Prostate Cancer

Only about 5% of hereditary prostate cancer (HPC) cases can be explained by known genetic variants, but a groundbreaking US Department of Veterans Affairs (VA) study could revolutionize the diagnosis, prevention, and treatment of HPC in a similar fashion that the discovery of the BRAC2 gene did in breast cancer.

The study, conducted at the VA Tennessee Valley Healthcare System in accordance with Vanderbilt University Medical Center and the VA Million Veteran Program (MVP), linked variants of the WNT9B gene with a greater risk of prostate cancer.

About 15,000 veterans are diagnosed with prostate cancer and treated at the VA annually, and > 200,000 veterans are prostate cancer survivors. According to Bruce Montgomery, MD, an oncologist with VA Puget Sound Health Care System, “Veterans are unique in that those men exposed to Agent Orange during the Vietnam War are at elevated risk for prostate cancer.” Montgomery added that germline pathogenic variants in genes such as BRCA2 and HOXB13 are other risk factors.

This genome-wide study searched for recurrently observed variants that carried the most risk. The study gathered data from a familial case-control population in the Nashville Familial Prostate Cancer Study (NFPCS) and International Consortium for Prostate Cancer Genetics (ICPCG). For evidence of replication, the study turned to 4 biobanks: the MVP, All of Us, the UK Biobank, and FinnGen.

The NFPCS is a case-control study based on family history. Patients included those undergoing treatment for prostate cancer and controls undergoing routine screening at Vanderbilt University Medical Center and the Nashville VA Medical Center between 2003 and 2009. Patients were included in the analysis if they had also had a first- or second-degree relative with prostate cancer. 

The ICPCG dataset encompasses unrelated HPC cases aggregated from 12 study sites across Finland, France, Germany, the UK, and the US. The MVP is the nation’s largest biorepository of veteran data and has one of the world’s most diverse cohorts of any genetic research program. More than 1 million veterans are enrolled, and 800-plus researchers are working on > 100 projects.

Pathogenic variants of only 2 genes met the replication requirement with genome-wide significance: HOXB13 and WNT9B. HOXB13 has been reported on in the literature, but this is the first study to investigate WNT9B.

Researchers identified 2 variants of the WNT9B gene: WNT9B E152K carried 2.5-fold risk and reached genome-wide significance under meta-analysis, collectively encompassing one-half million patients. The association of WNT9B E152K with prostate cancer was supported by the familial study populations and each biobank, with genome-wide significance. Variant WNT9B Q47R reached genome-wide significance in the Finnish study. The Q47R founder haplotype was also carried by familial prostate cancer cases in the US and UK.

Autosomal dominant WNT9B pathogenic variants are already known to cause embryonic developmental sequence defects, leading later to prostatic cysts, enlarged prostate, and seminal vesicle cysts. Seminal vesicle adenocarcinoma (or squamous cell carcinoma) and clear cell carcinoma of the prostate have also been reported. 

The study found that HOXB13 and WNT9B “share an unexpected commonality.” Both genes function in embryonic genitourinary development. WNT9B pathogenic variants cause the autosomal dominant Mayer-Rokitansky-Küster-Hauser syndrome, featuring genitourinary developmental defects. The study concluded: “Collectively, our observations implicate inherited variation in pathways guiding embryonic genitourinary development in the development of prostate cancer.”

“Significant investments” in VA-specific clinical trials recently have been pursued through a joint agreement between the VA and the Prostate Cancer Foundation, Montgomery said: “The Prostate Cancer Foundation is supporting tumor and germline sequencing of prostate cancer for veterans with advanced disease and providing resources to set up research infrastructure at 10 centers nationwide.” 

The VA has also published a prostate cancer clinical pathway and is in the process of creating a national prostate cancer registry. Such a database, as well as the MVP are both unique to the VA and key to research such as the Predicting Metastatic Progression of High Risk Localized Prostate Cancer study, which began in 2023. Five VA medical centers are collaborating on an artificial intelligence algorithm that will detect patterns indicative of aggressive prostate cancer. 

“A digital repository for data will allow for development, testing, and validation of prognostic classifiers that could positively impact clinical management of veterans with high-risk prostate cancer,” said Matthew Rettig, MD, chief of oncology and hematology at the Greater Los Angeles VA Medical Center who was coprincipal investigator for the study. “The infrastructure developed by this research will serve as a valuable hub for future discovery.”

About 12% of men with metastatic prostate cancer carry a pathogenic germline alteration that could warrant the use of PARP (poly [ADP-ribose] polymerase) inhibitors or platinum chemotherapy, neither of which is part of standard care. National Comprehensive Cancer Network guidelines recommend germline testing in men with metastatic prostate cancer. In addition, “the family members of veterans who carry these alterations could benefit from undergoing testing and taking advantage of potentially life-saving interventions and surveillance strategies if they are also carriers,” Montgomery wrote.

The VA is committed to improving access to germline testing for men with metastatic prostate cancer in several ways. Montgomery pointed to the system-wide VA genetic counseling and testing resource, the Genomic Medicine Service, and said somatic testing is available across the VA through the National Precision Oncology Program. Both programs can be extremely important to veterans because they provide access to precision oncology studies, along with off-label use of effective treatments. 

Precision oncology is the most rapidly moving area in prostate cancer, according to Montgomery. “In the VA, this has been embraced as a very specific need to find these therapeutic options for all veterans as quickly as possible. I am most excited by how the enthusiasm for these approaches is supported at all levels, both nationally and locally, because it makes implementing very significant changes to research and treatment possible.”

Only about 5% of hereditary prostate cancer (HPC) cases can be explained by known genetic variants, but a groundbreaking US Department of Veterans Affairs (VA) study could revolutionize the diagnosis, prevention, and treatment of HPC in a similar fashion that the discovery of the BRAC2 gene did in breast cancer.

The study, conducted at the VA Tennessee Valley Healthcare System in accordance with Vanderbilt University Medical Center and the VA Million Veteran Program (MVP), linked variants of the WNT9B gene with a greater risk of prostate cancer.

About 15,000 veterans are diagnosed with prostate cancer and treated at the VA annually, and > 200,000 veterans are prostate cancer survivors. According to Bruce Montgomery, MD, an oncologist with VA Puget Sound Health Care System, “Veterans are unique in that those men exposed to Agent Orange during the Vietnam War are at elevated risk for prostate cancer.” Montgomery added that germline pathogenic variants in genes such as BRCA2 and HOXB13 are other risk factors.

This genome-wide study searched for recurrently observed variants that carried the most risk. The study gathered data from a familial case-control population in the Nashville Familial Prostate Cancer Study (NFPCS) and International Consortium for Prostate Cancer Genetics (ICPCG). For evidence of replication, the study turned to 4 biobanks: the MVP, All of Us, the UK Biobank, and FinnGen.

The NFPCS is a case-control study based on family history. Patients included those undergoing treatment for prostate cancer and controls undergoing routine screening at Vanderbilt University Medical Center and the Nashville VA Medical Center between 2003 and 2009. Patients were included in the analysis if they had also had a first- or second-degree relative with prostate cancer. 

