Prof. Miloš Broďák: Introduction of new drugs has significantly improved results even in progressive and recurrent prostate cancers

What is currently being discussed the most in the professional community in the field of prevention and treatment of prostate cancer?

Primarily, it is the preparation for the smooth implementation of the newly introduced prostate cancer screening.

Furthermore, the impact of diet and lifestyle is being discussed. This factor is evident, for example, in the differences between the low incidence in Southeast Asian countries and the incidence in the same ethnic group living for several generations in the USA, where prostate cancer occurrence is similar to that of the general American population. 

Of course, there are always new developments in the treatment of locally advanced, recurrent, and metastatic prostate cancer. Among other things, we are continuously working on improving the quality of robot-assisted radical prostatectomy, especially when it comes to nerve-sparing techniques. In this area, we collaborate with other European robotic centers.

What significant advancements, particularly regarding the improvement of prostate cancer therapy outcomes, have occurred in recent years?

We treat prostate tumors according to the guidelines of the European Association of Urology (EAU) and the Czech Urological Society ČUS). There have undoubtedly been many important changes. Among the most significant are the more precise definitions of low-risk prostate cancers and greater support for their active surveillance. Moreover, discussions are ongoing, and new data are emerging regarding the treatment of localized and locally advanced prostate cancer. The treatment of recurrent or progressive disease has also become more precise, and we are achieving better results here. The introduction of new PET imaging methods has also made diagnostics significantly more accurate.

The most significant changes are evident in the pharmacotherapy of metastatic and castration-resistant tumors. New treatments are emerging, and indications for currently known as well as new drugs targeting androgen receptors (ARTA – androgen receptor axis targeted therapy). Genetic testing is being utilized more in diagnosis and prognosis.

Therapeutic outcomes have undoubtedly improved significantly over the past 20 years. This is confirmed by data from the Institute of Health Information and Statistics (ÚZIS). For example, five-year survival for localized prostate cancer exceeds 99%, and cancer-specific ten-year survival is higher than 85%. Similar improvements have been achieved in the therapy of metastatic and castration-resistant prostate cancer, mainly due to the introduction of new treatments such as ARTA, radium-223, poly (ADP-ribose) polymerase inhibitors (PARPi), and other modalities.

How do you decide which ARTA treatment to use in a particular case?

Based on experience and always in agreement with a multidisciplinary team. The administration must meet stringent indication criteria not only according to the EAU and ČUS guidelines but also according to insurance reimbursement conditions, which may vary slightly in specifics. Generally, the stage and risk of the cancer on one side, and the overall condition, comorbidities, and age of the patient on the other side are evaluated.

Do luteinizing hormone-releasing hormone (LHRH) analog drugs still play a significant role, or have they been replaced by modern androgen receptor blockers? What is their current position in the therapeutic algorithm?

LHRH analogs still play a crucial role in androgen deprivation therapy, especially for metastatic cancer or in combination therapy for high-risk prostate cancer along with hormone therapy. Androgen deprivation therapy is, in any case, the cornerstone, upon which other modern treatments are added.

What is the role of classic chemotherapy in prostate cancer therapy today?

It remains part of the treatment portfolio for high-risk and especially metastatic prostate cancer. Its indication must always be considered due to the higher risk of side effects. On the other hand, in indicated cases, especially in rapidly progressing and very aggressive forms of prostate cancer, chemotherapy is still used and effective.

Is it appropriate to indicate local treatment – surgical or radiation, if the disease is already in the metastatic stage?

In most cases, no. However, in recent years, particularly in clinical studies, it has been shown that patients could benefit from local treatment in oligometastatic prostate cancer. And local therapy is also obviously indicated in resolving complications such as urinary retention or bleeding from the cancer.

Who decides on the optimal treatment plan based on the characteristics and stage of the tumor disease? The oncologist or the urologist?

It is a joint decision within a multidisciplinary team. The proposed approach is thoroughly explained to the patient, who must then make the final decision. In everyday practice, however, most patients, despite being fully informed, ultimately ask what the urologist or oncologist would recommend and, in most cases, follow their advice and expertise.

Can you briefly summarize the basic principles and procedures in the current management of prostate cancer?

• For localized cancer with very low risk – active surveillance.
• For localized cancer with expected survival of more than 10 years – radical prostatectomy.
• For localized cancer with expected survival of 5–10 years or for locally advanced cancer – radiotherapy, possibly in combination with androgen deprivation therapy.
• For metastatic cancer – androgen deprivation therapy, in high-risk forms, supplemented with modern treatments, such as ARTA.
• For castration-resistant prostate cancer – androgen deprivation therapy supplemented with ARTA or chemotherapy, possibly including other modern modalities like PARPi or radium-223.

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