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The 12th Shanghai International Forum on Urologic Oncology and the Summit Forum of Prostate Cancer Expert Committee of the Chinese Society of Clinical Oncology, and the 2022 Annual Meeting of the Urological Oncology Special Committee of Shanghai Anti-Cancer Association were successfully held
online on November 26, 2022.
Since its first held in 2011, the Shanghai International Forum on Urologic Oncology has gone through 12 spring and autumn seasons and has become a comprehensive forum
that brings together top experts, young and middle-aged scholars and innovative research teams in the field of urologic oncology.
In the form of academic week, the conference carried out a series of academic activities
such as the application of radioligand therapy in prostate cancer, the interpretation of the progress of advanced prostate cancer treatment, and the analysis of immunotherapy hot spots in the field of urologic tumors.
Yimaitong is honored to invite Professor Ye Dingwei of Fudan University Cancer Hospital, Professor Han Bangmin of the First People's Hospital of Shanghai Jiao Tong University School of Medicine and Professor Gao Xu of Shanghai Changhai Hospital to share with us the current status of prostate cancer diagnosis and treatment and the importance of simultaneous monitoring of
PSA and testosterone in androgen deprivation therapy (ADT).
Prof.
Dingwei Yip
Vice President of Fudan University Cancer Hospital Chief expert of urological oncology MDT
Director of Shanghai Institute of Urological Oncology
Director of the Institute of Prostate Cancer, Fudan University
Chairman of the Prostate Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO).
Chairman of the Urology Committee of China Primary Health Care Foundation
Former Chairman of the Chinese Anti-Cancer Association Urogenital Tumor Committee (CACA-GU).
Vice President of the Oncology Group of the Urology Branch of the Chinese Medical Association (CUA) and Chairman of CPCC
Vice Chairman of the Urothelial Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO).
Vice Chairman of the Kidney Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO).
Vice Chairman of the Immunotherapy Expert Committee of the Chinese Society of Clinical Oncology (CSCO).
Chairman of the Urologic Oncology Collaborative Group (UCOG) of China Cancer Hospital
Standing Director of Chinese Anti-Cancer Association and Standing Director of Chinese Society of Clinical Oncology
Leader of the prostate cancer group of the Urogenital Tumor Committee of the Chinese Anti-Cancer Association (CACA-GU).
Professor Han Bangmin
Director of the Clinical Medical Center of Urology, First People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, M.
D.
, Chief Physician, Doctoral Supervisor
Member of Urology Branch of Chinese Medical Association Deputy Head of Robotics Group
Member of the Standing Committee and Deputy Director General of Andrologist Branch of Chinese Medical Doctor Association
Member of CACA-GU
Secretary General of Urology Branch of China Medical Equipment Association
Deputy leader of the Prostate Disease Group of Andrology Branch of Chinese Medical Association
Vice Chairman of Andrology Branch of Shanghai Medical Association
Vice President of Andrology Branch of the World Chinese Physicians Association
Professor Gao Xu
Chief physician, Department of Urology, Shanghai Changhai Hospital, medical doctor, doctoral supervisor
Shanghai "Excellent Academic Leader"
Shanghai Health System "Excellent Discipline Leader"
High-level scientific and technological top-notch talents in the whole army
Member of the Standing Committee of the Urology Branch of the Chinese Medical Equipment Association, Deputy Secretary-General of the Minimally Invasive Group of the Urology Branch of the Chinese Medical Association, Deputy President of the China Prostate Cancer Alliance, Deputy Head of the Digital and Artificial Intelligence Group of the Chinese Association of Urologists, Editorial Board Member of the Chinese Journal of Urology, Deputy Editor-in-Chief of the Chinese Journal of Laparoscopic Urology, etc
.
Could you please talk about the epidemiological status of urological tumors in China? What are the risk factors for the development of prostate cancer? Professor Yip:
The current situation of urinary tumors in China can be discussed
from the perspectives of urban and rural areas and gender.
