Journal: Prostate Cancer and Prostatic Diseases

As a randomised controlled trial, the PRECISION study¹ showed a clear benefit of an MRI pathway in terms of improved detected of clinically significant prostate cancers and decreased detection of clinically insignificant prostate cancers. However, it seems that not all urologists are convinced by the data or sufficiently motivated to change clinical practice on the strength of this study. That said, it is accepted that access to prostate MRI due to reimbursement issues could play a role in some jurisdictions.

The 2021 EAU Guidelines² have clearly spelt out a recommendation that an MRI should be performed prior to prostate biopsy whether it be those men who are biopsy naïve or have previously had a negative prostate biopsy.  The strength rating for both recommendations is “strong”.  The 2021 NCCN Guidelines³ are a little more guarded in that the recommendation for an MRI prior to prostate biopsy is qualified by the words ‘if available’.  Particularly in the US, 3T MRI is widely available but sadly, it is an issue of reimbursement despite the highest level of evidence to support its routine use prior to prostate biopsy.

Doctor: “You have prostate cancer.”

Patient: “Doctor, that’s awful. What can I do to help it grow slower and feel better?”

Doctor: “Eat right and exercise.”

Patients: “How much exercise should I do?”

Doctor: “I don’t know.”

While the above is a fictitious discussion between doctor and patient, my guess is that similar discussions occur every day. When diagnosed with cancer, patients want to improve their lifestyle and clamor for any information their provider can give them. Unfortunately, most providers don’t know what advice to give. Even if the provider is knowledgeable and interested, discerning the literature and coming up with an answer to a straightforward question such as “how much exercise” is not an easy task. Into this void, steps the systematic review and meta-analysis by Lopez and colleagues.

It is well appreciated that men with bone metastases are at risk for fracture and symptomatic skeletal-related events (SREs), and that men on long-term potent hormonal therapies are at risk for fragility fractures due to ongoing bone loss. However, the utilization of denosumab and zoledronic acid, despite the widespread guideline recommendations for their consideration, remains low internationally. This was recently highlighted at ASCO 2021 with the PEACE3 clinical trial, where the mandated use of bone antiresorptive therapy in this bone mCRPC protocol of enzalutamide +/- radium-223 led to an improvement in the use of these agents in this population from 55% to 97%, and reduced the observed fracture rate at 18 months with enzalutamide alone from 22% to 2.6%, a major reduction in risk.¹