if the growth of prostate cancer in the bone can be specifically targeted and inhibited, one of the most dangerous aspects of this disease can be thwarted. The mystery as to why prostate cancer will grow in bone but not in other sites of the body is starting to be unraveled and this new understanding points toward effective methods for the prevention of bone metastasis. Our presentation reviews the underlying causes for bone metastasis and defines the men who are at higher risk for developing bone metastasis. Specific treatments for men who have already developed bone metastasis are presented as are treatments for the prevention of bone metastasis.
Bone Targeted Therapies: Radiopharmaceuticals
Oliver Sartor, MD
Bone targeted radioisotopes are playing an increasing role in the management of hormone refractory prostate cancer. Initially used for palliative purposes, these agents are now being examined in clinical trials with therapeutic intent. Given that radio-sensitizing agents are available and active in prostate cancer, using combinations of these radio-sensitizers (Taxotere for example) and radio-pharmaceuticals are now part of the vanguard of therapies being tested in clinical trials.
In this brief talk I will cover randomized trials related to prostate cancer and bone targeted radio-pharmaceuticals and then begin to explore the newer realm of combining radio-pharmaceuticals with additional therapeutic agents. Whether or not the efficacy and toxicity of these combinations are favorable will determine the frequency of their future use.
Future – What’s in the lab
Mitchell Gross, MD, PhD
This talk will review the latest concepts in development for the treatment of prostate cancer. It will focus on material presented at the American Society of Clinical Oncology (ASCO) annual meeting held May 13-17, 2005 in Orlando, FL.
Living with Prostate Cancer
Ric is a stand-up poet, a teller of tales. In performance he can be both funny and poignant. His material is arranged in such a way that the audience has a sense of being engaged in a relevant conversation. Diagnosed with advanced prostate cancer in 1999, Ric has refocused his creative attention on the ups and downs of his battle with, as he puts it – “the Big C Monster” – a disease that in his case has mutated into de-differentiated neuroendocrine carcinoma. Fashioning the negative into something positive, Ric has put into words and says out loud what so many cancer patients often suffer in silence.
The Lovin' Ain't Over: Reviving Intimacy After Prostate Cancer
Ralph & Barbara Alterowitz
Ralph and Barbara Alterowitz will describe how to bring communication and closeness back into the relationship and setting the stage for great sex. Intimacy can be better than ever and help the man in his bout with prostate cancer. Ralph and Barbara discuss techniques for improving intimacy, benefits of erection-free sex, and therapies and medications obtaining erections- just – in case you think you can’t live without it.
Sunday – June 19
Developing pathways to treat Prostate Cancer
Donald Coffey, PhD
Dr. Coffey has been one of the leading scientists in the study of prostate cancer for many years. He will recount some of the leading developments that have contributed to our knowledge base and impacted the current treatment of the disease. He will also discuss recent developments that he believes will change the prevention and treatment options in the future.
Cause of PC, oxidative damage, obesity
William G. Nelson, M D, PhD
Prostate cancer incidence and death rates are generally high in the United States (U.S.) and Western Europe and low throughout Asia. However, Asian men adopt higher prostate cancer risks when residing in North America, especially after 25 years or more (see Nelson, W.G. et al. New Engl. J. Med., 349: 366-381, 2003). The diet has been the major lifestyle factor thus far implicated in prostate cancer development. Candidate prostate carcinogens have been identified in over-cooked meats while various fruits and vegetables appear to contain compounds that may protect against prostate cancer. Recently, increased attention has been directed at the role of prostatic infection and/or inflammation in the pathogenesis of the disease. About 9% of men between 40 and 79 years of age report suffering with symptomatic prostatitis, with half of these men having repeated episodes. Asymptomatic prostatitis seems to be even more common, though the prevalence and age distribution of asymptomatic prostatitis, in the U.S., in Europe, in Asia, or anywhere else, has not yet been reported. Increased prostate cancer risk has been associated with sexually transmitted infections, independent of the specific pathogen, hinting that the inflammatory response to infection, rather than the infectious agent itself, might lead to prostate cancer. Host responses to prostate infections may also underlie some familial prostate cancer clusters: two candidate genes implicated in familial clusters of prostate cancer, RNASEL and MSR1, encode proteins with critical functions in host responses to a variety of infectious pathogens. An inflammatory lesion in the prostate, proliferative inflammatory atrophy (PIA), appears to be a precursor to prostatic intraepithelial neoplasia (PIN) and to prostate cancer. The prostate may be particularly prone to develop cancer in the setting of chronic or recurrent inflammation because the early somatic genome alterations characteristic of prostate cancers tend to target genes that function in defenses against genome damage.
To End Prostate Cancer as a Threat to Any Man’s Life
Stephen B. Strum, MD with Bill Blair, co-presenter
William Shakespeare, the great observer of the human condition, uses the motif of a ‘play within a play’ in many of his tragedies; Hamlet for example. In the realm of prostate cancer, a real life tragedy, there exists an ‘illness within an illness’. For the sake of this discussion let’s call it the “illness within”. The illness within is a syndrome of apathy, indifference to one’s own cause & lack of unity, with an appropriately fitting acronym—AIL. Unless a critical number of men with PC realize this “illness within” and quash it, the advances so desperately needed by men with PC to vastly improve their outcomes will not be forthcoming. Then, unfortunately, we will continue with the status quo and be forced to witness the decline & death of our husbands, our buddies, our brothers, our fathers and even our sons from PC & associated maladies. This is a tragedy, and even more so, because it is unnecessary.
On the contrary, such dire outcomes could be avoided right now if an attitudinal change were to take place, and a PC Movement were to ensue. This would be a socio-economic-humanistic movement characterized by action, instead of apathy, by commitment instead of indifference and by togetherness instead of disunity (ACT). This is a call to arms, to action, to save your life and those you love. You are the change you wish to see in this world!
This presentation by a medical oncologist working on the front lines of PC treatment since 1983 (Stephen Strum), and co-partnered with a PC patient & support group leader (Bill Blair) will focus on a strategic plan to move men with PC to ACT, instead of to AIL.
Review and take home message
Charles Myers, MD
This talk will discuss the various observations presented during the conference.