The ICPCG dataset encompasses unrelated HPC cases aggregated from 12 study sites across Finland, France, Germany, the UK, and the US. The MVP is the nation’s largest biorepository of veteran data and has one of the world’s most diverse cohorts of any genetic research program. More than 1 million veterans are enrolled, and 800-plus researchers are working on > 100 projects.

Pathogenic variants of only 2 genes met the replication requirement with genome-wide significance: HOXB13 and WNT9B. HOXB13 has been reported on in the literature, but this is the first study to investigate WNT9B.

Researchers identified 2 variants of the WNT9B gene: WNT9B E152K carried 2.5-fold risk and reached genome-wide significance under meta-analysis, collectively encompassing one-half million patients. The association of WNT9B E152K with prostate cancer was supported by the familial study populations and each biobank, with genome-wide significance. Variant WNT9B Q47R reached genome-wide significance in the Finnish study. The Q47R founder haplotype was also carried by familial prostate cancer cases in the US and UK.

Autosomal dominant WNT9B pathogenic variants are already known to cause embryonic developmental sequence defects, leading later to prostatic cysts, enlarged prostate, and seminal vesicle cysts. Seminal vesicle adenocarcinoma (or squamous cell carcinoma) and clear cell carcinoma of the prostate have also been reported. 

The study found that HOXB13 and WNT9B “share an unexpected commonality.” Both genes function in embryonic genitourinary development. WNT9B pathogenic variants cause the autosomal dominant Mayer-Rokitansky-Küster-Hauser syndrome, featuring genitourinary developmental defects. The study concluded: “Collectively, our observations implicate inherited variation in pathways guiding embryonic genitourinary development in the development of prostate cancer.”

“Significant investments” in VA-specific clinical trials recently have been pursued through a joint agreement between the VA and the Prostate Cancer Foundation, Montgomery said: “The Prostate Cancer Foundation is supporting tumor and germline sequencing of prostate cancer for veterans with advanced disease and providing resources to set up research infrastructure at 10 centers nationwide.” 

The VA has also published a prostate cancer clinical pathway and is in the process of creating a national prostate cancer registry. Such a database, as well as the MVP are both unique to the VA and key to research such as the Predicting Metastatic Progression of High Risk Localized Prostate Cancer study, which began in 2023. Five VA medical centers are collaborating on an artificial intelligence algorithm that will detect patterns indicative of aggressive prostate cancer. 

“A digital repository for data will allow for development, testing, and validation of prognostic classifiers that could positively impact clinical management of veterans with high-risk prostate cancer,” said Matthew Rettig, MD, chief of oncology and hematology at the Greater Los Angeles VA Medical Center who was coprincipal investigator for the study. “The infrastructure developed by this research will serve as a valuable hub for future discovery.”

About 12% of men with metastatic prostate cancer carry a pathogenic germline alteration that could warrant the use of PARP (poly [ADP-ribose] polymerase) inhibitors or platinum chemotherapy, neither of which is part of standard care. National Comprehensive Cancer Network guidelines recommend germline testing in men with metastatic prostate cancer. In addition, “the family members of veterans who carry these alterations could benefit from undergoing testing and taking advantage of potentially life-saving interventions and surveillance strategies if they are also carriers,” Montgomery wrote.

The VA is committed to improving access to germline testing for men with metastatic prostate cancer in several ways. Montgomery pointed to the system-wide VA genetic counseling and testing resource, the Genomic Medicine Service, and said somatic testing is available across the VA through the National Precision Oncology Program. Both programs can be extremely important to veterans because they provide access to precision oncology studies, along with off-label use of effective treatments. 

Precision oncology is the most rapidly moving area in prostate cancer, according to Montgomery. “In the VA, this has been embraced as a very specific need to find these therapeutic options for all veterans as quickly as possible. I am most excited by how the enthusiasm for these approaches is supported at all levels, both nationally and locally, because it makes implementing very significant changes to research and treatment possible.”

Only about 5% of hereditary prostate cancer (HPC) cases can be explained by known genetic variants, but a groundbreaking US Department of Veterans Affairs (VA) study could revolutionize the diagnosis, prevention, and treatment of HPC in a similar fashion that the discovery of the BRAC2 gene did in breast cancer.

The study, conducted at the VA Tennessee Valley Healthcare System in accordance with Vanderbilt University Medical Center and the VA Million Veteran Program (MVP), linked variants of the WNT9B gene with a greater risk of prostate cancer.

About 15,000 veterans are diagnosed with prostate cancer and treated at the VA annually, and > 200,000 veterans are prostate cancer survivors. According to Bruce Montgomery, MD, an oncologist with VA Puget Sound Health Care System, “Veterans are unique in that those men exposed to Agent Orange during the Vietnam War are at elevated risk for prostate cancer.” Montgomery added that germline pathogenic variants in genes such as BRCA2 and HOXB13 are other risk factors.

This genome-wide study searched for recurrently observed variants that carried the most risk. The study gathered data from a familial case-control population in the Nashville Familial Prostate Cancer Study (NFPCS) and International Consortium for Prostate Cancer Genetics (ICPCG). For evidence of replication, the study turned to 4 biobanks: the MVP, All of Us, the UK Biobank, and FinnGen.

The NFPCS is a case-control study based on family history. Patients included those undergoing treatment for prostate cancer and controls undergoing routine screening at Vanderbilt University Medical Center and the Nashville VA Medical Center between 2003 and 2009. Patients were included in the analysis if they had also had a first- or second-degree relative with prostate cancer. 

The ICPCG dataset encompasses unrelated HPC cases aggregated from 12 study sites across Finland, France, Germany, the UK, and the US. The MVP is the nation’s largest biorepository of veteran data and has one of the world’s most diverse cohorts of any genetic research program. More than 1 million veterans are enrolled, and 800-plus researchers are working on > 100 projects.

Pathogenic variants of only 2 genes met the replication requirement with genome-wide significance: HOXB13 and WNT9B. HOXB13 has been reported on in the literature, but this is the first study to investigate WNT9B.

Researchers identified 2 variants of the WNT9B gene: WNT9B E152K carried 2.5-fold risk and reached genome-wide significance under meta-analysis, collectively encompassing one-half million patients. The association of WNT9B E152K with prostate cancer was supported by the familial study populations and each biobank, with genome-wide significance. Variant WNT9B Q47R reached genome-wide significance in the Finnish study. The Q47R founder haplotype was also carried by familial prostate cancer cases in the US and UK.

Autosomal dominant WNT9B pathogenic variants are already known to cause embryonic developmental sequence defects, leading later to prostatic cysts, enlarged prostate, and seminal vesicle cysts. Seminal vesicle adenocarcinoma (or squamous cell carcinoma) and clear cell carcinoma of the prostate have also been reported. 

The study found that HOXB13 and WNT9B “share an unexpected commonality.” Both genes function in embryonic genitourinary development. WNT9B pathogenic variants cause the autosomal dominant Mayer-Rokitansky-Küster-Hauser syndrome, featuring genitourinary developmental defects. The study concluded: “Collectively, our observations implicate inherited variation in pathways guiding embryonic genitourinary development in the development of prostate cancer.”

