Cancer is a frightening and life-altering diagnosis for any patient. When that cancer is particularly aggressive or widespread, it takes a diligent team of expert physicians to provide the best, most comprehensive care. For men with the most serious forms of prostate cancer, a new clinic at Washington University School of Medicine in St. Louis and Siteman Cancer Center is going on the offensive.
“I’d like to introduce the first of its kind CHARM Offensive against prostate cancer,” says Gerald L. Andriole, MD, Chief of the Division of Urologic Surgery. Andriole, who is also the Royce Distinguished Professor and a 2020 Distinguished Faculty Award recipient at the School of Medicine, refers to this clinic’s treatment as a “CHARM Offensive” because it is dedicated to the Care of men who have High risk, Advanced, Recurrent or Metastatic prostate cancer.
High risk refers to the likelihood—based on levels of prostate specific antigen (PSA), among other indicators—that the cancer has spread, even if conventional imaging has not detected that spreading.
Advanced prostate cancer is locally invasive, meaning that it has visibly spread to nearby areas, such as the bladder or rectum.
Recurrent prostate cancer has returned despite previous attempts to cure it through radiation, surgery or other treatments.
Metastatic cancer has spread beyond the local area and now affects parts of the body further from the prostate, including lymph nodes, organs and bones.
At the CHARM Clinic, Andriole offers each of these patients multidisciplinary treatment options targeted to his particular situation. Not all patient cases are the same, and a one-size-fits-all approach to treatment is not the best way to care for these men. Instead, the CHARM Clinic provides access to the full range of treatment options, including surgery, radiation, hormone therapy, chemotherapy, immunotherapy and cryoablation. For some patients, surgery may not require complete removal of the prostate. Some men can receive radiation to targeted areas, rather than to the entire pelvis, sometimes described to patients as “spot welding.”
“When you tell a guy, ‘We’re going to target a specific site for radiation, akin to spot-welding,’ he knows what you mean,” Andriole says. It is important to Andriole that patients understand their diagnoses and are part of the decision-making process involved in their treatment.
Next Gen Imaging Guides the Offensive
Because the forms of prostate cancer the CHARM Clinic fights are complex, it is important to see the cancer cells clearly. Andriole employs individualized treatment options fine-tuned to the patient’s needs, which are determined in part by the size, shape, location and amount of cancer detected.
Andriole describes newer, more precise forms of prostate cancer detection as “Next Gen Imaging.” MRI, PET scans and high frequency ultrasound, Andriole says, have the ability to better identify exactly where the cancer is located. Based on the patient’s situation, Andriole can employ the appropriate imaging technique, in collaboration with radiologists, to find cancer cells and develop a treatment plan. “’Next Gen’ imaging can tell us whether the cancer is abutting or distorting the prostate,” Andriole explains, “both of which suggest that the cancer may have spread.”
High frequency ultrasound—which takes pictures of the prostate at much higher frequency than previously available tests—boasts other additional benefits. This test can be done in a doctor’s office, meaning it comes at a lower cost than MRI, while also avoiding claustrophobia for some patients and the prohibitive factors of pacemakers and implanted metal devices for others.
“We have turned the detection of prostate cancer into something similar to what women have when they undergo mammography to look for breast cancer,” Andriole illustrates for comparison. “If a woman has a mammogram and there is a suspicious site in her breast, that’s the part of the breast the surgeon biopsies. We are now able to do the very same thing for men without all of the encumbrances, expense, claustrophobia and other limitations of MRI scanning for prostate cancer.”
Improved Screening Helps Target Those at High Risk
Prostate cancer is among the most common forms of cancer, according to the National Cancer Institute. One in five men will develop prostate cancer at some time in their life. While it is the second leading cause of cancer death among men in the United States, prostate cancer is often so slow-growing that monitoring is a better option than more aggressive treatment.
In the past, prostate cancer has been overdiagnosed. In some cases, the cancer may never have affected the man’s health during his lifetime because it was so slow-growing. This overdiagnosis contributes to the high likelihood that a man will have a family history of prostate cancer. Family history is one factor that puts a man at risk, but does not guarantee that he will have an aggressive form of prostate cancer like those treated at the CHARM Clinic.
So, who should get screened for prostate cancer?
The American Cancer Society recommends that men consider screening at age 50—sooner for men who are at higher risk, including African Americans and men whose father or brother was diagnosed younger than 65. By limiting to first-degree relatives, this recommendation addresses the past overdiagnosis while still accounting for risk factors in family history.
In addition to the traditional PSA blood test, Andriole offers patients a genetic test that can measure a man’s risk level by looking at specific genes. As testing becomes more targeted, it becomes possible to monitor patients who are at higher risk without overdiagnosing.
“There are a lot of different, nuanced ways we use the word ‘targeted,’” Andriole asserts. “We visually target an area if we see an abnormality in the prostate. We use targeted radiation to spot-weld cancer. But we are also targeting genetic defects in cancer.”
For Andriole, the CHARM Clinic is all about targeting and eliminating the most threatening forms of prostate cancer, but early detection and close monitoring are also vital to keeping patients healthy.
“We want men who are at high risk to get tested early in life,” Andriole says. “The idea is that, if we can do better at screening, you’ll be less likely end up in HARM’s way.”