Prostate Cancer Treatment

One of the earliest immunotherapies approved by the Food and Drug Administration (FDA) for the treatment of cancer was a vaccine called sipuleucel-T. It’s been used to treat metastatic prostate cancer since 2010.

Since then, the introduction of immune checkpoint inhibitors has revolutionized the field of cancer treatment. And patients with some types of cancer — such as melanoma and lung cancer — have benefitted greatly from that discovery. Others, including those with prostate cancer, have not benefited as much.

At MD Anderson, we are working hard to understand why, and what can we do to change it.

Few T cells in prostate tumors help thwart immune checkpoint inhibitors

A major reason immune checkpoint inhibitors don’t work as well against prostate cancer is that the gland doesn’t contain a lot of T cells, which do much of the immune system’s heavy lifting when it comes to killing cancer. 

Melanoma (a skin cancer) and lung cancers generally have more T cells. So, an immune checkpoint inhibitor, which takes the brakes off of T cells and allows them to keep working, is much less effective in a cancer that doesn’t have many T cells to begin with.

New class of immunotherapy makes the most of existing T cells

But a new class of immunotherapy, called T cell bi-specifics, also known as T cell redirectors, could be changing that. These drugs bind one part of themselves to a tumor cell and the other part to a T cell. Forcing the two cells together has yielded some remarkable results. 

A recent clinical trial involving an experimental drug called AMG 509/Xaluritamig, saw a reduction in blood levels of prostate-specific antigen (PSA), a tumor marker, in nearly half of participating patients. A quarter of participating patients whose tumors could be measured saw shrinkage on scans. This drug targets a protein called STEAP-1 on prostate tumor cells and an antigen called CD3 on T cells. Several clinical trials involving that drug are now underway at MD Anderson.

Another just-launched study, led by my colleague Sumit Subudhi, M.D., Ph.D. in collaboration with Brian Chapin, M.D., and me, is providing a unique lens to study these drugs. This clinical trial is using a first-in-its-class drug called REGN5678, which binds the prostate-specific membrane antigen (PSMA) on tumor cells and the CD28 protein on T cells. 

Patients with prostate cancer who will undergo surgery will receive the experimental drug for six weeks, then have their prostate glands removed. Analyzing the entire gland will help us understand exactly what the drug is doing, how it’s working and how we might be able to combine it with other drugs in the future, to potentially improve effectiveness.

Learning about new therapy’s side effects

We’re also looking at side effects. Immunotherapies can be very effective at attacking tumors. But they can also sometimes cause unwanted side effects, where the immune system starts attacking the body’s tissues and organs. 

As with CAR T cell therapy, the two major side effects of T cell bi-specifics are:

• Cytokine release syndrome (CRS): This causes flu-like symptoms such as high fever, fatigue and body aches in milder cases, and blood pressure problems and other issues in more severe cases. We treat CRS with steroids and a drug called tocilizumab.
• ICANS: This side effect, which stands for immune effector cell-associated neurotoxicity syndrome, makes patients confused or disoriented. They may also temporarily lose the ability to speak. Steroids are the most effective treatment.

As T-cell bi-specific drugs are new, we are also seeing new kinds of immune side effects.  But we are actively studying how to find a balance between keeping a good immune response to these drugs and separating it from the unwanted side effects. We monitor the patients receiving these treatments very closely.

Our hope for the future of prostate cancer treatment: the possibility of immune memory

Prostate cancer feeds on testosterone. So, we’ve known for more than 70 years that if we reduce or eliminate testosterone levels using hormone-suppressing drugs, prostate cancer will initially shrink. Unfortunately, prostate cancer often learns how to grow despite the absence of testosterone, making it what’s called “castration-resistant.” 

The average lifespan of a patient after a diagnosis of metastatic castration-resistant prostate cancer is two to three years. Approximately 30,000 men die of this disease annually.

So, the possibility of immune memory makes this form of therapy exciting. Immune memory is why vaccines work, and why once you’ve had chicken pox, you won’t get it again. Your immune system learns how to fight off certain threats it’s seen before and destroy them if it ever encounters them again.

