RSNA 2016: More research, awareness needed in fight against prostate cancer

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The negative impact of prostate cancer is woefully underestimated by the public, according to Professor and Vice Chair of Radiation Oncology Colleen A. Lawton, MD, of the Medical College of Wisconsin. She reviewed the history of prostate cancer screening and treatment in the Annual Oration in Radiation Oncology address at RSNA 2016.

While famous men such as John Kerry and Robert De Niro have undergone successful treatment and advocated for prostate research afterwards, it still hasn’t reached the awareness of other diseases such as breast cancer, according to Lawton.

“It kills over 27,000 men annually, but we think of it in our country as this disease men really don’t have to worry about,” she said. “By contrast, breast cancer kills more than 40,000 women annually, and we think of it as an epidemic that must be stopped.”

Lawton is all too familiar with this dichotomy—having been involved with prostate cancer research for over 30 years—and believes the flow of research must improve.

A digital rectal exam is an important low-tech screening tool, but often finds the disease in late-stages. Eventually, prostate-specific antigens (PSAs) came along in the late '80s and early '90s, proving to be very popular among oncologists. A bevy of research refined PSA screening—finding age- and race-specific specific PSA densities—and it looked for a period of time that PSA screening was lowering prostate cancer mortality.

“But this was short lived,” said Lawton. “Over the ensuing years, doctors became split over whether screening with PSAs was helpful, because it was diagnosing very early cancers that would never require treatment.”

This resulted in the United States Preventative Services Task Force recommending against PSA screening and men reacted with indifference. However, when the Task Force took a closer look at the efficacy of regular mammography, women fought for funding, signaling to legislators that mammography meant no votes.

“On the prostate cancer side, we clearly have much work to do in the research arena, to come up with the best way to screen,” said Lawton.

Treatment has also vastly improved. For patients with later stage cancer, radiotherapy or surgery can help eradicate disease. For patients with early stage cancer, the best treatment may be no treatment at all! Effective screening can help ensure that treatment only goes to the patients who need it, and active surveillance results in very low disease-specific mortality.

“Despite the early-stage diagnosis in many patients, some patients harbor more concerning disease,” said Lawton. “One area where the diagnostic radiologist has helped the treating radiologist enormously has been the research in MR, helping us distinguish normal from malignant glands.”

Multi-parametric MRI has given radiologists a grading scale for abnormalities, similar to BI-RADS for mammography—it’s even called PI-RADS.

Even in the face of this advancement, Lawton believes there is still enormous potential for diagnostic radiology research in the detection and treatment of prostate cancer.

“Where does the urethra traverse the prostate?” asked Lawton. “Can we view microscopic disease in the lymph nodes and bones? We need more help.”

Lawton called for additional researchers and funding dedicated to prostate cancer research, citing the mere 1.6 percent of the annual NIH budget that goes to radiation oncology research.

“We still have much work to do in getting help from the NIH or NTI,” said Lawton. “We need to keep research going for our families, our friends, our colleagues and our veterans, so as to improve their lives."