“Significant investments” in VA-specific clinical trials recently have been pursued through a joint agreement between the VA and the Prostate Cancer Foundation, Montgomery said: “The Prostate Cancer Foundation is supporting tumor and germline sequencing of prostate cancer for veterans with advanced disease and providing resources to set up research infrastructure at 10 centers nationwide.” 

The VA has also published a prostate cancer clinical pathway and is in the process of creating a national prostate cancer registry. Such a database, as well as the MVP are both unique to the VA and key to research such as the Predicting Metastatic Progression of High Risk Localized Prostate Cancer study, which began in 2023. Five VA medical centers are collaborating on an artificial intelligence algorithm that will detect patterns indicative of aggressive prostate cancer. 

“A digital repository for data will allow for development, testing, and validation of prognostic classifiers that could positively impact clinical management of veterans with high-risk prostate cancer,” said Matthew Rettig, MD, chief of oncology and hematology at the Greater Los Angeles VA Medical Center who was coprincipal investigator for the study. “The infrastructure developed by this research will serve as a valuable hub for future discovery.”

About 12% of men with metastatic prostate cancer carry a pathogenic germline alteration that could warrant the use of PARP (poly [ADP-ribose] polymerase) inhibitors or platinum chemotherapy, neither of which is part of standard care. National Comprehensive Cancer Network guidelines recommend germline testing in men with metastatic prostate cancer. In addition, “the family members of veterans who carry these alterations could benefit from undergoing testing and taking advantage of potentially life-saving interventions and surveillance strategies if they are also carriers,” Montgomery wrote.

The VA is committed to improving access to germline testing for men with metastatic prostate cancer in several ways. Montgomery pointed to the system-wide VA genetic counseling and testing resource, the Genomic Medicine Service, and said somatic testing is available across the VA through the National Precision Oncology Program. Both programs can be extremely important to veterans because they provide access to precision oncology studies, along with off-label use of effective treatments. 

Precision oncology is the most rapidly moving area in prostate cancer, according to Montgomery. “In the VA, this has been embraced as a very specific need to find these therapeutic options for all veterans as quickly as possible. I am most excited by how the enthusiasm for these approaches is supported at all levels, both nationally and locally, because it makes implementing very significant changes to research and treatment possible.”

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication

TOPLINE: A small study of veterans found that high-intensity focused ultrasound (HIFU) demonstrated similar oncologic outcomes when compared to standard treatments for localized prostate cancer, while maintaining erectile and urinary function. 

METHODOLOGY: 

•      A retrospective analysis at the Michael E. DeBakey Veterans Affairs Medical Center in Houston between 2018 and 2022, with data acquired from electronic health record.
•      A total of 43 veterans were included in the analysis; 31 patients (72%) receiving primary treatment and 12 patients (28%) receiving salvage therapy.
•      Patient risk stratification was performed using prostate specific antigen (PSA), Gleason Score, and clinical stage based on National Comprehensive Cancer Network and D'Amico criteria.
•      Follow-up assessments included serial PSA measurements at 3, 6, 12, 18, and 24 months, with functional outcomes evaluated through Sexual Health Inventory for Men and American Urological Association Symptom Score questionnaires.

TAKEAWAY:

•       The 31 patients in the primary treatment group had a median PSA nadir of 0.16, while the 12 patients in the salvage therapy group had a median PSA nadir of 0.12, with median follow-up periods of 23 and 25 months, respectively.
•       Local recurrence rates were comparable between groups, occurring in 5 patients (16%) in the primary group and 2 (17%) in the salvage group.
•       Sexual Health Inventory for Men scores and American Urological Association Symptom Score showed no statistically significant differences before and after HIFU therapy in both groups (P = .35). > .05).
•       Short- and intermediate-term results demonstrated HIFU's effectiveness in maintaining potency and urinary function while providing adequate oncological control for both primary and salvage therapies.
•      Two patients (7%) from the primary treatment group experienced 30-day complications, including one case of epididymo-orchitis and 1 case of urethral stricture.
•      Three patients (25%) from the salvage treatment group experienced 30-day complications, including one bladder neck contracture.

IN PRACTICE: "The application of HIFU in a veteran population is of particular interest due to the unique medical challenges this group faces. Veterans often present with complex medical conditions and a higher comorbidity burden compared to the general population, as indicated by a median Charleson Comorbidity Index of 7 in our primary HIFU group," wrote the authors of the study. 

SOURCE: The study was led by Sagar Patel and Ali Antar, Operative Care Line, Urology Section, Michael E. DeBakey Veteran Affairs Medical Center in Houston. It was published online in Life.

 LIMITATIONS: The study's relatively short median follow-up period of 23-25 months limits the assessment of long-term oncological outcomes in prostate cancer. The sample size, while substantial for an initial series, remains modest, particularly for the salvage therapy group. According to the authors, larger multi-center studies with longer follow-up periods will be necessary to confirm and extend these findings, especially for establishing the durability of oncological control and functional preservation. 

DISCLOSURES: The study received no external funding. The research was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Board in February 2024. Support was obtained from the Prostate Cancer Foundation-VALOR Challenge Program. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication

Overtreatment of men with prostate cancer and limited life expectancy (LE) has persisted in the era of active surveillance and worsened in some instances, according to a new study of nearly 250,000 veterans.

“Overtreatment of men with limited longevity for intermediate- and high-risk tumors has not only failed to improve but has actually worsened over the last 20 years,” Timothy Daskivich, MD, MSHPM, with Cedars-Sinai Medical Center, Los Angeles, said in an interview.

“Many doctors assume that the increase in uptake of active surveillance for low-risk prostate cancers has solved the problem of overtreatment, but this trend has not affected overtreatment of men with low likelihood of living long enough to benefit from treatment who have higher-risk tumors,” Daskivich said.

The study was published online on November 11 in JAMA Internal Medicine.

‘Concerning’ Real-World Data

For men with low- and intermediate-risk prostate cancer expected to live fewer than 10 years, prostate cancer screening and aggressive treatment are not recommended.

Daskivich and colleagues analyzed data on 243,928 men (mean age, 66 years) in the Veterans Affairs (VA) Health System with clinically localized prostate cancer diagnosed between 2000 and 2019.

About 21% had LE < 10 years, and about 4% had LE < 5 years, according to the validated age-adjusted Prostate Cancer Comorbidity Index.

Overtreatment was defined as aggressive treatment (surgery or radiation) in those with LE < 10 years and low- to intermediate-risk disease and in those with LE < 5 years and high-risk disease, in line with current guidelines.

Among men with LE < 10 years, the proportion of men overtreated with surgery or radiotherapy for low-risk disease decreased 22% but increased 22% for intermediate-risk disease during the study period.

Among men with LE < 5 years, the proportion of men treated with definitive treatment for high-risk disease increased 29%.