If we can successfully harness this therapy’s power to create immune memory for our prostate cancer patients, then they might finally be able to achieve long-term benefits. So, this is a really exciting time to be studying immunotherapy.

Clinical trials for prostate cancer are usually only open to patients who have advanced-stage, metastatic disease. That’s where the need is greatest. But there are also studies for patients who have early-stage prostate cancer with a high risk of recurrence. Talk to your oncologist if you’re interested in enrolling to see if one might be a good option for you.

Bilal Siddiqui, M.D., is a medical oncologist who specializes in the treatment of prostate cancer and other genitourinary cancers.

Request an appointment at MD Anderson online or call 1-877-632-6789.

When Howard Walton visited his primary care doctor in August 2022, she was concerned his prostate-specific antigen (PSA) levels were rising too quickly. Later that month, Howard saw his urologist, who found that his PSA levels had risen significantly since he’d last seen Howard.

Howard’s urologist ordered a biopsy, and the results showed he had prostate cancer. He met with doctors at an Ohio hospital; they discussed two options: radiation therapy or surgery. Howard and his wife were already planning to spend the winter with their daughter in Houston, so instead of waiting to start treatment until they were back in Ohio, Howard told his urologist he wanted to go to MD Anderson. He called and got an appointment with John Ward, M.D., in November. 

Another treatment option: high-intensity focused ultrasound 

At his initial appointment, Ward suggested Howard might be a candidate for high-intensity focused ultrasound (HIFU), a treatment that uses heat generated by focused ultrasound waves to kill cancer tissue in the prostate. Patients who have early-stage prostate cancer with an MRI-identified tumor are typically good candidates for HIFU. 

During HIFU treatment, the patient is put under general anesthesia before the doctor places an ultrasound probe in the rectum and takes an image of the prostate. Data from the image is used to create a three-dimensional model of the prostate to determine the exact location, size and shape of the tumor. The probe, under robotic control, then releases focused, high-energy sound waves to the tumor to heat and kill cancer cells.

Howard had never heard of HIFU, but after Ward described the procedure, he was convinced it would be the best option instead of radiation therapy. 

“I found the idea of a one-time treatment much more preferable than six or seven weeks of radiation every day,” Howard says. “My mind was made up. I was convinced that if I was eligible, that's what I wanted to have done.”

‘Best decision’ to undergo HIFU 

After undergoing an MRI, Howard was determined to be eligible for HIFU. He underwent the procedure in December and went home the same day. At the end of the procedure, Ward inserted a Foley catheter, a soft tube that continuously drains urine from the bladder into a drainage bag. It was removed a week later.

Howard calls undergoing HIFU "the best decision” for him. Even though Ward cautioned that a recurrence of the cancer was possible, Howard says Ward’s confidence in the procedure convinced him to choose HIFU over other treatment options. 

“Dr. Ward exuded confidence, and I could feel that,” Howard says. “It made me more comfortable. Everyone I saw in connection with the procedure was so professional, kind and courteous. I have told more people, especially men, how common prostate cancer is. I tell them, ‘If you get prostate cancer, call MD Anderson. There’s no place like it.’”

Request an appointment at MD Anderson online or call 1-877-632-6789. 

With a family history of prostate cancer, Keith Burchfield did not wait to talk to his doctor about the risks and benefits of early prostate cancer screening.

At his yearly exam, his prostate-specific antigen (PSA) levels had significantly changed since the previous year. There was a 50% chance that he had early-stage prostate cancer. PSA levels show up through a blood test that measures the amount of PSA circulating in the blood. This level is used to assess prostate cancer risk.

Knowing MD Anderson is the top cancer hospital in the nation, he requested an appointment online right away. “I live in the Dallas area and was willing to make the 4-hour drive for the expertise and top treatment options,” says Keith. “I did not want to waste any time.”

Finding expertise and reassurance at MD Anderson

Keith’s first appointment at MD Anderson was scheduled in November 2020, during the COVID-19 pandemic. He met with urologist Justin Gregg, M.D., who ordered an MRI to be done in Dallas so Keith could be close to home.

