Editor’s Note: The “4th Chinese Medical Association Urology Surgeons Branch Yanqi Lake Conference (2024)” was successfully held in Beijing from April 13th to 14th. The conference not only focused on clinical practices in urology surgery but also discussed cutting-edge developments and important topics in the industry. At the conference, Professor Xuesong Li from Peking University First Hospital shared insights on “Optimizing Prostate Cancer Management to Safeguard Men’s Lives.” “Oncology Frontier – Urology News” has specially compiled relevant content for readers.

In the era of chronic diseases, comprehensive management of prostate cancer

Prostate cancer ranks first among malignant tumors in men worldwide and sixth in terms of mortality rate among malignant diseases. Although the incidence of prostate cancer in China continues to rise, thanks to the continuous improvement in treatment techniques, its mortality rate has shown a stable downward trend, and the survival expectancy of patients has also improved. Currently, the five-year survival rate of Chinese prostate cancer patients has reached 69.2%, marking the gradual entry of this disease into the stage of chronic disease management. However, compared with developed countries, the prognosis of prostate cancer patients in China is still inadequate. There are many factors contributing to the less-than-ideal overall prognosis of prostate cancer in China, including deficiencies in patient screening, awareness of seeking medical treatment, and comprehensive disease management.

As a multi-stage progressive tumor, prostate cancer exhibits significant differences in molecular biology characteristics, drug sensitivity, and resistance mechanisms at each stage of the disease, leading to adjustments in treatment goals and strategies. Patients need to actively intervene under the guidance of physicians to implement standardized comprehensive management measures for different stages of the disease, thereby delaying the progression to metastasis or terminal stages and extending survival. Therefore, it is crucial to carry out comprehensive management of prostate cancer from early screening, diagnosis, treatment, to follow-up under the guidance of physicians, which cannot be overlooked.

In the era of precision medicine, individualized management of prostate cancer

Prostate cancer’s clinical manifestations and genetic characteristics exhibit significant heterogeneity, resulting in differences in disease presentation among patients. Guiding individualized treatment plans based on the principles of precision medicine is expected to significantly improve patients’ prognosis and quality of life. With the continuous advancement of diagnostic and treatment strategies, individualized management tailored to each patient has become the trend in prostate cancer treatment.

Individualized management mainly includes individualized screening, treatment, and follow-up. In terms of individualized screening, a more personalized assessment is required to reduce overdiagnosis and overtreatment. According to the European Association of Urology (EAU) guidelines, individualized screening should be conducted based on the risk stratification of prostate cancer. According to the Chinese Prostate Cancer Screening and Early Diagnosis and Treatment Guidelines, the National Cancer Center Guidelines recommend PSA screening for high-risk populations. Men with a life expectancy of more than 10 years and meeting one of the following conditions: aged 60-74; aged ≥45 with a family history of prostate cancer; aged ≥40 with BRCA2 gene mutations are classified as high-risk populations for prostate cancer. Serum PSA testing should be performed with informed consent. If PSA ≤ 4.0 ng/ml, monitor every 2 years and follow-up. If PSA is > 4.0 ng/ml on two occasions, further clinical examination, intervention, and follow-up are necessary.

The 2023 CSCO guidelines emphasize precision screening for prostate cancer, with PHI and PHI combined with MRI improving the predictive accuracy of prostate cancer. PHI has high accuracy in detecting prostate cancer and distinguishing between invasive and non-invasive prostate cancer. Additionally, the 2023 CSCO guidelines also recommend standardizing and optimizing the pathway for prostate biopsy to improve the clinically significant detection rate of prostate cancer. The guidelines state that the assessment of prostate cancer risk should focus on detecting clinically significant prostate cancer (≥ GG2+), and the combination of biomarkers, prostate MRI, and prostate biopsy techniques may increase detection rates and safety.

For mHSPC, ADT-based treatment strategies are the cornerstone of all regimens. For CRPC, maintaining androgen deprivation therapy (ADT) is still necessary. CRPC can still exhibit androgen receptor dependence through various mechanisms, including the continuous presence of androgens due to the re-synthesis of testosterone within the tumor. The CSCO guidelines clearly state that the treatment of CRPC should be based on maintaining ADT. Treatment principles include multi-disciplinary team collaboration in the diagnosis and treatment of metastatic castration-resistant prostate cancer (mCRPC); selection of drug treatment plans based on patient physical status, symptoms, disease severity, pathological characteristics, and patient preferences, while considering the treatment effects of previous drugs on hormone-sensitive metastatic prostate cancer; continued maintenance of ADT; consideration of supportive treatment on the basis of systemic treatment; regular disease monitoring and efficacy assessment, and genetic testing.

The follow-up strategy for prostate cancer also needs to be individualized. EAU and CSCO prostate cancer guidelines suggest that follow-up strategies should be individualized based on comprehensive disease staging, past symptoms, prognostic factors, and treatment plans. After the start of ADT, patients should be assessed every 3-6 months, with individualized planning. During the initial 6 months of ADT treatment, testosterone should be monitored monthly to assess the risk of disease progression. The Chinese Urology Surgeons Branch of the Chinese Medical Association has developed and released a standardized process for testosterone monitoring and management during ADT treatment.

