From the Guidelines
Intraductal prostate cancer (IDC-P) requires more aggressive management compared to typical adenocarcinoma due to its higher risk profile, and patients with IDC-P should be excluded from active surveillance protocols 1. When IDC-P is found alongside invasive adenocarcinoma, treatment should follow guidelines for high-risk disease, typically involving radical prostatectomy or radiation therapy with androgen deprivation therapy (ADT) 1. For radiation, this often means external beam radiation therapy (EBRT) at doses of 75.6-81 Gy with 18-36 months of ADT using medications like leuprolide 7.5mg monthly or 22.5mg every 3 months. The management of IDC-P is guided by the latest European Urology guidelines, which recommend radical prostatectomy as a first-line treatment for high-risk and locally advanced prostate cancer, including IDC-P 1. Key considerations in the management of IDC-P include:
- Exclusion from active surveillance protocols due to high-risk profile 1
- Radical prostatectomy as a first-line treatment for high-risk and locally advanced disease 1
- Radiation therapy with ADT as an alternative to radical prostatectomy 1
- Close monitoring with frequent PSA testing and earlier consideration of additional therapies if biochemical recurrence occurs 1 It is essential to note that the management of IDC-P should be individualized based on patient-specific factors, including life expectancy, comorbidities, and tumor characteristics 1.
From the Research
Management of Intraductal Prostate Cancer
- Intraductal carcinoma of the prostate (IDC-P) is a rare subset of prostate cancer, and its management is not well established 2.
- A study found that treatment with unimodal surgery was associated with decreased 10-year cause-specific survival, while unimodal treatment with radiotherapy was associated with decreased 5- and 10-year overall survival 2.
- Radical prostatectomy alone was non-inferior to radical prostatectomy with adjuvant radiotherapy in the context of 10-year overall survival 2.
Comparison with Adenocarcinoma
- IDC-P is often associated with high-grade invasive adenocarcinoma and advanced stage disease (pT3) 3.
- A study found that patients with IDC-P typically have high-grade (Gleason score 7 or greater) invasive adenocarcinoma and most have advanced stage disease (pT3) 3.
- The presence of IDC-P is associated with a poor prognosis, and its response to androgen deprivation therapy (ADT) can predict prostate cancer prognosis in radical prostatectomy patients 4.
Treatment Outcomes
- A study found that treatment with unimodal radiotherapy among patients with IDC-P was associated with decreased survival compared to treatment with radical prostatectomy ± adjuvant radiotherapy 2.
- Another study found that abiraterone was observed to have a better therapeutic efficacy than docetaxel as the first-line therapy in IDC-P(+) metastatic castration-resistant prostate cancer (mCRPC) patients 5.
- The response of IDC-P to ADT can predict prostate cancer prognosis in radical prostatectomy patients, and some cases with IDC-P responded to ADT and demonstrated favorable clinical outcomes similar to those of cases without IDC-P 4.
Diagnostic and Reporting Issues
- There is a lack of clarity regarding the diagnosis and reporting of IDC-P, which has been compounded by divergent expert recommendations regarding the grading of invasive prostate cancers associated with an intraductal component 6.
- The International Society of Urological Pathologists (ISUP) recommends that the IDC-P component should be incorporated into the Gleason score, while the Genitourinary Pathology Society (GUPS) recommends excluding it when grading prostate cancer 6.