After the MRI, Gregg confirmed Keith had four lesions. The previous hospital had only detected three. Keith had a biopsy at MD Anderson, then went back to Dallas to wait for his results. Shortly thereafter, Gregg called to let Keith know that the biopsy confirmed he had stage II prostate cancer.

Gregg outlined Keith’s prostate cancer treatment options: surgery, radiation therapy or active surveillance – also known as watchful waiting. “Dr. Gregg answered all my questions with great care. This helped me and my wife, Judy, decide what type of treatment was best for me,” says Keith.

He did not want to postpone treatment by choosing active surveillance. He also didn’t want to face the possibility of side effects from surgery. So, Keith chose radiation therapy. He knew he had a window of opportunity and did not want to wonder if the cancer would become aggressive.

“I was presented with the gift of early detection and wanted to do something as soon as possible,” he says.

Undergoing SBRT for prostate cancer treatment

In February 2021, Keith traveled to Houston to meet with radiation oncologist Karen Hoffman, M.D., and Sarah Todd, her physician assistant at the time.

“Dr. Hoffman and Sarah took the time to explain the types of radiation therapy treatments that I qualified for,” remembers Keith. Each radiation type uses a different number of treatments, either daily radiation for weeks or a short-term radiation for five sessions.

After talking it over with his wife, Keith decided to undergo a short-term radiation therapy called stereotactic body radiation therapy (SBRT). SBRT typically consists of five treatments using a high dose of radiation to treat the tumor’s exact location and shape. A customized treatment plan sets the angles and intensities of the radiation beams.

Keith decided to commute to Houston from Dallas for his five daily SBRT treatments. It happened to be the week of the February 2021 winter storm, an historic winter weather event in Houston resulting in road closures, widespread power outages, loss of heat and broken pipes across Texas.

“I am very thankful that Dr. Hoffman and Sarah are so easy and wonderful to work with. They stayed in continuous communication with me. They made sure I was able to stay on track with my treatments during the bad winter storm – even treating me on a Saturday to make up a missed appointment during the week,” he says.

Keith does not recall experiencing any significant side effects from SBRT. “While every treatment has side effects, I did not notice anything out of the norm from treatment. I had energy to drive back and forth each day,” he says. “And the staff accommodated my travel schedule and arranged my appointments for later in the morning or early afternoon.”

Cherishing every moment after successful SBRT

Three years after treatment, Keith continues to enjoy life after cancer. He meets with Todd every six months to review his PSA levels via a telehealth visit and make sure his prostate cancer stays in remission. In July, he will switch to annual visits.

“My father was diagnosed with stage IV prostate cancer many years ago when they did not have the technology and treatment options available today,” says Keith. “I’m thankful for the advances in radiation therapy.”

Keith is glad he got annual exams to keep an eye on his PSA levels. Most people with stage I or II prostate cancer do not show any symptoms. He tells other men: If you develop prostate cancer and catch it early, you will have more treatment options and a better chance of getting cured.

Not doing active surveillance was an easy decision for Keith. He did not want to have regrets, and he knew the treatment would be more challenging if he was diagnosed with advanced disease.

“Know the prostate cancer warning signs and stay on top of your PSA screenings, especially if you have a family history,” he says. “Early diagnosis is the key to effective treatment.”

Request an appointment at MD Anderson online or call 1-877-632-6789.

Nikki Samms, DPT, knows the region of the body she treats can make people uncomfortable.

As an MD Anderson pelvic floor physical therapist, Samms spends her days helping patients navigate a wide range of pelvic floor issues ranging from trouble using the bathroom to pain with intercourse to organ prolapse.

“Our society puts a lot of taboo on discussing all things pelvis,” she says. “A lot of my patients feel like they're sort of suffering in silence or they're the only human on earth experiencing the problems that they are because we've just put so much shame around our pelvises.”

Thankfully, pelvic floor physical therapy can help those who are experiencing pelvic floor issues. Ahead, Samms answers questions about the pelvic floor and pelvic floor physical therapy, including what treatments are used, who might benefit and what happens during an appointment. 

What is the pelvic floor?