First of all, the situation of urinary tumors in China is not optimistic, and there are differences
in the incidence of urban and rural tumors.
According to the analysis of national statistical data, urban areas with more developed social economy and richer health resources have more cases and higher incidence
.
Secondly, according to the gender analysis of the incidence of tumors in various provinces, male prostate cancer is basically in the top 10 positions, of which Shanghai and other developed areas have entered the top 4
.
From the perspective of the whole country, the burden of kidney cancer and bladder cancer in women is slightly lighter
than that of men.
Compared with the incidence order, the death order of bladder cancer, prostate cancer and kidney cancer is lower than that of the disease in each province, which indirectly reflects the relatively good
clinical diagnosis and treatment effect of urinary tumors in China.
For men, prostate cancer is relatively high in death order, and bladder cancer and kidney cancer are relatively low
.
How should we deal with the sharp increase in the incidence of genitourinary tumors and the high risk of death? I think it should be divided into several levels:
(1) From the national and government level, the screening of prostate cancer and other diseases should be strengthened, so as to improve the early detection rate, improve the disease cure rate, and prolong survival;
(2) Professional societies should play an important role in strengthening the popularization of the concept of genitourinary tumor prevention and treatment, so that the public can realize the importance of early detection and early treatment concepts;
(3) From the public level, we should embrace advanced concepts and knowledge, and improve the public's health awareness by accepting the concept of scientific prevention and treatment, regularly participating in tumor screening, etc.
, and better "early screening and early treatment"
.
Prostate cancer is one of the most rapidly increasing malignant tumors in China and has become the most common malignant tumor
in urology.
The data show that the incidence of prostate cancer in China is much lower than that in Europe and the United States, and the standardized incidence of prostate cancer in China is 9.
1/100,000, and that in the United States is 75.
7/100,000; However, China's mortality rate is relatively high, and China's 4.
7/100,000 is close to the United States' 7.
7/100,000, which may be related
to the lack of prostate cancer screening in China.
Since most of the early prostate cancer has no symptoms, many patients in China are often in an advanced stage
when they are treated.
Prostate cancer screening is an important means to reduce the mortality rate of prostate cancer, and screening in the early stage of prostate cancer can improve the cure rate, reduce mortality, and improve the treatment effect
.
Like most malignant tumors, the causes of prostate cancer include endogenous factors and exogenous factors, but prostate cancer has its own particularities
.
In terms of endogenous factors, the biggest cause is the hereditary nature
of prostate cancer.
According to epidemiological data, an immediate family member with prostate cancer has an increased risk of prostate cancer by more than 1 times; If 2 or more immediate family members have prostate cancer, the risk increases to about
10 times.
In addition, there is a saying that as long as a man lives long enough and has normal levels of testosterone, he will get prostate cancer
sooner or later.
Therefore, age and testosterone levels are also endogenous factors
in the onset of prostate cancer.
The exogenous factors of prostate cancer are related to lifestyle habits, such as excessive alcohol intake, too low or too high vitamin D levels, and the metal element zinc intake
.
However, from a medical point of view, exogenous factors do not directly lead to the occurrence of prostate cancer, so it is difficult to change the incidence of prostate cancer by adjusting living habits.
.
It has been more than 6 years since the first edition of the "Chinese Expert Consensus on Prostate Puncture" was released, and it has contributed to
promoting the standardization of prostate puncture in China.
Could you please talk about the current problems of prostate puncture in China? What are the key points of the 2023 version of Consensus? Professor Yip:
The premise of treatment is to clarify the pathological diagnosis of prostate cancer, and prostate biopsy is the key link
to obtain pathological diagnosis.
At present, there are still irregular behaviors in prostate puncture in China, such as large differences in puncture methods, different puncture sites, irregular puncture process, etc.
, and even some still have problems such as finger-guided blind piercing, so the puncture concept
needs to be further standardized.