“While lower-risk tumors are treated less aggressively across the board, including in men with limited longevity, it seems that we are more indiscriminately treating men with higher-risk disease without considering their expected longevity,” Daskivich said, in an interview.

Is This Happening in the General US Population?

Daskivich noted that the sample included a large sample of men diagnosed with localized prostate cancer in the VA Health System.

“Rates of overtreatment are likely to be lower in the VA [Health System], so the problem may be worse in the community setting. The VA [Health System] has been exemplary in its uptake of active surveillance for low-risk cancers, leading the effort to reduce overtreatment of men with low-risk cancers. However, the problem of overtreatment of men with limited longevity persists in the VA [Health System], underscoring the pervasiveness of this problem,” he explained.

“We don’t have a perfect head-to-head comparison of overtreatment in the VA setting vs in the community. [However, one study shows] that this is not a VA-specific phenomenon and that there is an increase in overtreatment of men with limited longevity in a Medicare population as well,” Daskivich noted.

Is Overtreatment All Bad?

Overtreatment of prostate cancer, especially in cases where the cancer is unlikely to progress or cause symptoms, can lead to significant physical, psychological, and financial harms, Christopher Anderson, MD, urologist with Columbia University Irving Medical Center in New York City, who wasn’t involved in the study, noted in an interview.

In the study by Daskivich and colleagues, over three quarters of the overtreatment was radiation therapy, which carries the risk for urinary, bowel, and sexual issues.

“Overscreening, which can lead to overtreatment, is a core issue,” Anderson said. It’s easy to order a “simple” prostate-specific antigen blood test, but in an older man with limited LE, that can lead to a host of further testing, he commented.

Stopping the pipeline of overscreening that then feeds into the cascade of overtreatment is the first step in addressing the problem of prostate cancer overtreatment, Nancy Li Schoenborn, MD, MHS, with Johns Hopkins University School of Medicine, Baltimore, and Louise C. Walter, MD, with University of California San Francisco, wrote in an editorial in JAMA Internal Medicine.

Considering LE during screening decision-making is “fundamental to reducing harms of prostate cancer overdiagnosis and overtreatment” because limited LE increases the likelihood of experiencing “harms all along the diagnostic and treatment cascade following screening,” the editorial writers said.

The time spent diagnosing, monitoring, and treating asymptomatic prostate cancer in men with limited LE distracts from monitoring and treating chronic symptomatic life-limiting illnesses, they noted.

Tough to Talk About?

Anderson noted that, in general, doctors are not great at estimating and counseling patients on LE. “It’s sometimes difficult to have that conversation,” he said.

Daskivich said physicians may fail to include average LE when advising patients on treatments because they believe that the patients do not want to discuss this topic. “Yet, in interviews with patients, we found that prostate cancer patients reported they wanted this information,” he continued, in an interview.

Solving the problem of overscreening and overtreatment will require a “multifaceted approach, including improving access to life expectancy data at the point of care for providers, educating providers on how to communicate this information, and improving data sources to predict longevity,” Daskivich said.

He said it’s equally important to note that some men with prostate cancer may choose treatment even if they have a limited longevity.

“Not all patients will choose conservative management, even if it is recommended by guidelines. However, they need to be given the opportunity to make a good decision for themselves with the best possible data,” Daskivich said.

This work was supported in part by a US Department of VA Merit Review. Daskivich reported receiving personal fees from the Medical Education Speakers Network, EDAP, and RAND; research support from Lantheus and Janssen; and a patent pending for a system for healthcare visit quality assessment outside the submitted work. Schoenborn, Walter, and Anderson had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Overtreatment of men with prostate cancer and limited life expectancy (LE) has persisted in the era of active surveillance and worsened in some instances, according to a new study of nearly 250,000 veterans.

“Overtreatment of men with limited longevity for intermediate- and high-risk tumors has not only failed to improve but has actually worsened over the last 20 years,” Timothy Daskivich, MD, MSHPM, with Cedars-Sinai Medical Center, Los Angeles, said in an interview.

“Many doctors assume that the increase in uptake of active surveillance for low-risk prostate cancers has solved the problem of overtreatment, but this trend has not affected overtreatment of men with low likelihood of living long enough to benefit from treatment who have higher-risk tumors,” Daskivich said.

The study was published online on November 11 in JAMA Internal Medicine.

‘Concerning’ Real-World Data

For men with low- and intermediate-risk prostate cancer expected to live fewer than 10 years, prostate cancer screening and aggressive treatment are not recommended.

Daskivich and colleagues analyzed data on 243,928 men (mean age, 66 years) in the Veterans Affairs (VA) Health System with clinically localized prostate cancer diagnosed between 2000 and 2019.

About 21% had LE < 10 years, and about 4% had LE < 5 years, according to the validated age-adjusted Prostate Cancer Comorbidity Index.

Overtreatment was defined as aggressive treatment (surgery or radiation) in those with LE < 10 years and low- to intermediate-risk disease and in those with LE < 5 years and high-risk disease, in line with current guidelines.

Among men with LE < 10 years, the proportion of men overtreated with surgery or radiotherapy for low-risk disease decreased 22% but increased 22% for intermediate-risk disease during the study period.

Among men with LE < 5 years, the proportion of men treated with definitive treatment for high-risk disease increased 29%.

“While lower-risk tumors are treated less aggressively across the board, including in men with limited longevity, it seems that we are more indiscriminately treating men with higher-risk disease without considering their expected longevity,” Daskivich said, in an interview.

Is This Happening in the General US Population?

Daskivich noted that the sample included a large sample of men diagnosed with localized prostate cancer in the VA Health System.

“Rates of overtreatment are likely to be lower in the VA [Health System], so the problem may be worse in the community setting. The VA [Health System] has been exemplary in its uptake of active surveillance for low-risk cancers, leading the effort to reduce overtreatment of men with low-risk cancers. However, the problem of overtreatment of men with limited longevity persists in the VA [Health System], underscoring the pervasiveness of this problem,” he explained.

“We don’t have a perfect head-to-head comparison of overtreatment in the VA setting vs in the community. [However, one study shows] that this is not a VA-specific phenomenon and that there is an increase in overtreatment of men with limited longevity in a Medicare population as well,” Daskivich noted.

Is Overtreatment All Bad?

Overtreatment of prostate cancer, especially in cases where the cancer is unlikely to progress or cause symptoms, can lead to significant physical, psychological, and financial harms, Christopher Anderson, MD, urologist with Columbia University Irving Medical Center in New York City, who wasn’t involved in the study, noted in an interview.

In the study by Daskivich and colleagues, over three quarters of the overtreatment was radiation therapy, which carries the risk for urinary, bowel, and sexual issues.

“Overscreening, which can lead to overtreatment, is a core issue,” Anderson said. It’s easy to order a “simple” prostate-specific antigen blood test, but in an older man with limited LE, that can lead to a host of further testing, he commented.

Stopping the pipeline of overscreening that then feeds into the cascade of overtreatment is the first step in addressing the problem of prostate cancer overtreatment, Nancy Li Schoenborn, MD, MHS, with Johns Hopkins University School of Medicine, Baltimore, and Louise C. Walter, MD, with University of California San Francisco, wrote in an editorial in JAMA Internal Medicine.

