Prostate Cancer Awareness Efforts Target Patient Education, Treatment Access, and Survivorship Care

Bertram Yuh, MD, MISM, MSHCPM

Prostate Cancer Awareness Month, which occurs each September, reminds both patients and healthcare providers that it is vital to continue disseminating knowledge about emerging therapies, changing treatment approaches, ongoing health disparities, and genetic testing tools, all of which could improve current understanding of the complexities of managing this disease, according to Bertram Yuh, MD, MISM, MSHCPM.

“We know that prostate cancer awareness discussions and testing did lose some steam through changes in the last 10 years in screening recommendations, COVID-19, and other factors. This has also lent [a hand] to more advanced presentations of prostate cancer and more difficult-to-treat cancers,” Yuh explained during an interview with OncLive^®.

In the interview, Yuh discussed the value of genetic testing and biomarker-driven therapies in the treatment of patients with prostate cancer, expanded on the need for long-term care and toxicity management to promote survivorship both during and following treatment, and highlighted the importance of Prostate Cancer Awareness Month for encouraging vital discussions between patients and providers about this disease.

Yuh serves as a professor in the Division of Urology and Urologic Oncology in the Department of Surgery, director of the Urologic Oncology and Robotic Surgery Fellowship, associate chief medical information officer, and a clinical documentation and analytics lead at City of Hope in Duarte, California.

OncLive: What role do genetic factors, such as BRCA mutations, play in the risk stratification of patients with prostate cancer?

Yuh: Genetic assessment and its impact is an exciting but developing field in prostate cancer. We know that prostate cancer is one of the most heritable cancers. Therefore, genetic testing can yield a lot of information. There's a fair bit of clustering of prostate cancer in certain families, making it important to assess for family history of cancers when talking to a patient. The risk of [developing] prostate cancer is increased with DNA damage repair mutations, [such as] BRCA1 and BRCA2 mutations, most notably in the setting of prostate cancer.

Men who have family members with breast cancer, ovarian cancer, or pancreatic cancers, should oftentimes consider genetic testing and counseling. In addition to having a higher risk of developing prostate cancer, we also know that BRCA carriers can also have more aggressive [disease] features, such as a higher grade, higher stage, and even worse survival outcomes. There's also an association [between] prostate cancer and colorectal cancer [CRC], as it pertains to lynch syndrome.

When patients are diagnosed with prostate cancer and we find that they harbor a genetic mutation, this can also assist in guiding their family members [to receive] genetic counseling or genetic testing and can provide more information for the family as a whole. There is a lot of ongoing research and work on genetic factors and their impacts on treatment decisions.

Currently, I would say that the most important considerations for treatment would be in later-stage prostate cancer. In general, there is vast potential for genetic testing [to improve] understanding [of disease] prognosis as well as future treatment. At City of Hope, we do recommend routine testing for all our patients with prostate cancer for genetic mutations.

What have been some of the most exciting advancements with targeted therapies or immunotherapy in advanced or metastatic prostate cancer?

Biomarker-directed therapies, such as PARP inhibitors, the use of platinum-based chemotherapy, and eligibility for clinical trials, are [considered] most widely in prostate cancer, mostly in the advanced setting. There's also a lot of research being done on radioligand therapies that are designed to target prostate cancer with a therapeutic radionuclide that delivers cytotoxic radiation. Lutetium Lu 177 vipivotide tetraxetan [Pluvicto; formerly 177Lu-PSMA-617] has been used to treat a lot of men with prostate-specific membrane antigen–positive prostate cancer; this and other radioligand therapies continue to be explored in earlier lines of treatment.

With registry-based analyses and other research tools, there are ongoing efforts to individualize and personalize local treatments. We use nomograms and artificial intelligence–based tools to assess how to deliver specific types of surgery, radiation, and lymph node–directed therapy. Ongoing efforts to combine various forms of therapy for these more advanced, stubborn cancers will ultimately lead to optimized outcomes as well.

What are the most critical long-term management strategies for patients who have undergone prostate cancer treatment?