The new edition of the "Chinese Expert Consensus on Prostate Puncture" elaborates on the indications of prostate puncture, imaging examination before puncture, implementation of puncture, specimen collection, standardized pathology report, treatment of puncture complications and interpretation of puncture results, which will significantly promote the further improvement of prostate puncture technology by Chinese experts in the future
.
.
In recent years, the diagnosis and treatment of prostate cancer has paid more and more attention to PSA and testosterone in parallel, please briefly talk about why the industry continues to emphasize that PSA and testosterone should be monitored simultaneously during ADT? How to implement it in the clinic? Professor Yip:
In clinical treatment, PSA is one of the indicators that clinicians focus on, but testosterone levels are not highly concerned
.
However, testosterone monitoring remains important in clinical management
.
Clinical practice has continuously shown that testosterone is closely related to prostate cancer risk assessment, treatment selection, efficacy evaluation and survival prognosis, and is a key indicator
to evaluate the efficacy of ADT.
For example, when PSA is elevated during ADT, whether it is due to the effect of ADT drugs, or whether prostate cancer develops CRPC, needs to be determined
by testosterone monitoring.
Several authoritative guidelines recommend
simultaneous monitoring of PSA and testosterone levels.
The Chinese Expert Consensus on the Management of Testosterone in Prostate Cancer (2021) pointed out that testosterone < 20ng/dl during ADT, that is, deep ketone lowering is associated with better disease prognosis and outcome, and timely and synchronous monitoring of testosterone and PSA
in different disease treatment stages is required.
The Chinese Guidelines for the Diagnosis and Treatment of Urology and Andrology Diseases (2019) pointed out that about 25% of patients may not show PSA elevation at the time of clinical progression, and testosterone and PSA
need to be monitored in time at the onset of prostate cancer, treatment switching point, and disease progression stage.
In clinical practice, doctors in our department attach great importance to the synchronous monitoring of PSA and testosterone, especially during ADT treatment and the whole process of patient management, and strive to standardize and synchronize the concept of synchronous monitoring
.
At present, the most common clinical testosterone detection techniques include radioimmunoassay, chemiluminescence immunoassay, and chromatography-mass spectrometry
.
The first two are more common
due to the higher accuracy but more expensive and low penetration of chromatography-mass spectrometry.
Lowering testosterone is the standard and basic treatment for endocrine therapy for prostate cancer, and in the whole management of prostate cancer, attention should be paid to the simultaneous monitoring
of testosterone and PSA.
For the first 6 months of endocrine therapy, it is recommended to test testosterone and PSA once a month to monitor whether testosterone is castrated to determine the efficacy
of castration therapy.
After 6 months, testosterone and PSA testing can be progressively extended depending on the severity of the condition
.
High-risk cases can be tested every three months, and low-risk patients can be tested semi-annually, but testosterone and PSA levels
need to be monitored throughout the process.
The lower the level of testosterone maintenance, the better
the patient's treatment outcome.
Figure 1Standardized process of testosterone monitoring and management during ADT therapy
At present, many prostate cancer patients will observe PSA and testosterone levels
simultaneously during the overall treatment process.
Data released by many large research centers show that during the treatment of prostate cancer, PSA and testosterone levels decline rapidly and steadily, and when they are at a deeply reduced level, patients will have better treatment effects, faster symptom improvement, and longer treatment effects
.
In clinical work, how to find out in time whether the patient's testosterone level has reached the ideal "therapeutic target level", and whether the PSA decline is fast enough? Regular monitoring
is the most feasible approach.
In the Department of Urology of our hospital, all prostate cancer patients undergoing endocrine therapy are required to undergo regular follow-up and re-examination, and regularly test PSA and testosterone, so that doctors can grasp the treatment situation of patients in time, adjust the treatment plan in time, and bring better prognosis to patients
.
.