Considering LE during screening decision-making is “fundamental to reducing harms of prostate cancer overdiagnosis and overtreatment” because limited LE increases the likelihood of experiencing “harms all along the diagnostic and treatment cascade following screening,” the editorial writers said.

The time spent diagnosing, monitoring, and treating asymptomatic prostate cancer in men with limited LE distracts from monitoring and treating chronic symptomatic life-limiting illnesses, they noted.

Tough to Talk About?

Anderson noted that, in general, doctors are not great at estimating and counseling patients on LE. “It’s sometimes difficult to have that conversation,” he said.

Daskivich said physicians may fail to include average LE when advising patients on treatments because they believe that the patients do not want to discuss this topic. “Yet, in interviews with patients, we found that prostate cancer patients reported they wanted this information,” he continued, in an interview.

Solving the problem of overscreening and overtreatment will require a “multifaceted approach, including improving access to life expectancy data at the point of care for providers, educating providers on how to communicate this information, and improving data sources to predict longevity,” Daskivich said.

He said it’s equally important to note that some men with prostate cancer may choose treatment even if they have a limited longevity.

“Not all patients will choose conservative management, even if it is recommended by guidelines. However, they need to be given the opportunity to make a good decision for themselves with the best possible data,” Daskivich said.

This work was supported in part by a US Department of VA Merit Review. Daskivich reported receiving personal fees from the Medical Education Speakers Network, EDAP, and RAND; research support from Lantheus and Janssen; and a patent pending for a system for healthcare visit quality assessment outside the submitted work. Schoenborn, Walter, and Anderson had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Overtreatment of men with prostate cancer and limited life expectancy (LE) has persisted in the era of active surveillance and worsened in some instances, according to a new study of nearly 250,000 veterans.

“Overtreatment of men with limited longevity for intermediate- and high-risk tumors has not only failed to improve but has actually worsened over the last 20 years,” Timothy Daskivich, MD, MSHPM, with Cedars-Sinai Medical Center, Los Angeles, said in an interview.

“Many doctors assume that the increase in uptake of active surveillance for low-risk prostate cancers has solved the problem of overtreatment, but this trend has not affected overtreatment of men with low likelihood of living long enough to benefit from treatment who have higher-risk tumors,” Daskivich said.

The study was published online on November 11 in JAMA Internal Medicine.

‘Concerning’ Real-World Data

For men with low- and intermediate-risk prostate cancer expected to live fewer than 10 years, prostate cancer screening and aggressive treatment are not recommended.

Daskivich and colleagues analyzed data on 243,928 men (mean age, 66 years) in the Veterans Affairs (VA) Health System with clinically localized prostate cancer diagnosed between 2000 and 2019.

About 21% had LE < 10 years, and about 4% had LE < 5 years, according to the validated age-adjusted Prostate Cancer Comorbidity Index.

Overtreatment was defined as aggressive treatment (surgery or radiation) in those with LE < 10 years and low- to intermediate-risk disease and in those with LE < 5 years and high-risk disease, in line with current guidelines.

Among men with LE < 10 years, the proportion of men overtreated with surgery or radiotherapy for low-risk disease decreased 22% but increased 22% for intermediate-risk disease during the study period.

Among men with LE < 5 years, the proportion of men treated with definitive treatment for high-risk disease increased 29%.

“While lower-risk tumors are treated less aggressively across the board, including in men with limited longevity, it seems that we are more indiscriminately treating men with higher-risk disease without considering their expected longevity,” Daskivich said, in an interview.

Is This Happening in the General US Population?

Daskivich noted that the sample included a large sample of men diagnosed with localized prostate cancer in the VA Health System.

“Rates of overtreatment are likely to be lower in the VA [Health System], so the problem may be worse in the community setting. The VA [Health System] has been exemplary in its uptake of active surveillance for low-risk cancers, leading the effort to reduce overtreatment of men with low-risk cancers. However, the problem of overtreatment of men with limited longevity persists in the VA [Health System], underscoring the pervasiveness of this problem,” he explained.

“We don’t have a perfect head-to-head comparison of overtreatment in the VA setting vs in the community. [However, one study shows] that this is not a VA-specific phenomenon and that there is an increase in overtreatment of men with limited longevity in a Medicare population as well,” Daskivich noted.

Is Overtreatment All Bad?

Overtreatment of prostate cancer, especially in cases where the cancer is unlikely to progress or cause symptoms, can lead to significant physical, psychological, and financial harms, Christopher Anderson, MD, urologist with Columbia University Irving Medical Center in New York City, who wasn’t involved in the study, noted in an interview.

In the study by Daskivich and colleagues, over three quarters of the overtreatment was radiation therapy, which carries the risk for urinary, bowel, and sexual issues.

“Overscreening, which can lead to overtreatment, is a core issue,” Anderson said. It’s easy to order a “simple” prostate-specific antigen blood test, but in an older man with limited LE, that can lead to a host of further testing, he commented.

Stopping the pipeline of overscreening that then feeds into the cascade of overtreatment is the first step in addressing the problem of prostate cancer overtreatment, Nancy Li Schoenborn, MD, MHS, with Johns Hopkins University School of Medicine, Baltimore, and Louise C. Walter, MD, with University of California San Francisco, wrote in an editorial in JAMA Internal Medicine.

Considering LE during screening decision-making is “fundamental to reducing harms of prostate cancer overdiagnosis and overtreatment” because limited LE increases the likelihood of experiencing “harms all along the diagnostic and treatment cascade following screening,” the editorial writers said.

The time spent diagnosing, monitoring, and treating asymptomatic prostate cancer in men with limited LE distracts from monitoring and treating chronic symptomatic life-limiting illnesses, they noted.

Tough to Talk About?

Anderson noted that, in general, doctors are not great at estimating and counseling patients on LE. “It’s sometimes difficult to have that conversation,” he said.

Daskivich said physicians may fail to include average LE when advising patients on treatments because they believe that the patients do not want to discuss this topic. “Yet, in interviews with patients, we found that prostate cancer patients reported they wanted this information,” he continued, in an interview.

Solving the problem of overscreening and overtreatment will require a “multifaceted approach, including improving access to life expectancy data at the point of care for providers, educating providers on how to communicate this information, and improving data sources to predict longevity,” Daskivich said.

He said it’s equally important to note that some men with prostate cancer may choose treatment even if they have a limited longevity.

“Not all patients will choose conservative management, even if it is recommended by guidelines. However, they need to be given the opportunity to make a good decision for themselves with the best possible data,” Daskivich said.

