Urology Expert Speaks on Key Advancements, PSA Testing in Prostate Cancer

Bryan A. Mehlhaff, MD

The life expectancy of patients with metastatic castrate-resistant prostate cancer (mCRPC) has doubled in recent years thanks to a multitude of new therapies, and there are still many more advancements to come, said Bryan Mehlhaff, MD.

Mehlhaff, medical director of research for Oregon Urology Institute, spoke with OncLive during the Large Urology Group Practice Association (LUGPA) Annual Meeting about recent advancements in prostate cancer care, controversy surrounding prostate-specific antigen (PSA) testing, and where he sees the field of prostate cancer going in the future.

OncLive: What are some of the key advancements recently in prostate cancer, and what do you see on the horizon in this field?

Mehlhaff: The things that we have been doing for a while are sipuleucel-T (Provenge), the immune therapy; the 2 oral medications, abiraterone acetate (Zytiga) and enzalutamide (Xtandi); radium-223, the liquid radiation for bone metastases; and then I think most groups have been attending to bone health with denosumab (Xgeva) or paying attention to calcium and vitamin D when you have patients that become hypogonadal with LHRH drugs.

Going forward now, I think we’re going to see a whole new wave of drugs that are in development, looking at why you have failures on abiraterone and enzalutamide, and whether there are medications that can be useful when patients have progressed, so there’s a whole new horizon of new things coming.

What role do you see urologists playing in advanced prostate care?

I think advanced prostate cancer is something every urologist is capable of understanding. I think it’s been a challenge. All these new things have come out very quickly; it wasn’t part of our residency training. This includes a new way of thinking about prostate cancer as a continuing hormone-sensitive disease.

I think we as urologists should embrace this. These are our patients, we originally diagnosed them, many times we originally treated them, and now we have these metastatic recurrences of their prostate cancer. We shouldn’t advocate that to others; that should still be in the purview of urology.

Are there any ongoing clinical trials in this space that you’re excited to see the data from?

There is a plethora of trials going on currently. Some of them are very exciting, maybe drugs that will work when a patient has the genetic variant called a AR-V7 splice variant. Those drugs may be able to take on that variant which is uniquely resistant to the 2 oral medications we have now.

Can you discuss the controversy surrounding PSA testing in prostate cancer?

Since the United States Preventative Services Task Force came out with their grade ‘D’ recommendation for PSA, I think that has led to a lot less screening, especially men in the earlier ages of 50s or 60s, and delayed diagnosis of the prostate cancers that we know exist. Just because you don’t screen and don’t see it, that doesn’t mean it doesn’t exist.

I think across the country we’re all seeing more men show up with advanced stage, hormone-sensitive, new diagnosis prostate cancer.

How would you describe how far we have come in this field and where you see it going in the future?

If you go back 6 or 8 years, urologists gave hormone therapy, maybe we used the first generation receptor blockers, and then there really wasn’t a lot to offer — for chemotherapy, we would send patients to the medical oncologists.

We’ve now literally doubled the life expectancy of mCRPC, and those are quality added years, not just life extension, but also good quality. And it’s amazing that we’re not done yet; it looks like we have more things on the horizon.

It’s a phrase I use with patients in my office: It’s not great that you have metastatic prostate cancer, but frankly, you chose a good time to have this disease.

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View more from the 2016 LUGPA Annual Meeting