Prostate Cancer Is Often a Manageable Disease

According to data from the Lithuanian Health Information Center, prostate cancer is the most common malignancy affecting men in Lithuania. At the same time, it is one of the few cancers for which clinically insignificant disease—typically detected at an early stage—does not always require immediate treatment. Instead, active surveillance may be sufficient. For many patients, who are accustomed to hearing that cancer should be treated as early as possible, this approach can be difficult to understand. How should prostate cancer be managed? How do physicians determine which patients require treatment and which can be safely monitored? What advances can patients with advanced disease expect? We discussed these questions with Prof. Mindaugas Jievaltas, Head of the Department of Urology at the Lithuanian University of Health Sciences.

There has been considerable discussion about prostate cancer in recent years. Can it be said that the disease is now diagnosed earlier and that more patients are being cured?

Over the past 10–15 years, both worldwide and in Lithuania, physicians have been diagnosing an increasing number of early-stage prostate cancers. In Lithuania, approximately 60–70% of newly diagnosed cases are detected at stages I and II. In fact, even many stage III cases are considered early because these patients may still be candidates for radical treatment.

In my opinion, the discovery of the prostate-specific antigen (PSA) marker represented a major breakthrough in prostate cancer diagnostics. In addition, Lithuania's national prostate cancer early detection program, which has been in place for the past seven years, has contributed significantly to earlier diagnosis.

This trend is encouraging for the urological community because earlier detection enables us to offer patients a wider range of effective treatment options. However, early diagnosis has also created a new challenge. We now know that not every prostate cancer requires treatment. Today, physicians face the difficult task of distinguishing patients who require intervention from those who can be safely monitored. In other words, only aggressive, life-threatening forms of prostate cancer should be treated.

The real diagnostic challenge is therefore no longer detecting prostate cancer early, but identifying which tumors are biologically aggressive. At present, there are still no definitive criteria for selecting patients with truly aggressive, life-threatening disease. It is hoped that biological markers will soon help identify these patients more accurately. Urologists have high expectations for these emerging diagnostic tools.

You mentioned that genetic markers may help distinguish patients who require treatment from those who can be managed with surveillance. Could you elaborate?

At present, there are no genetic markers that can be routinely used in clinical practice, although research in this field is progressing rapidly. Scientists are investigating genes such as BRCA2, PCA3, and several others, but it is still too early to define their exact clinical role in prostate cancer management.

The PCA3 gene has been studied extensively and is already mentioned in some clinical recommendations. However, it is currently used mainly in research settings rather than routine clinical practice. According to recent findings, PCA3 testing may prove particularly valuable during the diagnostic stage by helping identify patients who are at increased risk of developing aggressive prostate cancer.

Quite often, patients present with elevated PSA levels but negative prostate biopsy results. Despite the absence of detectable cancer on biopsy, these individuals remain at increased risk of developing prostate cancer. Once PCA3 testing becomes part of routine practice, such patients could undergo additional evaluation, allowing physicians to identify those at substantially higher risk of developing not only prostate cancer but also its more aggressive forms.

Testing for BRCA2 mutations may also be valuable, particularly in hereditary prostate cancer, as it can help identify men with an increased genetic risk of developing the disease.

The national prostate cancer early detection program has generated some controversy. Do you believe it is justified, or are there alternative methods for detecting early prostate cancer?

Criticism of prostate cancer screening programs largely stems from the fact that many clinically insignificant or low-risk cancers are detected. These tumors often do not require treatment, yet many patients still undergo surgery or radiation therapy. Since these treatments are expensive and associated with potential side effects, an important question arises: would these patients have lived just as long without radical treatment?

According to urologists, nearly half of all patients diagnosed with stage I or II prostate cancer could be managed with active surveillance for five to ten years without receiving immediate treatment. Active surveillance involves regular PSA testing every three to six months and repeat prostate biopsy every two to three years. Using this approach, approximately 60–70% of monitored patients could avoid radical treatment altogether.

In other words, many of these men would live normal lives and ultimately die from causes unrelated to prostate cancer, such as myocardial infarction, stroke, or other illnesses.

Active surveillance is already practiced in Lithuania. Although precise epidemiological data are unavailable, I estimate that approximately 15% of newly diagnosed prostate cancer patients could currently be managed in this way. I expect this proportion to increase in the future.

Are there any important innovations in prostate cancer diagnostics? Has positron emission tomography (PET) become part of routine clinical practice?

At present, PET imaging is not routinely used for prostate cancer diagnosis, although it remains a very promising technique. Researchers are evaluating various PET tracers in an effort to determine whether metastatic spread to regional lymph nodes can be detected more accurately.

Studies have demonstrated encouraging sensitivity and specificity, but PET imaging has not yet become part of the routine diagnostic arsenal for prostate cancer.

For early-stage prostate cancer, patients may be managed with active surveillance or offered one of two radical treatment options: surgery (radical prostatectomy) or radiotherapy. Patients diagnosed with advanced prostate cancer are generally treated with hormone therapy, which aims to prolong survival rather than achieve a cure. Naturally, the chances of complete recovery are greatest when the disease is diagnosed at an early stage.

Is there effective treatment for advanced prostate cancer? Could you comment on the latest treatment options and whether they are available to patients in Lithuania?