This work was supported in part by a US Department of VA Merit Review. Daskivich reported receiving personal fees from the Medical Education Speakers Network, EDAP, and RAND; research support from Lantheus and Janssen; and a patent pending for a system for healthcare visit quality assessment outside the submitted work. Schoenborn, Walter, and Anderson had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

Many Veterans with cancer experience substantial side effects related to their chemotherapy treatments resulting in impaired quality of life. Prompt management of such symptoms can improve adherence to therapy and potentially clinical outcomes. Previous studies in cancer patients have shown that mobile apps can improve symptom management and quality of life, though there are limited studies using oncology-focused apps in the VA population. The VA Annie App is an optimal platform for Veterans since it relies primarily on SMS-based texting and not on internet capabilities. This would address several well-known barriers to Veterans’ care access (limited internet connectivity, transportation) and enhance symptom reporting between infrequent provider visits. Providers can securely collect app responses within the VA system and there is already considerable VA developer experience with designing complex protocols. The OCTAGON project (Optimizing Cancer Care with Telehealth Assessment for Goal-Oriented Needs) will have the following goals: 1) To develop Annie App protocols to assist in management of cancer and/or chemotherapy-related symptoms (OCTAGON intervention), 2) To examine initial acceptability, feasibility, and Veteran-reported outcomes, 3) To explore short term effects on the utilization of VA encounters.

Methods

All patients who are primarily being managed at the VA Ann Arbor for their cancer therapy and are receiving one of the following therapies are considered eligible: EGFR inhibitors (lung cancer), antiandrogen therapies (prostate cancer), BTK inhibitors (lymphoma).

Discussion

Drug-specific protocols will be developed in conjunction with clinical pharmacists with experience in outpatient oral chemotherapy toxicity monitoring. Questions will have either a Yes/No, or numerical response. Interventions will be administered weekly for the first 3 months after enrollment, then decrease to monthly for a total of 6 months on protocol. Patients will be directed to contact their providers with any significant changes in tolerability. Planned data collected will include intervention question responses, adverse events, demographics, diagnosis, disease response, hospitalizations, treatment dose reductions or interruptions, provider and staff utilization. Survey responses to assess treatment acceptability (Treatment Acceptability/Adherence Scale), usability (System Usability Scale), general health (PROMIS-GH), and patient satisfaction will also be collected. Funding: VA Telehealth Research and Innovation for Veterans with Cancer (THRIVE).

Background

This program implements a prospective surveillance physical therapy program to prioritize the well-being and quality of life of individuals affected by cancer, particularly veterans, by overcoming barriers associated with the prospective surveillance model (PSM) and lessening negative treatment effects. Recent cancer care research emphasizes the significance of PSM and prehabilitation in improving outcomes and mitigating the adverse effects of cancer and its treatments. However, barriers hinder PSM implementation despite its established efficacy in managing cancer-related dysfunctions. Notably, current cancer treatment lacked physical therapy (PT) consultation for cancer rehabilitation.

Methods

A new care model was developed, incorporating PT consultation at cancer diagnosis for veterans with cancer. Comprehensive clinical education and necessary equipment were provided to PTs for high-quality treatment. A cancer rehabilitation guidebook was created and distributed to educate patients and cancer providers in VA hospital and community-based outpatient clinics. Veterans with cancer diagnoses have access to physical therapy services at any time during cancer treatment and survivorship. Data were collected and analyzed to identify trends in cancer rehab PT consults.

Results

The biggest barrier to PSM was a lack of knowledge about its efficacy and available services. Before FY23, no cancer rehab PT consults were conducted. FY23, 47 PT consults were conducted, increasing to 79 consults in FY24 through 05/31/24.

Conclusions

PT services are needed throughout the cancer journey for veterans, from diagnosis to treatment and survivorship. This project demonstrates the feasibility of developing a PSM with a cancer rehabilitation PT consult. Utilizing established surveillance intervals can minimize cancer-related sequelae. Other VA medical centers can adopt similar PSMs in PT to improve functional outcomes and minimize the negative impacts of cancer and its treatments.

Background

This program implements a prospective surveillance physical therapy program to prioritize the well-being and quality of life of individuals affected by cancer, particularly veterans, by overcoming barriers associated with the prospective surveillance model (PSM) and lessening negative treatment effects. Recent cancer care research emphasizes the significance of PSM and prehabilitation in improving outcomes and mitigating the adverse effects of cancer and its treatments. However, barriers hinder PSM implementation despite its established efficacy in managing cancer-related dysfunctions. Notably, current cancer treatment lacked physical therapy (PT) consultation for cancer rehabilitation.

Methods

A new care model was developed, incorporating PT consultation at cancer diagnosis for veterans with cancer. Comprehensive clinical education and necessary equipment were provided to PTs for high-quality treatment. A cancer rehabilitation guidebook was created and distributed to educate patients and cancer providers in VA hospital and community-based outpatient clinics. Veterans with cancer diagnoses have access to physical therapy services at any time during cancer treatment and survivorship. Data were collected and analyzed to identify trends in cancer rehab PT consults.

Results

The biggest barrier to PSM was a lack of knowledge about its efficacy and available services. Before FY23, no cancer rehab PT consults were conducted. FY23, 47 PT consults were conducted, increasing to 79 consults in FY24 through 05/31/24.

Conclusions

PT services are needed throughout the cancer journey for veterans, from diagnosis to treatment and survivorship. This project demonstrates the feasibility of developing a PSM with a cancer rehabilitation PT consult. Utilizing established surveillance intervals can minimize cancer-related sequelae. Other VA medical centers can adopt similar PSMs in PT to improve functional outcomes and minimize the negative impacts of cancer and its treatments.

Background

This program implements a prospective surveillance physical therapy program to prioritize the well-being and quality of life of individuals affected by cancer, particularly veterans, by overcoming barriers associated with the prospective surveillance model (PSM) and lessening negative treatment effects. Recent cancer care research emphasizes the significance of PSM and prehabilitation in improving outcomes and mitigating the adverse effects of cancer and its treatments. However, barriers hinder PSM implementation despite its established efficacy in managing cancer-related dysfunctions. Notably, current cancer treatment lacked physical therapy (PT) consultation for cancer rehabilitation.

Methods

A new care model was developed, incorporating PT consultation at cancer diagnosis for veterans with cancer. Comprehensive clinical education and necessary equipment were provided to PTs for high-quality treatment. A cancer rehabilitation guidebook was created and distributed to educate patients and cancer providers in VA hospital and community-based outpatient clinics. Veterans with cancer diagnoses have access to physical therapy services at any time during cancer treatment and survivorship. Data were collected and analyzed to identify trends in cancer rehab PT consults.

Results

The biggest barrier to PSM was a lack of knowledge about its efficacy and available services. Before FY23, no cancer rehab PT consults were conducted. FY23, 47 PT consults were conducted, increasing to 79 consults in FY24 through 05/31/24.

Conclusions

PT services are needed throughout the cancer journey for veterans, from diagnosis to treatment and survivorship. This project demonstrates the feasibility of developing a PSM with a cancer rehabilitation PT consult. Utilizing established surveillance intervals can minimize cancer-related sequelae. Other VA medical centers can adopt similar PSMs in PT to improve functional outcomes and minimize the negative impacts of cancer and its treatments.