What are the advantages of triptorelin in the treatment of prostate cancer? In the current epidemic, what convenience does ADT long-acting dosage form bring to patients? Professor Yip:
Triptorelin reduces PSA and testosterone levels simultaneously and is stable and persistent
.
A multicenter, open-label, single-arm study evaluated the effectiveness
of triptorelin in patients with locally advanced or metastatic prostate cancer.
The study included 126 patients with locally advanced or metastatic prostate cancer who were treated
with the triptorelin dosage form for 3 months.
Two injections were given at weeks 1 and 13 to assess the effects
of triptorelin treatment on PSA and testosterone levels.
The results of the study showed that after 8 weeks of treatment, the median PSA level remained below 4 ng/ml until the end of
the study.
By 26 weeks of treatment, PSA levels decreased by 96.
0%, and the proportion of patients who maintained testosterone levels < 20 ng/dl was 90.
0%.
Triptorelin was originally in a 1-month dosage form and had a good
effect on deep ketone lowering and PSA lowering and maintenance.
After the dosage form was launched in March, we found that the efficacy of the dosage form in March was still very good, and the proportion of reducing testosterone to less than 20ng/dl was very high, which became a very important choice
in the full management of prostate cancer in our center.
For castration therapy for prostate cancer, drug therapy is basically used, and the three most commonly used drugs include triptorelin, goserelin and leuprolide.
The use of gonadotropin-releasing hormone (GnRH) agonists (GnRH-a) can reduce testosterone to castration levels (50 ng/dl), and expert consensus suggests that testosterone levels down to 20 ng/dl, or even below 10 ng/dl, benefit patients better
.
A retrospective analysis comparing changes in testosterone levels over 9 months with the three drug therapies showed that all patients in the triptorelin-treated group reduced testosterone levels to <20 ng/dL<b10> at 6 and 9 months.
There was a significant difference in the proportion of patients with testosterone below 10 ng/dl between the three groups, with 34.
6% in the goserelin group, 89.
5% in the triptorelin group, and 83.
3%
in leuprolide at 9 months.
The results suggest that among the three drugs, triptorelin has the strongest castration effect
.
The epidemic prevention and control is temporary, but the whole process of management of prostate cancer patients is indeed long-term
.
During the epidemic prevention and control period, many patients delayed the treatment of injectable drugs due to the inconvenience of seeking medical treatment, but the emergence of long-acting dosage drugs has brought convenience
to the treatment of prostate cancer patients during the epidemic.
Taking triptorelin as an example, although the 1-month dosage form can reduce testosterone to low levels and delay disease progression, 1 monthly hospital injection brings some trouble
to patients.
The emergence of triptorelin long-acting dosage form allows patients to maintain testosterone castration levels for several months, reduces the travel risk of patients, meets the convenience needs of patients, and also saves patients' medical costs and reduces the burden of
medical resources.
into the treatment of prostate cancer.
What is the development prospect of new antiandrogers? Professor Han Bangmin:
The emergence of new androgen receptor (AR) inhibitors has taken the treatment of prostate cancer a big step forward, whether in terms of efficacy, side effects or other aspects, it has created a new situation
for the treatment of prostate cancer.
At present, new endocrine therapy drugs such as enzalutamide, apatamide and darolutamide are more widely used in clinical applications, domestic original drugs are catching up, and a new generation of drugs such as revilumide reflects China's original research strength
.
At present, studies have shown that for hormone-sensitive prostate cancer patients with high tumor burden and high-risk metastasis, the combination of new endocrine therapy on the basis of traditional ADT can prolong the survival time of patients and improve their quality of life
.
The treatment of tumors, on the one hand, is to prolong survival, on the other hand, to improve the quality of life, the new endocrine therapy meets these two requirements at the same time, bringing great benefits
to prostate cancer patients.
With the progress of clinical research and the accumulation of clinical experience, the arrangement and combination of various drugs and the timing of treatment are constantly updated, which will bring new hope
to patients.
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