Treatment options for advanced prostate cancer have improved considerably in recent years. The standard treatment for metastatic prostate cancer remains androgen deprivation therapy, which suppresses the body's natural production of testosterone by the testes. This approach has been used in clinical practice for 30–40 years, and the researchers who pioneered hormonal treatment for prostate cancer were awarded the Nobel Prize.

Since then, substantial advances have been made, with several new hormonal therapies becoming available. One of the most promising is abiraterone acetate. It can be used in hormone-sensitive disease as well as in castration-resistant prostate cancer when the disease continues to progress despite chemotherapy.

Discussions with the National Health Insurance Fund regarding reimbursement of abiraterone acetate have been ongoing. The drug was considered for reimbursement last year, and discussions have continued this year with the aim of including it among reimbursed medications.

Patients with advanced prostate cancer therefore have reason for optimism. Several entirely new classes of drugs with different mechanisms of action are becoming available. These include next-generation antiandrogens, and additional agents such as enzalutamide are currently undergoing clinical evaluation and are attracting considerable attention at international scientific meetings.

What are the latest developments in prostate cancer management that are particularly relevant for family physicians? How can they contribute to patient care?

Family physicians play a crucial role in the early detection of prostate cancer. They should inform eligible patients about the national screening program and recommend PSA testing when appropriate. Much of the improvement in early diagnosis has been possible because of their involvement.

An important recent development is that family physicians are now authorized to order PSA testing for patients who have already been diagnosed with prostate cancer. This change was introduced by an order issued by the Minister of Health in April 2013. Previously, only specialists could request these tests. Although the order does not specify the maximum number of PSA tests that may be performed each year, it clearly allows at least one reimbursed test annually.

Family physicians also frequently monitor patients who are being treated by urologists. They are often the first to notice signs of disease progression, such as worsening bone pain or declining kidney function. In such cases, patients should be referred promptly to a urologist so that treatment can be reassessed.

For this reason, family physicians should be familiar with the general principles of prostate cancer management, recognize signs of disease progression, and ensure timely referral to specialist care.

Are there any plans to update prostate cancer treatment guidelines in the near future?

Lithuanian urologists currently follow the European Association of Urology (EAU) Guidelines on Prostate Cancer, which have been translated into Lithuanian. The Ministry of Health has proposed adapting these guidelines specifically for Lithuania.

In my opinion, this would be unnecessary. The European guidelines are already widely accepted and successfully used by Lithuanian urologists. There is little value in creating separate national recommendations when comprehensive European guidelines already exist. Moreover, the EAU guidelines are reviewed and updated annually, something that would be difficult to achieve with a separate national document.

A more important issue concerns reimbursement policies. In 2011, Lithuania approved an algorithm governing reimbursement for prostate cancer diagnostics and treatment. It is a modern framework that continues to guide decisions regarding access to reimbursed medications.

Which new treatments and medications are expected to become available in the future?

As I mentioned earlier, the most important developments involve next-generation antiandrogen therapies, including abiraterone acetate, enzalutamide, and ipilimumab. Other promising treatments, such as cabazitaxel and radium-223, have already entered routine clinical practice in the United States and several European countries, and we hope they will eventually become available in Lithuania as well.

Another exciting development is the successful evaluation of a therapeutic vaccine in the United States for patients with advanced prostate cancer and bone metastases. This personalized approach allows physicians to create an individualized vaccine tailored to each patient's disease, helping to slow cancer progression.

New medications have also been introduced for the treatment of bone metastases, including denosumab. Overall, most recent advances have focused on patients with advanced prostate cancer. These innovations provide physicians with more therapeutic options and offer patients the opportunity to live both longer and with a better quality of life.

There has also been discussion about prostate cancer prevention, particularly regarding foods such as coffee, milk, or tomatoes. What is your opinion on this?

Unfortunately, the exact causes of prostate cancer remain unclear, making effective prevention difficult.

Several risk factors are well established. Age is one of the strongest, but it is obviously beyond our control. Race is another, with African American men having a higher risk of developing prostate cancer. Heredity also plays a major role. Men whose fathers or grandfathers had prostate cancer—particularly if they died from the disease—have a five- to eightfold higher risk than men without such a family history. Unfortunately, genetic predisposition cannot be changed.

In my opinion, early detection remains the most effective preventive strategy currently available. However, as we discussed earlier, early diagnosis also creates a new challenge. Some patients diagnosed with clinically insignificant prostate cancer undergo unnecessary treatment when active surveillance would be sufficient. At the same time, many patients find it psychologically difficult to accept a cancer diagnosis without immediate treatment and therefore request intervention.

Regarding diet, I would emphasize that there is currently no convincing scientific evidence that any particular food reduces the risk of prostate cancer. The protective effects of selenium, green tea, tomatoes, and other commonly suggested foods have not been confirmed in high-quality studies. Recent review articles likewise conclude that because the underlying causes of prostate cancer remain poorly understood, no dietary strategy has been proven effective for prevention.

General recommendations for cancer prevention remain appropriate. Avoiding smoking and minimizing exposure to harmful environmental factors continue to be among the most important measures for reducing overall cancer risk.

Thank you for your time.

Interview by Natalija Voronaja.