Timing of ADT in the Era of STAMPEDE and LATITUDE: What Should You Do with Men You Do Not Biopsy, or Whose Biopsy Is Negative?

Timing of ADT in the Era of STAMPEDE and LATITUDE: What Should You Do with Men You Do Not Biopsy, or Whose Biopsy Is Negative?

In the field of prostate cancer treatment, two recent studies have shed light on important considerations for clinicians. The first study, presented at SIU 2019, examined the timing of androgen deprivation therapy (ADT) in the era of STAMPEDE and LATITUDE trials. The second study, presented at EAU 2020, explored what should be done with men who do not undergo biopsy or have a negative biopsy result. Although these two studies may seem unrelated, they share common points that can be connected naturally, providing valuable insights into prostate cancer management.

Retrospective data from SIU 2019 suggests that abiraterone + prednisone alone, without ADT, effectively suppresses testosterone synthesis in prostate cancer patients. This finding challenges the traditional notion that ADT is necessary for the suppression of testosterone levels. However, it is important to note that antiandrogen monotherapy appears to be less effective than medical and surgical castration and is not recommended as primary ADT.

On the other hand, the EAU 2020 study focuses on patient-centered decision making in the context of prostate cancer diagnosis. It highlights the potential of utilizing magnetic resonance imaging (MRI) to determine the need for biopsy. According to the study, 42% of patients with a PIRADS lesion could avoid biopsy if using a threshold of PSAD > 0.15ng/mL, with only 6% of clinically significant cancers being missed. This demonstrates the value of MRI in reducing unnecessary biopsies and potentially minimizing patient discomfort and complications.

However, it is crucial to consider the different definitions of MRI and clinically significant prostate cancer. There are two definitions of MRI, namely PIRADS < 3 and PIRADS < 4. Similarly, two definitions of clinically significant prostate cancer exist, GGG 2-5 and GGG 3-5. These variations in definitions can impact the accuracy of MRI in determining the need for biopsy. Therefore, careful consideration and consultation with experts are necessary in interpreting MRI results.

Now, let's explore the common points between these two studies. Both studies emphasize the importance of personalized medicine in prostate cancer management. In the SIU 2019 study, the effectiveness of ADT varied depending on the specific treatment modality employed. This highlights the need for individualized treatment plans tailored to each patient's unique circumstances. Similarly, the EAU 2020 study emphasizes the importance of patient-centered decision making by utilizing MRI to guide biopsy decisions. This approach takes into account the individual patient's risk factors, preferences, and the potential risks and benefits of biopsy.

Based on the insights from these studies, here are three actionable pieces of advice for clinicians:

1. Consider alternative approaches to ADT: While traditional ADT remains the gold standard in prostate cancer treatment, the SIU 2019 study suggests that alternative therapies, such as abiraterone + prednisone, may have a role in suppressing testosterone synthesis. However, it is important to consult with experts and consider individual patient factors before deviating from standard treatment protocols.

2. Utilize MRI as a tool for biopsy decision-making: The EAU 2020 study highlights the potential of MRI in reducing unnecessary biopsies. By utilizing a threshold of PSAD > 0.15ng/mL, clinicians can identify patients who may safely avoid biopsy. However, it is crucial to consider the different definitions of MRI and clinically significant prostate cancer to ensure accurate interpretation of results.

3. Embrace patient-centered decision making: Both studies emphasize the importance of tailoring treatment plans and biopsy decisions to each patient's unique circumstances. By involving patients in the decision-making process and considering their preferences, risk factors, and potential risks and benefits, clinicians can provide more personalized and effective care.

In conclusion, the SIU 2019 and EAU 2020 studies offer valuable insights into prostate cancer management. While the SIU study challenges traditional notions of ADT timing, the EAU study highlights the potential of MRI in guiding biopsy decisions. By connecting these common points, we can gain a deeper understanding of personalized medicine in prostate cancer care. By considering alternative approaches to ADT, utilizing MRI as a tool for biopsy decision-making, and embracing patient-centered decision making, clinicians can provide more tailored and effective care to prostate cancer patients.