Background

VA Whole Health (WH) is an approach that empowers and equips people to take charge of their health and well-being. In 2020, 18 WH Flagship sites demonstrated reduced opiate use and smaller increases in pharmacy costs as well as favorable veteran self-reported measures. VA mandated WH integration into mental health and primary care. Purose: To incorporate WH within Dayton VA cancer care, using the Personal Health Inventory (PHI) as an intake tool, a tumor-agnostic WH oncology clinic was established.

Methods

Led by an oncologist, a referral-based clinic opened in 2021. Pre-work included EHR items (stop codes/templates), staff training and leverage of mental health integration. VA’s generic PHI was utilized until an oncology-specific PHI was developed by leaders in the field.(3-5) Clinic data was tracked.

Results

170 visits offered (June 2021-May 2024). 32 referrals received (one without cancer; deaths: two pre-intake/five post-intake); 70 appointments occurred among 30 veterans (30 intake/40 follow-up) for 41% fill rate (up 5% from 1st six months). 96% PHI completion rate. Referral sources: fellows (43%), attendings (17%), PCP (3%), Survivorship Clinic (3%), self-referral (33%)--40% of these from cancer support group members. Cancer types (one dual-diagnosis; total >100%): 24% breast, 17% prostate, 17% NSCLC, 10% NHL, 10% pancreatic, 7% Head/Neck, 7% SCLC, 3% each colon/esophageal/kidney. Cancer Stages represented: I (10%), II (20%), III (23%) and IV (47%). Participant info: Age range (36-85); 69% male and 31% female with 86% on active cancer therapy (hormonal, immune-, chemo- or chemoradiation). Supplements were discussed at 26% of visits and referrals ordered at 27% (4-massage therapy, 1-acupuncture, 1-chiropractic, 2-health coaching, 1-cardiology, 1-lymphedema therapy, 1-social work, 1-survivorship clinic, 1-yoga, 1-diabetes education, 1-ENT, 1-nutrition, 1-pathology, 1-pulmonary, 1-prosthetics).

Conclusions

WH within cancer care is feasible for veterans on active treatment (all types/stages) and at a non-Flagship/unfunded site. Veterans gain introduction to WH through the PHI and Complementary-Integrative Health referrals (VA Directive 1137). Cancer support group attendance prompts WH clinic self-referrals. Next steps at DVAMC are to offer mind-body approaches such as virtual reality experiences in the infusion room and VA CALM sessions via asynchronous online delivery; funding would support WH evolution in oncology.

Background

VA Whole Health (WH) is an approach that empowers and equips people to take charge of their health and well-being. In 2020, 18 WH Flagship sites demonstrated reduced opiate use and smaller increases in pharmacy costs as well as favorable veteran self-reported measures. VA mandated WH integration into mental health and primary care. Purose: To incorporate WH within Dayton VA cancer care, using the Personal Health Inventory (PHI) as an intake tool, a tumor-agnostic WH oncology clinic was established.

Methods

Led by an oncologist, a referral-based clinic opened in 2021. Pre-work included EHR items (stop codes/templates), staff training and leverage of mental health integration. VA’s generic PHI was utilized until an oncology-specific PHI was developed by leaders in the field.(3-5) Clinic data was tracked.

Results

170 visits offered (June 2021-May 2024). 32 referrals received (one without cancer; deaths: two pre-intake/five post-intake); 70 appointments occurred among 30 veterans (30 intake/40 follow-up) for 41% fill rate (up 5% from 1st six months). 96% PHI completion rate. Referral sources: fellows (43%), attendings (17%), PCP (3%), Survivorship Clinic (3%), self-referral (33%)--40% of these from cancer support group members. Cancer types (one dual-diagnosis; total >100%): 24% breast, 17% prostate, 17% NSCLC, 10% NHL, 10% pancreatic, 7% Head/Neck, 7% SCLC, 3% each colon/esophageal/kidney. Cancer Stages represented: I (10%), II (20%), III (23%) and IV (47%). Participant info: Age range (36-85); 69% male and 31% female with 86% on active cancer therapy (hormonal, immune-, chemo- or chemoradiation). Supplements were discussed at 26% of visits and referrals ordered at 27% (4-massage therapy, 1-acupuncture, 1-chiropractic, 2-health coaching, 1-cardiology, 1-lymphedema therapy, 1-social work, 1-survivorship clinic, 1-yoga, 1-diabetes education, 1-ENT, 1-nutrition, 1-pathology, 1-pulmonary, 1-prosthetics).

Conclusions

WH within cancer care is feasible for veterans on active treatment (all types/stages) and at a non-Flagship/unfunded site. Veterans gain introduction to WH through the PHI and Complementary-Integrative Health referrals (VA Directive 1137). Cancer support group attendance prompts WH clinic self-referrals. Next steps at DVAMC are to offer mind-body approaches such as virtual reality experiences in the infusion room and VA CALM sessions via asynchronous online delivery; funding would support WH evolution in oncology.

Background

VA Whole Health (WH) is an approach that empowers and equips people to take charge of their health and well-being. In 2020, 18 WH Flagship sites demonstrated reduced opiate use and smaller increases in pharmacy costs as well as favorable veteran self-reported measures. VA mandated WH integration into mental health and primary care. Purose: To incorporate WH within Dayton VA cancer care, using the Personal Health Inventory (PHI) as an intake tool, a tumor-agnostic WH oncology clinic was established.

Methods

Led by an oncologist, a referral-based clinic opened in 2021. Pre-work included EHR items (stop codes/templates), staff training and leverage of mental health integration. VA’s generic PHI was utilized until an oncology-specific PHI was developed by leaders in the field.(3-5) Clinic data was tracked.

Results

170 visits offered (June 2021-May 2024). 32 referrals received (one without cancer; deaths: two pre-intake/five post-intake); 70 appointments occurred among 30 veterans (30 intake/40 follow-up) for 41% fill rate (up 5% from 1st six months). 96% PHI completion rate. Referral sources: fellows (43%), attendings (17%), PCP (3%), Survivorship Clinic (3%), self-referral (33%)--40% of these from cancer support group members. Cancer types (one dual-diagnosis; total >100%): 24% breast, 17% prostate, 17% NSCLC, 10% NHL, 10% pancreatic, 7% Head/Neck, 7% SCLC, 3% each colon/esophageal/kidney. Cancer Stages represented: I (10%), II (20%), III (23%) and IV (47%). Participant info: Age range (36-85); 69% male and 31% female with 86% on active cancer therapy (hormonal, immune-, chemo- or chemoradiation). Supplements were discussed at 26% of visits and referrals ordered at 27% (4-massage therapy, 1-acupuncture, 1-chiropractic, 2-health coaching, 1-cardiology, 1-lymphedema therapy, 1-social work, 1-survivorship clinic, 1-yoga, 1-diabetes education, 1-ENT, 1-nutrition, 1-pathology, 1-pulmonary, 1-prosthetics).

Conclusions

WH within cancer care is feasible for veterans on active treatment (all types/stages) and at a non-Flagship/unfunded site. Veterans gain introduction to WH through the PHI and Complementary-Integrative Health referrals (VA Directive 1137). Cancer support group attendance prompts WH clinic self-referrals. Next steps at DVAMC are to offer mind-body approaches such as virtual reality experiences in the infusion room and VA CALM sessions via asynchronous online delivery; funding would support WH evolution in oncology.

