Improving outcome in patients with prostate and kidney cancer: heading in the right direction?

Advances in prostate and kidney cancer are truly inspiring when one thinks of the limited options available only a few years ago. The breakthrough in kidney cancer came with the advent of tryosine kinase inhibitors, and now immunotherapy has added itself as a game changer that has drastically changed the lives of some patients. The changing landscape and the role of immunotherapy in kidney cancer is reviewed by Karakiewicz et al. (pp. 325–333). The challenge of patient selection, as well as timing and combinations, remains to be resolved, but with the intensity and quality of ongoing research, I am optimistic for the future. In personalizing our approach to cancer, one of the most exciting areas in prostate cancer at the present time is in the use of poly ADP ribose polymerase (PARP) inhibitors. The first reports of significant improvements in progression as well as survival have been seen in patients who have detectable mutational profiles that predict sensitivity to PARPi. In whom, how best to screen and when to introduce this therapeutic approach has become an intense area of research. This is elegantly reviewed by de Bono and his team (pp. 339–343). Some of the most practicing changing results for metastatic prostate cancer have been in the use of docetaxel and abiraterone in metastatic hormone-sensitive prostate cancer. Hamilou et al. (pp. 334–338) review the use of these effective agents for metastatic castration resistant prostate cancer in the metastatic hormone sensitive prostate cancer setting, which have led to truly significant improvements in survival. Again, the questions regarding who we should treat and which of the two should be used remains the recurring question. Clearly, patient and physician choice is important, but the field will need to evolve towards a biologic rationale depending on the cancer we treat rather than the profile of the drug being used. Another area of research that has been in the forefront is metastases prevention. The recent reports of two phase three clinical trials in high-risk nonmetastatic prostate cancer demonstrating significant delays in metastases has generated a lot of excitement as well as many questions. Although delaying metastases is extremely rewarding for us as clinicians, as well as for patients living with recurrent prostate cancer, we clearly need to determine, which patient will benefit from those who may be observed. This is critical for both our patients as well as the healthcare systems we live in. We need to avoid going back to an era where every prostate specific antigen rise provoked fear and generated the need for intervention. On the other hand, for patients at high risk of metastases or death early intervention with active, well-tolerated therapeutics is hugely beneficial. The challenge of establishing reliable criteria is essential, and the next wave of research will be regarding how best to manage these patients when they eventually develop resistance to these very effective agents that target the androgen receptor. Niazi et al. (pp. 351–358) and Pouliot et al. (pp. 359–365) each bring insight in new frontiers of prostate cancer. Pouliot reports on improved imaging with agents such as prostate specific membrane antigen (PSMA) that target the cancer, and allow for a more precise evaluation of disease state and extent as well as eventually for treatment response. Also exciting is the growing field of PSMA-linked therapeutics. With more precise imaging, there is also the possibility of directed therapeutics in the case of oligometastatic states of the disease. Niazi discusses how the role and effectiveness of radiation therapy in the management strategy of oligometastatic prostate cancer is still under investigation, but is growing in the real world. Finally, Delouya and Dautruche (pp. 344–350) review the management of an infrequent, but debilitating, condition such as radiation-induced hemorrhagic cystitis. This is a challenge that almost every physician dealing with pelvic cancers will encounter. Adequate and effective management is reviewed in this edition with the hopes of restoring some degree of quality in those patients who experience this complication from extremely effective therapy. Even though the risk of this complication has diminished tremendously over the years and treatment options are quite effective in most, finding ways to prevent this from happening remains a challenge. The balance between maximizing effectiveness while reducing risk at every stage of every disease we treat must remain our priority for our patients’ well-being. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest Consultant and research funding: Astellas, Janssen, Sanofi, AstraZeneca, Bayer.

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