In April 2024, the Chinese Prostate Cancer Research Collaborative Group (CPCC) released the “Chinese Expert Consensus on the Follow-up Management of Drug-Based Androgen Deprivation Therapy for Prostate Cancer (2024 Edition).” This consensus proposed the concept of “treatment critical periods” for the first time, clearly defining five major population groups: namely, the neoadjuvant treatment stage, within the first 6 months of starting high-risk prostate cancer adjuvant treatment, biochemical recurrence stage, within the first 6 months of initial drug treatment for mHSPC, and patients in the mCRPC stage. The consensus emphasizes the importance of focusing on the quality of life and follow-up of prostate cancer patients, advocating a treatment concept of close follow-up for the “treatment critical periods” population. The “treatment critical periods” have a significant impact on the survival and quality of life of prostate cancer patients. Patients require professional, standardized, and close follow-up, and should return to the ADT treatment hospital for follow-up visits every month to promptly detect disease progression and adjust treatment plans to improve patient treatment compliance.

Prostate cancer management teams and tools

In China, many prostate cancer patients are diagnosed with metastases, and surgery alone cannot cure them. Comprehensive treatment through surgery, radiotherapy, drugs, etc., is needed to achieve the desired therapeutic effect. This requires multidisciplinary teams to make decisions together, determine the most suitable treatment method for patients to prolong life, and improve quality of life. MDT teams can optimize perioperative management, promote rapid recovery, and reduce postoperative complications.

Individualized follow-up models with patient self-management are gradually replacing traditional models. This management model is led by a healthcare worker responsible for daily management, acting as a coordinator and primary contact for patient follow-up management. A specialized urology oncology clinical nurse supervises, while overall responsibility for the patient remains with the urologist/oncologist. Patients do not have specific follow-up times, and follow-up management is conducted through a customized online system, where patients and the prostate cancer management team can track prostate cancer recurrence through regular PSA testing. Through various questionnaire scales, patient needs, adverse treatment reactions, quality of life, psychological health status, concerns about cancer recurrence, self-management initiative, and general health status are assessed. The patient self-management follow-up model had lower demand intensity at 4 months (P = 0.025).

Additionally, the development of network technology brings possibilities for online patient management. Prostate cancer management apps can facilitate the sharing of patient education materials, manage nutrition and metastasis stages, calculate and assess risks, schedule appointments, and consult doctors online, while providing warnings for dietary precautions and laboratory tests. Hospital-home continuity of care based on a cloud follow-up platform has been applied and accumulated relevant experience in elderly prostatectomy patients.

Primary medical institutions can serve as the mainstay of prostate cancer follow-up and leverage the advantages of tertiary diagnosis and treatment. After the initial follow-up in the hospital, prostate cancer patients will be transferred to primary medical institutions for management by general practitioners. This facilitates the establishment of a bidirectional referral and information sharing network between general medical and specialized medical care. It ensures that prostate cancer patients receive the most effective, convenient, timely, and appropriate services; at the same time, it can strengthen cooperation between general practitioners and specialists in various aspects such as information collection, disease monitoring, disease system management and behavioral guidance, appropriate use of new technologies, and medical research, thereby comprehensively improving the quality of medical services and efficiency.

Conclusion

The prognosis of prostate cancer patients continues to improve, entering the era of chronic disease management. Emphasis on comprehensive management of prostate cancer from early screening, diagnosis, treatment, to follow-up is crucial. With the continuous enrichment of prostate cancer diagnostic and treatment methods, individualized screening, treatment, and follow-up are inevitable trends, especially emphasizing the pivotal role of ADT in comprehensive treatment. Close follow-up monitoring of disease progression and adverse reactions is necessary at the beginning of treatment. The development and progress of management methods such as multidisciplinary teams, tertiary diagnosis and treatment, and network platforms bring more convenient management methods for prostate cancer patients, helping to improve management levels and ultimately improve patient prognosis.

Xuesong Li

Professor

Chief Physician, Professor

Doctoral Supervisor, Postdoctoral Co-Supervisor

Director, Department of Urology, Peking University First Hospital

Vice Dean, Urology Physician Training Institute, Peking University

Curator, Beijing Urology Endoscopy Museum

Leader, Upper Urinary Tract Repair Professional Group, Peking University Department of Urology

Member and Deputy Secretary-General, Chinese Medical Association Urology Surgeons Branch (CUDA)

Deputy Director, Male Reproductive Medicine Branch, China International Exchange and Promotion Association for Medical and Healthcare

Deputy Director, Robot Group, Chinese Urology Surgeons Branch, Chinese Medical Association (CUA)

Deputy Group Leader, Repair and Reconstruction Group, CUDA

Leader, Upper Urinary Tract Repair Collaboration Group, CUDA

Deputy Group Leader, Digital and Artificial Intelligence Group, CUDA

Deputy Director, Postgraduate Medical Education Committee (Urology), Chinese Medical Association

Standing Committee Member, Second Session of the Chinese Medical Equipment Association Artificial Intelligence and Medical Robotics Working Committee

Standing Committee Member, Surgical Group, Fifth Session of the Chinese Medical Association Evidence-Based Medicine Committee

Committee Member, Minimally Invasive Surgery Group, Chinese Anti-Cancer Association Male Reproductive System Tumor Professional Committee

Deputy Group Leader, Urinary Tract Repair and Reconstruction Group, Beijing Medical Association Urology Branch

Chairman, Prostate Cancer Professional Committee, Beijing Cancer Prevention and Treatment Society

Committee Member, Clinical Research Committee, Asian Robotic Urology Society (ARUS)

Academic Chair, Society of Robotic Surgery (SRS)