Page 13 - CUAJ Dec. 2022

Managing advanced prostate cancer: No longer
CUA NEWS
text the primary domain of general urology

Armen Aprikian arly in many of our careers, the management of advanced prostate cancer
(PCa) was done primarily by the general urologist. For decades, urologists
CUA President Etreated metastatic (m) PCa with surgical/chemical castration. We did a great
job managing the disease and played the central physician role, even into the pal-
Cite as: Aprikian A. Managing advanced prostate liative stage. Fortunately, the life expectancy for men with mPCa has increased
cancer: No longer the primary domain of general significantly due to the advent of many new treatment options; however, the field
urology. Can Urol Assoc J 2022;16(12):387. has become very complex.
http://dx.doi.org/10.5489/cuaj.8196 There are now several options available for untreated mPCa. Beyond andro-
gen deprivation therapy (ADT), new life-prolonging approaches include several
androgen receptor axis targeted therapies (ARATs), docetaxel chemotherapy, and
Pour la version française, voir cuaj.ca ARAT/docetaxel combination. In addition, many patients still benefit from local
radiotherapy despite having metastases. We can add to the mix the growing need
The CUA exists to promote the to verify the mutational status of the germline and/or tumor tissue for homologous
highest standard of urologic care recombination deficiency and the eventual addition of poly (ADP-ribose) polymerase
for Canadians and to advance inhibitors. Moreover, the entire field of prostate-specific membrane antigen (PSMA)
the art and science of urology. imaging, PSMA-targeted therapies, and stereotactic radiation to select metastases is
rapidly evolving, adding to the complexities of management.
When ARATs became indicated in the castration-resistant stage, we argued gen-
eral urologists were well-positioned to employ these agents since they are essentially
an extension of ADT. Many CME hours were offered to fulfill the educational needs
for urologists to get on board. Well, it turns out many patients are not receiving ADT
intensification in the castration-sensitive or -resistant stages despite these drugs being
available for years. There are several possible reasons for this, including the need
for closer monitoring of internal medicine-type parameters, greater side effects, and
the “hassle factor” in getting provincial permission. Perhaps another reason is that
these patients have not been consulted by a urologic or medical oncologist and their
team. Surprisingly, and unfortunately, there are still many men who die from PCa
who never even received chemotherapy despite being eligible. Referring patients to
medical oncology when they are fast-progressing, symptomatic, and frail is too late.
The management of advanced PCa requires a team, with strong nursing and phar-
macy support, frequent assessments, and lab monitoring. The traditional, “If PSA is
OK, all is good,” approach is no longer appropriate; more is required to monitor the
patient and the disease. Furthermore, with the benefit of docetaxel chemotherapy in the
castration-sensitive metastatic state, evaluation of whether a patient is “fit for chemo-
therapy” cannot be done by general urology. The same argument applies as to who
is best suited to weigh the clinical merits of chemotherapy vs. ARAT or combination
with the patient. Finally, decisions made at early stages of mPCa, as well as timing of
referral, can profoundly affect potential remaining therapeutic options down the road.
We should accept that general urologists are not the best-equipped to be at the
center of advanced PCa management but rather be members of a team, where the
medical or urologic oncologist has the principal role. We need greater integration
of general urology with medical/urologic oncologists involving the establishment
of local teams and access to regional tumor boards. We should take advantage of
the benefits learned from the pandemic regarding tele/virtual medicine. With the
help of our colleagues in GUMOC (GU Medical Oncologists of Canada) and our
Community Urology Committee, the CUA is poised to facilitate this integration as
much as possible.

CUAJ • December 2022 • Volume 16, Issue 12 387
© 2022 Canadian Urological Association