Clinical States Treatment Model

Some men may not have a diagnosis of prostate cancer, but because they have an elevated or rising PSA or a family history of the disease, they are at higher risk of developing the disease. Men in this state are closely watched and undergo regular digital rectal examinations and PSA testing.

Memorial Sloan-Kettering is one of the few cancer centers that offer a computer-assisted family history analysis. Our genetic counselors can help men whose family histories suggest an increased risk of hereditary prostate cancer, as well as their family members, to further evaluate their risk.

As a result of widespread PSA testing, men whose prostate cancer is seemingly confined to the prostate now make up the largest group of prostate cancer patients. Their disease may be curable with therapy directed solely at the prostate. Physicians carefully assess the patient's disease and stratify his risk to determine the best treatment choice. Treatment ranges from watchful waiting (also called active surveillance or deferred therapy) to radiation or surgery. For patients with localized disease who are unlikely to be cured through these approaches, we offer multimodality therapy combining hormonal and/or systemic therapy and radiation.

Researchers here are also beginning to use new treatment combinations for patients with high-risk disease. These include chemotherapy with either hormonal therapy, radiation therapy, or surgery in patients whose cancers do not appear to have spread, but who, judging by various test results, have a poor prognosis if they were to receive radiation therapy or surgery alone.

Men whose PSA levels rise after treatment comprise the second largest segment of the prostate cancer population. For these patients, therapy is directed toward preventing the disease from progressing to the point that it is detectable on a scan or by physical examination, or from becoming symptomatic.

Patients with rising PSA levels have unique clinical needs. For some, the rising PSA represents the first evidence that the cancer is no longer confined to the prostate, the prostate bed, or even the pelvis, and may now be a systemic problem (cancer that has spread throughout the body). For others, the rising PSA may signify persistent disease that is local. Our physicians can help distinguish one circumstance from the other. This distinction can be difficult to make, as frequently the increase in PSA level is the only evidence of disease activity.

For men with locally persistent disease, therapeutic approaches may include observation alone or further treatments to the prostate or the prostate bed. Some patients in this group who have undergone surgery to remove the prostate (prostatectomy) will benefit from further radiation therapy, and some who have received radiation therapy will benefit from salvage surgery, while others will require systemic treatment. Our team is expert at determining who will benefit most from which approach and has defined optimal care for these patients.

For men with systemic disease (cancer that has spread throughout the body), men face a broad set of choices depending on the risk that their disease presents. For those at high risk, aggressive therapies may be warranted; for others, watchful waiting may be the best approach. Our team of experts can guide a patient into the track appropriate to his situation based on his needs, priorities, and preferences.

Researchers at Memorial Sloan-Kettering are at the forefront of efforts to define which type or combination of treatments is likely to be most effective for these patients, tailored specifically to the risks that the rising PSA may portend. We offer patients in this group a range of clinical trials of new approaches, which are also risk-adapted, from vaccine therapy to hormonal therapy to chemotherapy to biologic treatments.

Our Clinical Trials Learn more about our clinical trials for prostate cancer more

Physicians at Memorial Sloan-Kettering consider a variety of treatment options for men who are diagnosed with metastatic disease (cancer that has spread from the prostate to other sites) and whose testosterone levels are normal. Most patients in this group will receive hormonal therapy, which is not curative but can slow the progress of the disease. We are also looking into novel ways to incorporate chemotherapy or to harness the immune system to enhance the effects of hormonal therapy. Our medical oncologists and basic scientists have a number of collaborative research efforts under way to improve the outlook for this group of patients.

In some men, prostate cancer continues to spread after therapy is administered to lower the level of testosterone in the blood. These tumors differ on a molecular level from other metastatic prostate tumors.

Treatments for this group of patients can include additional hormonal therapies, chemotherapy, or, for those who are eligible, investigational approaches available through clinical trials. Treatments are tailored to the individual based on the aggressiveness of his cancer and the predicted molecular profile of his disease. Our basic scientists and clinicians are at the forefront of developing new drugs for these patients. These efforts have resulted in new generations of hormonal therapies, the testing of new biologic therapies and bone-directed treatments, and novel methods of identifying patients' unique biology through molecular imaging and detection of circulating tumor cells. (To learn more about our research efforts, visit the lab pages of Dr. Charles Sawyer and Dr. Neal Rosen.)

Therapies for patients with metastatic disease who do not respond to hormonal treatments are not curative, but are designed to slow, control, or reverse progression of the disease, as well as to promote quality of life.

Patients whose disease is resistant to testosterone-reducing therapy fall into two groups:

• Men who may not need chemotherapy; who might not have yet received it; or having received it are not resistant to it
• Men who have received but are no longer responsive to active chemotherapy

The needs, risks, and disease manifestations of the members of each of these groups differ. Our approach, both in terms of treating the cancer and supportive care, is tailored accordingly. For patients for whom chemotherapy may not be appropriate, we are developing new hormonal therapies and other non-chemotherapeutic approaches. For those who require chemotherapy, we are developing more potent chemotherapy combinations. For those resistant to chemotherapy, we are developing drugs that treat the disease by methods that are based on the newest scientific research in prostate cancer biology. We are focused on finding new therapies for these patients that both extend and improve life. [LINK to Trials] Because prostate cancer can be slow-growing and have a prolonged natural history, many patients in this clinical state live a long life.

In addition, our medical oncologists, psychiatrists, pain and palliative care specialists, surgeons, and radiation oncologists work together as a team to treat the physical and psychological effects of disease among these patients.

¹Scher HI, Heller G. Clinical states in prostate cancer: toward a dynamic model of disease progression. Urology. 2000 Mar;55(3):323-7. [PubMed Abstract]