Topic: Prostate Cancer

New Standards of Care for Advanced Prostate Cancer

In this 20-minute presentation, William K. Oh, MD, Chief of the Division of Hematology and Medical Oncology at the Mount Sinai Health System and Deputy Director of The Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai, addresses new standards of care in 2021 for advanced prostate cancer and focuses on non-metastatic castration-resistant prostate cancer (nmCRPC), concluding that apalutamide, enzalutamide, and darolutamide improve MFS in men with nmCRPC by ~2 years; SPARTAN, PROSPER, and ARAMIS established favorable benefit-risk for patients with nmCRPC and PSADT<10 months; and these studies provide the best evidence supporting early treatment. He also focuses on metastatic, hormone-sensitive prostate cancer (mHSPC) and concludes that upfront treatment with either abiraterone + prednisone, apalutamide, enzalutamide, or docetaxel is the standard of care and he asserts that new evidence from PEACE-1 and ARASENS supports triple therapy with a novel hormonal therapy +ADT+docetaxel for chemotherapy patients.

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Appropriate Use of PSMA PET in Clinical Practice

In this 10-minute video, Thomas Hope, MD, Assistant Professor in Abdominal Imaging and Nuclear Medicine in the Department of Radiology at the University of California, San Francisco, discusses the appropriate use criteria (AUC) of PSMA PET in clinical practice. He summarizes the guidelines for the appropriate use of PSMA PET and delves into the studies that inform them.

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Advanced Prostate Cancer Clinical Trials Updates

David S. Morris, MD, FACS, of Urology Associates, PC in Nashville, Tennessee discusses advanced prostate cancer updates, including those shared recently at medical conferences including the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology’s Genitourinary Cancers Symposium (ASCO GU) as well as several studies, namely the STAMPEDE trial, PEACE-1, ARASENS, ENZAMET, PROpel, and MAGNITUDE. Dr. Morris unpacks the takeaways, explaining that doctors should consider adding abiraterone to androgen deprivation therapy (ADT) for high-risk, non-metastatic disease; consider adding abiraterone or darolutamide for patients with mCSPC whose therapy will include using docetaxel; and consider adding poly-ADP-ribose polymerase inhibitors (PARPi) to abiraterone in patients with first-line mCRPC.

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Current Status of PSMA PET in the United States

Philip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses PSMA PET and how it is poised to supplant conventional imaging techniques in the diagnosis of prostate cancer. He begins by observing the shortcomings of conventional imaging techniques such as bone scintigraphy and computed tomography. While these remain the current standard of care, they result in false negative diagnoses in most patients with biochemical recurrence, especially when the lesion is less than 1 cm with a PSA of <20 ng/ML. Dr. Koo then focuses on prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging. He cites a study that found PMSA has double the detection rates over fluciclovine, with an exception of lesions in the prostate bed, indicating that different tools may be appropriate depending on lesion location. However, Dr. Koo clarifies that there currently is no data that proves the superiority of a specific PET radiopharmaceutical. Additionally, he cautions that overdiagnosis using next-generation imaging, such as PSMA PET, is likely as physicians continue to learn the benefits and drawbacks. To that end, he notes that there is a spectrum of visible lesions when using PET and a threshold below which it cannot detect disease. Dr. Koo concludes that while conventional imaging is more readily available than next-generation imaging, its limited sensitivity indicates a necessary shift to more advanced tools like PMSA PET. Similarly, since prostate cancer will advance after initial treatment in 30-50% of patients, he sees an opportunity to use PSMA PET to identify patients who require further treatment or who have metastases undetected by conventional imaging.

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Transperineal Mapping Biopsy: Does Technique Matter?

Nelson N. Stone, MD, Professor of Urology, Radiation Oncology, and Oncological Sciences at the Icahn School of Medicine at Mount Sinai and at the Derald H. Ruttenberg Cancer Center at Mount Sinai School of Medicine in New York, discusses transperineal mapping biopsy (TPMB). He explains that treating a single quadrant as identified by MRI may leave unidentified clinically-significant prostate cancer behind. For focal therapy, Dr. Stone advocates for what he calls a unified approach using TPMB, which can be done under local anesthesia.

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Genetic Testing for Identifying Who is at Risk of Prostate Cancer and Lethal Cancer

Jianfeng Xu, MD, DrPH, Vice President of Translational Research at NorthShore University HealthSystem (NorthShore), the Ellrodt-Schweighauser Family Chair of Cancer Genomic Research, Director of the Program for Personalized Cancer Care (PPCC) at NorthShore, and a Research Professor at the University of Chicago Pritzker School of Medicine, discusses the role of genetic testing in prostate cancer risk identification. Dr. Xu discusses who is at elevated risk for prostate cancer, the relationship among three inherited risk factors (family history [FH], monogenic rare pathogenic mutations [RPMs], and polygenic genetic risk score [GRS]), the idea that monogenic and polygenic may be tested at the same time, key challenges for germline testing, and the improvement of current guidelines for prostate cancer early detection.

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Brachytherapy: The Royal Flush of Radiation Treatment for Men with High-Risk Prostate Cancer

Mira Keyes, MD, FRCPC, a Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), discusses the benefits of prostate brachytherapy (PB) for men with high- and very high-risk prostate cancer. Dr. Keyes explains PB has excellent long-term outcomes (with the best cure rates of all radiation therapy [RT] treatments), requires less androgen deprivation therapy (ADT), has less downstream toxicity and lower cost than alternatives, calling it a “royal flush” treatment when used as a boost with external beam radiation therapy (EPRT).

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Updates in Prostate Cancer Biomarkers

Matthew R. Cooperberg, MD, MPH, Professor of Urology and Epidemiology & Biostatistics and Helen Diller Family Chair in Urology at the University of California, San Francisco, addresses prostate-specific antigen (PSA) testing and explains that a PSA below the median has a very strong negative predictive value (NPV) in terms of meaningful cancer. He asserts that, when combined with secondary biomarker testing before biopsy, early baseline PSA can be very effective in terms of risk assessment. He also explains that as research on biomarkers evolves, the field will get closer to being able to use genomic information derived from the primary tumor to make initial and follow-on treatment decisions.

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How to Integrate PSMA PET Findings Into Treatment Algorithms

Jérémie Calais, MD, MSc, Associate Professor of Nuclear Medicine and Theranostics in the Department of Molecular and Medical Pharmacology at the University of California, Los Angeles (UCLA), Director of the UCLA Theranostics Program, and Director of the Clinical Research Program of the Ahmanson Translational Theranostics Division discusses how to integrate prostate-specific membrane antigen (PSMA) positron emission tomography (PET) findings into treatment algorithms. Dr. Calais explains that PSMA PET results in new staging categories, has predictive value, and has value in response assessment. He emphasizes that inclusion criteria of randomized phase-3 trials must include PSMA PET staging/screening/selection for PSMA PET to be integrated into treatment algorithms.

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