Background

The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.

Methods

A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.

Results

There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).

Conclusions

This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.

Background

The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.

Methods

A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.

Results

There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).

Conclusions

This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.

Background

The adoption of Stereotactic Body Radiation Therapy (SBRT) for prostate cancer has allowed treatment to be completed in less than 2 weeks, but has predominantly been given to the prostate only. Currently, very few prospective studies have compared delivery of SBRT versus hypofractionated radiotherapy (HFX) when giving concurrent pelvic radiation. The aim of the study is to evaluate the tolerance and efficacy of pelvic node radiotherapy and SIB to the prostate in prostate patients requiring nodal irradiation.

Methods

A total of 58 patients were irradiated with SBRT and initiated ADT therapy between 2014 and 2023. 57 patients were treated with 7.5 Gy to the prostate and 1 to 7.25 Gy. All patients were treated with 5 Gy x 5 fraction to the pelvis. This group was compared to a preselected historical cohort of 65 HFX patients with 57 of these patients treated with 67.5/50 Gy in 25 fractions, 1 with patient 67.5/45 Gy in 25 fractions, and 6 patients with 60/44-46 Gy in 20 fractions. Patients were evaluated for GU and GI toxicities according to Radiation Therapy Oncology Group Toxicity criteria at one year post radiation therapy.

Results

There were 31 grade 0 (53.4%), 1 grade 1 (1.7%), 25 grade 2 (43.1%), 1 grade 3 (1.7%) events in the SBRT group and 29 GU grade 0 (44.6%), 3 grade 1 (4.6%), and 33 grade 2 (50.8%) GU toxicities in the HFX group with no significant difference between the groups (p=0.464). There were 55 grade 0 (94.8%), 1 grade 1 (1.7%), and 2 grade 2 (3.4%) GI toxicities in the SBRT group and 59 grade 0 (90.8%), 1 grade 1 (1.5%), and 5 grade 2 (7.7%) events in the HFX group with no significant difference between the groups (p=0.381).

Conclusions

This prospective study provides data to support the use of concurrent pelvic radiation with SBRT to the prostate. Our findings suggest there is no difference in toxicity between HFX and 25 Gy pelvic radiation (5 Gy/5 fractions) concurrent with SBRT to the prostate, therefore it appears to be a safe and convenient option for veterans with prostate cancer.

Background

Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.

Methods

Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.

Results

Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.

Discussion

During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.

Conclusions

There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.

Background

Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.

Methods

Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.

Results

Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.

Discussion

During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.

Conclusions

There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.

Background

Prostate cancer is the most common cancer in the VHA. Telehealth use has increased and has the potential to improve access for patients. We examined patterns of care for VHA patients with prostate cancer, including whether visits were in person, by telephone or by video.

Methods

Using the VHA Corporate Data Warehouse, we extracted data on all incident cases of prostate cancer from 1/1/2016-1/31/2023 with sufficient information (Gleason score, prostate-specific antigen [PSA], and tumor stage) to categorize into National Comprehensive Cancer Network (NCCN) risk strata. We excluded patients who died within 1 year of diagnosis and those with no evidence of PSA testing, prostate biopsy or treatment within 2 years. We categorized all outpatient visits related to a person’s Urology- and Medical Oncology based care – including the visit modality – based on administrative visit stop codes. We defined ‘during COVID’ as visits after 3/11/2020. We calculated the percent of visits performed by modality in each year after diagnosis.

Results

Among the 60,381 men with prostate cancer, 61% were White, 33% Black; 5% Hispanic; 32% rural. For NCCN category, 30% had high risk prostate cancer, which increased with age, 50% had intermediate risk and 20% had low risk. Prior to COVID, for visits to Urology within the first year after diagnosis, 79% were in person, 20% were by telephone and 0.1% were by video. Visits to Oncology within the first year after diagnosis were similar—82% in person, 16% by phone and 0.3% by video.

Discussion

During the COVID period, video visits increased significantly but remained a small proportion, accounting for only 2% of visits for both Urology and Oncology. Video visits increased during the COVID-19 pandemic but remained rare. Across many diseases and conditions, the quality of care for video visits has been at least as good as for in-person care.

Conclusions

There is a missed opportunity to provide care by video within VHA for patients with prostate cancer, particularly given that about 1/3 of patients are from rural areas. Future analyses will examine barriers to video telehealth and the impact of video visits on quality and equity of prostate cancer care.

Background

Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases. 

Case Presentation

Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.

Discussion

Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.

Conclusions

Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.

Background

Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases. 

Case Presentation

Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.

Discussion

Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.

Conclusions

Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.

Background

Metastatic prostate cancer typically manifests with metastases to the lungs, bones, and adrenal glands. Here, we report a unique case where the initial presentation involved pleural nodules, subsequently leading to the discovery of pleural and pericardial metastases. 

Case Presentation

Our patient, a 73-year-old male with a history of active tobacco use disorder, COPD, and right shoulder melanoma (2004), initially presented to his primary care physician for a routine visit. Following a Low Dose Chest CT scan (LDCT), numerous new pleural nodules were identified. Physical examination revealed small nevi and skin tags, but no malignant characteristics. Initial concerns centered on the potential recurrence of malignant melanoma with pleural metastases or an inflammatory condition. Subsequent PET scan results raised significant suspicion of malignancy. PSA was 2.41. Pleuroscopy biopsies revealed invasive nonsmall cell carcinoma, positive for NKX31 and MOC31, but negative for S100, PSA, and synaptophysin. This pattern strongly suggests metastatic prostate cancer despite the absence of PSA staining. (Stage IV B: cTxcN1cM1c). A subsequent PSMA PET highlighted extensive metastatic involvement in the pericardium, posterior and mediastinal pleura, mediastinum, and ribs. Treatment commenced with Degarelix followed by the standard regimen of Docetaxel, Abiraterone, and prednisone. Genetic counseling and palliative care services were additionally recommended.

Discussion

Prostate cancer typically spreads to bones, lungs, liver, and adrenal glands. Rarely, it appears in sites like pericardium and pleura. Pleural metastases are usually found postmortem; clinical diagnosis is rare. Pericardial metastases are exceptionally uncommon, with few documented cases. The precise mechanism of metastatic dissemination remains uncertain, with theories suggesting spread through the vertebral-venous plexus or via the vena cava to distant organs. Treatment approaches vary based on symptomatic effusions, ranging from pericardiocentesis, thoracocentesis to chemotherapy, radiotherapy, and hormone therapy. Studies have shown systemic docetaxel to be effective in managing pleural and pericardial symptoms. Despite their rarity, healthcare providers should consider these possibilities when encountering pleural thickening or pericardial abnormalities on imaging studies.

Conclusions

Pleural and pericardial metastases represent uncommon occurrences in prostate cancer. Continued research efforts can facilitate early detection of metastatic disease, enabling more effective and precisely targeted management strategies when symptoms manifest.