Artificial intelligence (AI) and long-term outcomes data are all reshaping how clinicians and patients navigate treatment decisions in prostate cancer. CancerNetwork® spoke with Herbert Lepor, MD, Martin Spatz Chair of the Department of Urology and director of the Smilow Comprehensive Prostate Cancer Center at NYU Langone Health, about where AI currently stands in his own decision-making, his surveillance protocol following focal cryoablation, how he counsels patients weighing focal therapy against radical prostatectomy, and how personalized, shared decision-making in prostate cancer has evolved.
How is AI currently being used in prostate cancer decision-making, and where do you see it having the greatest impact going forward?
Eventually AI is going to revolutionize a lot of the decision-making in prostate cancer. For example, risk assessment and treatment options. In terms of my practice, I deal primarily with prostate cancer screening, detection, and early-stage disease, and today, it has not made a big impact in my decision-making. With large data sets, we are going to gain better insights into who we should be screening, who we should be treating, and the various options, especially for medical oncologists.
When I was a resident, all we had was hormonal therapy; today there are 10 to 20 approved treatments for advanced prostate cancer, and the question becomes how you sequence these treatments, and whether you can do personalized treatment. That is where AI is going to have a big impact. Today, honestly, in my practice, AI has not revolutionized the decisions I make: Should I biopsy this patient? How do I treat this patient in terms of surveillance, focal therapy, or radical prostatectomy vs radiation therapy? AI has not yet made a major impact on those decisions, but do I think it will? Yes.
Given a 91% negative predictive value but 25% sensitivity of MRI after focal cryoablation, what is your current recommendation for the ideal long-term surveillance protocol, and when should a protocol biopsy be mandated despite a negative MRI?
What we do today is a PSA [prostate-specific antigen] test every 6 months, and an MRI at 6 months, 2 years, 3.5 years, 5 years, 7.5 years, and soon 10 years. When we first started the focal therapy journey, we did not have a good sense of whether we were effectively destroying the disease, or whether disease was developing out of field, so we biopsied everybody at 6 months and again at 2 years. What we found is that if the MRI showed no suspicion for recurrence in or out of field, and there was no progressive increase in PSA, the detection of what we call clinically significant cancer—any Gleason pattern 4—was about 10%. When we make decisions about who we biopsy, we realize that if we want to identify every single cancer, we would have to biopsy everybody, so we accept a threshold of what we are willing to miss on a biopsy to avoid over-biopsying.
Read full interview: https://www.cancernetwork.com/view/balancing-oncologic-outcomes-with-patient-priorities-in-prostate-cancer-care
