Prostate Cancer Management – We Need Better Options for Early-Stage Disease

As a physician, researcher, and biotech leader with personal experience of prostate cancer in my family, I’ve long advocated for putting patients first in our quest for medical innovation. Today, I believe we need to adopt this approach to address an important issue in prostate cancer management: the need for better treatment options for early-stage disease.

Throughout my career, from treating patients to leading research in autoimmune disease and cancer, I’ve seen firsthand the importance of considering the full patient journey and experience. This perspective is crucial as we navigate the evolving landscape of prostate cancer treatment, particularly for early-stage disease where our options need to be expanded.

Prostate cancer remains one of the most common cancers among men, with the American Cancer Society estimating about 299,010 new cases and 35,250 deaths in the United States for 2024. 

For low-risk prostate cancers, there has been a shift toward active surveillance in many patients. This involves closely monitoring the cancer through regular check-ups, blood tests, imaging tests, and periodic prostate biopsies. This approach is often chosen because in many cases of low-risk prostate cancer, the disease progresses only slowly. Active surveillance allows patients to avoid or delay the potential complications and side effects of radical therapy (surgery or radiotherapy) as well as hormonal therapy (androgen deprivation therapy), which may be quite significant.  

While active surveillance is a valuable approach for many, it isn’t for all.  First, many patients (30-50%) will still need to undergo radical prostatectomy (surgery) or radiotherapy within five  years due to progression of the disease. They will still face the side effects and complications of currently available radical therapies and hormonal treatment at that time, and there may still be progression of the disease afterwards. Second, many patients on active surveillance experience significant anxiety, because they are worried about their cancer’s potential growth. To truly evaluate the effectiveness of active surveillance, we must broaden our perspective to encompass these aspects of mental health and the entire patient experience.

I have not only learned the critical importance of capturing and understanding the patient’s experience in drug development in oncology, but earlier also in autoimmune diseases. For example, many years ago we were involved in the development of TNF inhibitors as a new treatment for rheumatoid arthritis (RA). As physician-scientists, we were initially mainly focused on the effects of these new treatments on the joints: improvement of pain, joint swelling, and disability. What we learned from our patients, however, was the critical importance of improvement of fatigue and mind fog. Thus, if we want to innovate and develop transformative treatments, we will need to consider the whole patient experience. 

This lesson clearly applies to drug development in prostate cancer. In defining treatment goals, we need to consider preventing cancer-related anxiety and depression as well as avoiding or delaying the need to undergo radical therapy after progression during follow up, as this is associated with erectile dysfunction and urinary incontinence, as well as the many side effects of androgen deprivation therapy like hot flashes, fatigue, and mood changes.

In prostate cancer research, we’ve traditionally strongly focused on survival rates. While survival is obviously very important, it is not the whole story. If a patient is still alive but faces signs and symptoms due to locoregional progression or metastatic disease, then this may have a big impact on patients’ lives. The same is true for the unwanted consequences of standard of care treatments, discussed above. Therefore, our therapeutic goal in the active surveillance population is to stop the progression of the disease with a relatively simple therapeutic intervention. 

Similarly, for patients with more aggressive, intermediate-high risk prostate cancers, who will need to undergo radical therapy, there is an opportunity to improve disease outcomes, by creating synergy with standard of care radiotherapy. If it is possible to increase the number of patients who will be ‘disease-free’, then it can be expected that less patients will develop locoregional progression or metastatic disease over time, and that less patients will need long term androgen deprivation therapy over time.

Innovative approaches for early, localized, non-metastatic prostate cancer

Despite significant advancements in cancer treatment overall, there’s been relatively little progress in the treatment of early stage, localized prostate cancer over the past 25 years. This is partly due to the long-term nature of prostate cancer progression, which makes clinical trials in this area challenging. It’s clear that we need to expand our arsenal of treatment options for early-stage prostate cancer to provide patients with more choices that can effectively manage their disease while preserving their quality of life.

There is a pressing need for improved outcomes for patients with early-stage disease. I’ve seen firsthand the importance of designing clinical trials that could lead to better treatments for both patients with low-intermediate risk prostate cancer in the active surveillance population and for patients with intermediate-high risk prostate cancer who will receive radiotherapy. 

Innovation in research aims to develop treatments that can effectively manage the disease while minimizing the impact on patients’ daily lives. To truly put patients first in our work, we must ensure that our research and clinical trials represent the full spectrum of those affected by prostate cancer and understand how potential therapies impact diverse patient populations. 

Looking ahead: A future of patient-centered innovation

As we continue to make advances in prostate cancer research, it is clear that there is no one-size-fits-all approach. The decision between active surveillance, radical prostatectomy, radiotherapy, androgen deprivation therapy, and emerging therapies will be made individually, considering the specific risk profile of the cancer, the patient’s overall health, the benefit/risk of the treatment, and personal preferences. While the goal of maintaining survival will remain unaltered, there will be an increased focus on preventing locoregional progression and metastatic disease as well as avoiding the side effects and complications of currently available treatments.

The future of prostate cancer care lies in our ability to offer a range of options tailored to each patient’s unique circumstances. To achieve this, we need to continue investing in research for early stage, localized prostate cancer, develop treatments that balance efficacy with quality-of-life considerations, ensure diverse representation in clinical trials, and listen to patients and incorporate their perspectives into treatment development and decision-making. 

We must continue our efforts to expand the treatment landscape for early-stage prostate cancer. The current binary choice between active surveillance and aggressive treatment leaves many patients caught with cancer-related anxiety, progressive disease, and side effects due to conventional treatments. By developing new therapies that help the patient’s immune system to fight cancer more effectively, we aim to offer patients greater control over their disease and improve disease outcomes, while minimizing side effects and complications of current standard of care.

Photo by poncho via Getty Images

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