The prostate cancer team at the Comprehensive Cancer Center at Wake Forest Baptist Medical Center has recently focused on two primary areas: minimally invasive care and clinical research.

In Spring 2013, our prostate cancer team launched a program to provide nonsurgical management options for prostate cancer in a common setting that allowed the involvement of physicians from different specialties. This minimally invasive program gave specific attention to four procedures: transperineal prostate biopsy, cryotherapy, low dose rate brachytherapy (commonly referred to as a “seed implant”) and high dose rate brachytherapy. All four of these procedures share a common OR and a common staff dedicated to making the entire process as painless and pleasant for the patient as possible.

In addition to offering low dose rate and high dose rate brachytherapy, which are relatively common components of a minimally invasive program, we also offer cryotherapy. Prostate cryoablation, performed by Daniel B. Rukstalis, MD, professor, Urology, is performed as a percutaneous surgery under intravenous anesthesia with ultrasound guidance. The ability to kill specific regions of the prostate with cold temperatures allows for a very flexible procedure that can be individualized to the specific circumstances of each patient’s cancer.

Similar to low dose rate brachytherapy, cryoablation is performed as an outpatient procedure with only a short recovery period. Importantly, prostate cryoablation has demonstrated a positive effect on the benign enlargement of the prostate that often accompanies prostate cancer, resulting in an improved ability to urinate following the procedure.

In early 2012, our prostate cancer team joined forces with all interested researchers to form a working clinical research team. This team is composed of physicians from the three core treating specialties (urology, radiation oncology, and medical oncology), as well as scientists doing specialized work in the field of prostate cancer management.

In the time this group has been working together, we have increased the number of clinical trial options available for men with prostate cancer at all stages. As a result, we have greatly increased the number of men involved in clinical trials.

We are especially pleased to have recently completed a trial created by members of our own group in the setting of recurrent prostate cancer. The lead investigator on the trial is Gary Schwartz, PhD, MPH, associate professor of Cancer Biology and head of the Prostate Cancer Center of Excellence. The rationale for this trial is based on the findings from three prospective studies indicating that men with serum calcium levels that are high but normal are significantly more likely to die from prostate cancer. This led us to attempt to lower serum calcium (which is a known mitogen for prostate cancer cells) in men with recurrent prostate cancer using a drug proven to lower calcium in the setting of chronic kidney disease. The last participant has completed the trial and the results will be available soon for review by the scientific community.

We are also excited to have recently opened a trial exploring new means to control prostate cancer that recurs following surgery. This trial was co-authored by one of our medical oncology team members, Rhonda Bitting, MD, assistant professor, hematology and oncology, and will be conducted at Wake Forest and two other institutions in the United States. The STREAM study (Salvage Therapeutic Radiation with Enzalutamide and ADT in Men with Recurrent Prostate Cancer; NCT02057939) looks at the value of adding systemic hormonal therapy to standard external beam radiation in hopes of improving the rate of cure in men with rising PSA after surgery.

In addition to salvage radiation therapy to the prostate bed, men will be treated with 6 months of androgen deprivation therapy along with the androgen receptor inhibitor enzalutamide. Enzalutamide is known to slow cancer progression and improve survival in more advanced prostate cancer, and preclinically, androgen receptor inhibitors have been shown to synergize with radiation therapy. Therefore, this combination therapy approach is hypothesized to improve cure rates in men with recurrent prostate cancer. The primary objective for the trial will be to describe the 2-year progression- free survival.

Any man with a nonmetastatic biochemical recurrence of his prostate cancer within 4 years of surgery will be eligible for the STREAM study as long as his PSA is between 0.2 and 4.0. Physicians interested in referring patients for this study should contact Rhonda Bitting, MD, at (336) 716-0327.

Bart Frizzell, MD

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Advancing Prostate Cancer Care