Prostate cancer survivorship is a very important, but often underlooked, aspect of cancer care. A key consideration to keep in mind is that prostate cancer treatments are generally very effective, so the vast majority of men who receive treatment will be cancer survivors, but that also means that they are going to be affected by potential adverse effects [AEs] and alterations for a longer period. It is also important to understand that prostate cancer itself creates a lot of AEs including urinary issues and sexual dysfunction, even in a state where the disease has not been treated.

[Not only] are there the natural effects of aging, but also cancer as its own biologic behavior that creates AEs. In the setting of survivorship, close monitoring for recurrence is always crucial. All forms of prostate cancer treatments [can] impact urinary control and incontinence and our major elements of survivorship. However, things like bowel dysfunction, cardiovascular effects, anxiety and depression, osteoporosis, and fracture risk that should be discussed as well.

We often talk about [how] things like social determinants of health, diet, and optimizing exercise [impact] survivorship. It's also important for these men to consider screening for other cancers that could be a secondary effect of pelvic radiation, like bladder cancer or CRC. All of this needs to be wrapped into a package where education and reinforcement are continually important. We believe that setting aside a sufficient amount of time with patients during survivorship visits is extremely important to cover all these aspects. It's also important to provide [patients with] access to sexual health experts and reconstructive surgeons, [who can] assist with improving urinary and sexual function. Behavioral health specialists and patient support groups are all key to a robust and diverse survivorship program.

What factors primarily contribute to health-related disparities in prostate cancer, and how might they be addressed to ensure equitable care?

[Addressing health-related disparities] is an ongoing challenge. One aspect of this [problem] is access to care, which has been shown to [impact] outcomes. [For example], if African American men have less access to high quality care, screening initiatives, and educational resources, their outcomes will be affected negatively. There can also be a lack of trust in the health care system, and there's a fair bit of societal stigma associated with prostate cancer that compounds the difficulty here. On top of all these factors, African American men may harbor more aggressive prostate cancer. Therefore, they're dealing with societal [limitations] such as [a lack of disease] education, lack of resources, and travel difficulties, on top of a more biologically aggressive disease.

Awareness efforts from high-profile] individuals like athletes and celebrities have been helpful in shedding light on this common condition. I can't even count how many patients I've had that bring this up as being important for them to raise their own awareness of prostate cancer. Kudos to people in the limelight that are sharing their stories or sharing information and bringing awareness to prostate cancer. Healthcare systems, providers, insurance companies, nonprofits, and even device or pharmaceutical companies involved in prostate cancer all need to collectively be more involved in patient education to raise awareness. It's a team effort.

Have any community-based initiatives or research efforts made meaningful strides towards closing this gap?

The short answer is that there have not been significant initiatives making tremendous differences, unfortunately. There's many hospitals and advocacy groups, including our cancer institute doing a lot of grassroots efforts, targeted education outreach, and regional initiatives to help close some of these gaps. However, I don't necessarily see [these efforts] moving the needle significantly on a national or large scale. [Better] education is needed to address this, but trying to build trust between patients, their physicians, and the healthcare systems that they have access to [is also vital].

It is also important to encourage African American men and other groups where there can be disparities to be involved in more clinical trials, when possible, to try to improve their treatment options into the future. These groups are often underrepresented in trials, so trying to have more inclusion would be beneficial.

There's also the fact that research efforts are challenged by limits to national research funding. Research funding for prostate cancer has traditionally lagged behind some other cancers. For example, breast and prostate cancer both affect a similar number of patients, yet research funding for prostate cancer is only half that of breast cancer. Research funding for prostate and pancreatic cancers are quite similar, despite prostate cancer affecting about 5 times as many men. However, a lot more research will need to be done.

Why is it important to recognize and spread the word about Prostate Cancer Awareness Month?

It's always an important time to talk about prostate cancer awareness, but it is especially [critical right] now, and we still need to raise a lot more awareness. Although we have made significant strides in understanding and [managing] prostate cancer, it's still a disease that affects and kills too many men. We do recommend that men try to seek information that's provided and try to seek multiple opinions.

[Access to care] in a specialty cancer facility or in a multidisciplinary setting can have benefits, especially if you’re looking [to use] more novel therapies or [evaluating] more aggressive cancers that require multimodal treatment. This is where men should be talking to their doctors and trying to see specialists if needed.