First things first: What exactly is the pelvic floor? Where is it? And what does it do?

Samms describes the pelvis as a ‘tight neighborhood’ housing a variety of organs including the bladder, rectum and, for women, the uterus. 

There are three layers of muscles at the bottom of the pelvis. These muscles are called the pelvic floor, and they are used for many everyday activities. 

“These muscles are very special. They stabilize your spine, they hold up your internal organs, they help you with pooping, peeing, sexual function, potentially being pregnant and giving birth,” Samms says.

How do you know if you need pelvic floor physical therapy?

Because the pelvic floor has so many different roles, there are many reasons someone might need pelvic floor physical therapy.

Samms says these might include: 

• urinary or fecal incontinence
• constipation
• pelvic organ prolapses
• tailbone pain 
• anal-rectal pain
• pain with intercourse
• pain during vaginal exams
• sacroiliac joint pain 

Because other medical concerns can cause symptoms similar to those caused by pelvic floor issues, patients are often screened for other health concerns before being referred to pelvic floor physical therapy.

“We want to be aware of what's within our wheelhouse but appreciate that it's not just muscles. There are organ systems there. We have to say, ‘Hey, what's really happening?’ with a good thorough interview or an examination,” she says.

What happens during the examination at a pelvic floor physical therapy appointment?

Before a pelvic floor physical therapy appointment at MD Anderson, your provider will review your chart to better understand your situation.

At a patient’s first appointment, Samms says she shares information about the pelvic floor muscles before asking patients questions about any pain they may be experiencing, as well as their bladder, bowel and sexual function. 

Then, it is time for a physical exam. This may include an external examination of the pelvis during which the provider lightly touches the region to determine if a patient feels pain or tenderness. This may be followed by an internal examination of the vaginal or rectal canal to determine whether there is any pain, tenderness or restrictions. During an internal examination of the pelvic floor, a provider may ask you to activate, or squeeze, certain muscles to better understand how they are functioning. 

From there, Samms works with her patients to create a unique care plan that enhances their quality of life. 

Success looks different for every patient: some will measure success by their ability to better control their bladder or bowels, others by their ability to have pain-free intercourse.

“We come up with a very individualized, tailored, thorough plan,” Samms says.

What kinds of exercises are used in pelvic floor physical therapy?

Pelvic floor physical therapy might draw to mind pelvic muscle strengthening exercises such as Kegels, or biofeedback, which uses computers to assess the body while a patient performs exercises.  

While Samms notes that Kegels and biofeedback are components of pelvic floor physical therapy, it also includes many other exercises and modalities that can be customized for each patient based on their symptoms and goals. 

“Those are just such small tools in the toolbox of a pelvic floor practitioner,” she says.

Pelvic floor physical therapy might also include exercise, muscle strengthening or coordination training. 

Additionally, Samms uses pain neuroscience to help her patients better understand pain and the role it plays in protecting the body from harm. 

Pelvic floor physical therapy also considers nutrition, sleep hygiene and mental health.

"Pelvic floor physical therapy is really best when it is holistic and takes into consideration partners and we're not working in silos and we're considering the whole mind-body machine,” Samms says.

What is the role of pelvic floor physical therapy in cancer treatment?

There are many reasons someone undergoing cancer treatment may be referred to pelvic floor physical therapy. Patients may have preexisting pelvic floor health issues or only begin experiencing them as side effects from cancer treatment such as chemotherapy, radiation or surgery. 

Chemotherapy can affect the bladder and urinary system and lead to urinary incontinence.

Additionally, radiation shortens muscles and connective tissue making it harder for them to move. This can cause urinary incontinence, constipation or pain with intercourse.

Surgery can also impact organs in the pelvis and the pelvic floor. For example, if the prostate is removed during prostate cancer treatment, it can alter the body’s anatomy and lead to urinary incontinence. 

“If you remove that prostate from underneath that bladder, that urinary support is no longer there. Whereas you did have a star quarterback for you for urinary incontinence, now you have to use your backup players, which are the pelvic floor,” Samms says. 

Request an appointment at MD Anderson online or by calling 1-877-632-6789.