Tracks 1-7
DR GOMELLA: For a young patient, like this 37-year-old man, who theoretically
has 40 more years of life to live, you want to be as aggressive as possible in this
high-risk situation and should consider putting the patient on a protocol. The
CALGB is conducting a trial (CALGB-90203) that is evaluating neoadjuvant
docetaxel and hormone therapy versus neoadjuvant hormone therapy alone
(1.1). Patients with high-risk disease who are otherwise candidates for radical
prostatectomy are eligible.
DR ZELEFSKY: In my opinion, local therapy alone would initially be the
correct approach. For a young patient, I would lean more toward surgery than
a radiation therapy-based modality. These approaches probably provide the
patient with equal longevity outcomes, but radiation therapy carries a slightly
increased risk of secondary malignancies for such a young patient.
If the urologist believes a reasonable chance exists of obtaining negative
margins after prostatectomy, I believe that’s the correct way to go. Then, based
on the pathology, recommendations can be made regarding adjuvant therapy.
DR KEANE: If a patient has a T3 tumor and a high PSA level with a Gleason 4 + 3
biopsy result, he needs all of the options explained to him up front. I believe he should
see the radiation therapist and the medical oncologist before undergoing local therapy.
DR GOMELLA: I strongly believe that virtually every patient with newly
diagnosed prostate cancer who’s a candidate for local therapy should see a
radiation oncologist, a medical oncologist and a urologist.
DR LOVE: Even the patients with low-risk disease?
DR GOMELLA: Yes, absolutely. Clinical practice has changed dramatically in
the past 10 or 15 years with regard to the polarity that existed between radiation
oncologists and urologic surgeons when treating prostate cancer. We’re
working together now, recognizing that this is no longer simply a surgical
disease or simply a radiation therapy-sensitive disease.
DR KEANE: The message that recently emerged at ASCO is that the treatment
you receive depends on whom you see ( Jang 2007; [1.2]).
DR GOMELLA: The best practice is for the patient to see all the specialists at the
same time because no one really knows the correct approach for these men.
This way the patient is presented with a balanced view and the discussions
take place in front of him. We often go in together — the radiation oncologist
and the surgeon — to talk to our patients and answer their questions.
DR LOVE: Assuming a patient has high-risk disease postoperatively, the prevailing
strategy right now is observation until the PSA level rises as opposed to treating
with adjuvant therapy immediately after surgery. Mike, do you agree with that?
DR ZELEFSKY: I believe many clinicians would monitor the patient’s PSA level
and if it reached a nadir at zero, then follow him closely. However, depending
on the pathology findings, you could make a strong argument for sending
him to the medical oncologist and radiation oncologist for further counsel. If
this patient had positive margins, even if his PSA level dropped to zero, I’d
probably treat him with adjuvant radiation therapy.
DR LOVE: Would you consider adjuvant hormone therapy also?
DR ZELEFSKY: Probably, but we have fewer data to extract from right now in
this particular setting. For the patient who is younger, I’m not thrilled about
using hormone therapy unless he experiences a relapse.
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