Topic: Prostate Cancer

Contrast-Enhanced Ultrasound of the Prostate

Ethan J. Halpern, MD, Professor and Vice-Chair for Research in the Department of Radiology at Jefferson University Hospital, reviews the history and limitations of using standard grayscale and doppler TRUS imaging to identify cancers within the prostate. He further discusses contrast-enhanced ultrasound of the prostate, and how, when combined with subharmonic flash replenishment imaging, it represents a major step forward in identifying malignant vascular patterns within the prostate.

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The Cardiovascular Effects of Orchiectomy Versus LHRH Agonists

Jeremy Y.C. Teoh, MBBS, FRCSEd, FCSHK, FHKAM, Assistant Professor at the Chinese University of Hong Kong, outlines the increased risk of cardiovascular events associated with patients undergoing bilateral orchiectomy compared to patients treated instead with luteinizing hormone-releasing hormone (LHRH) agonists or antagonists. He discusses an important study that confirmed the increase in these events for men undergoing orchiectomy. Dr. Teoh continues by discussing another study, on which he was the lead investigator, that confirmed that orchiectomy conferred increased risk of ischemic stroke or myocardial infarction versus LHRH agonists in Chinese men. He concludes that the lower level of testosterone in men undergoing orchiectomy as well as the rise in follicle-stimulating hormone (FSH) levels may be contributing factors in the heightened cardiovascular risk of this procedure.

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More Arrows in Our Quiver – Targeting the Adaptive Molecular Landscape of Advanced Prostate Cancer

Martin Gleave, MD, FRCSC, FACS, Co-Founder and Director of the Vancouver Prostate Centre, reviews the molecular mechanisms of treatment resistance in metastatic castrate-resistant prostate cancer, as well as efforts to refine precision treatment of disease. He discusses how defining these mechanisms has yielded new processes and drugs, shows how molecular subclassification is key to drug selection and sequencing, and highlights new studies demonstrating how circulating tumor DNA monitoring can show real-time genetic adaptations in cancer cells.

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Recent Clinical Radionuclide Therapy Advances in mCRPC

Ulka Vaishampayan, MD, Professor of Oncology at Wayne State University and Chief of Solid Tumor Oncology at the Karmanos Cancer Center, discusses the phase 3 randomized controlled trial of 177-Lutetium-PSMA radionuclide therapy. In this brief summary, Dr. Vaishampayan discusses the mechanism of action of this novel therapy, how to identify patients utilizing a PSMA-based PET scan, and the inclusion/exclusion criteria from the phase 3 randomized control trial of this targeted agent.

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Overview of Treatment for Advanced Prostate Cancer, including Metastatic Disease – Novel Treatment

Christopher Sweeney, MD, MBBS, gives an overview of the most promising research into novel treatments for metastatic castration-resistant prostate cancer (mCRPC), focusing on phosphatidylinositol 3-kinase (PI3Kinase)/Akt inhibition, Poly ADP-ribose polymerase (PARP) inhibitors, and lutetium-labeled prostate-specific membrane antigen (Lu-PSMA). He emphasizes the importance of careful patient selection for these therapies, and suggests that future studies should focus on combination therapies and avoid duplicative research.

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Prostate Cancer Initial Staging and Evaluation of Recurrent Disease with PSMA-Targeted PET

Steven Rowe, MD, PhD, gives an overview of current data on prostate-specific membrane antigen (PSMA)-targeted PET imaging for initial staging of prostate cancer (PCa) and evaluation of recurrent disease. He emphasizes PSMA’s limited sensitivity for initial diagnosis and high sensitivity for recurrent disease, while also noting potential strengths and weaknesses of PSMA that are independent of sensitivity.

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Biochemical Recurrence After Local Therapy: Assessment and Management

Peter R. Carroll, MD, MPH, Taube Family Distinguished Professor in Urology, Department of Urology at the University of California, San Francisco, outlines detection and treatment options for biochemical recurrence following a prostatectomy or radiation therapy. He details how recurrence can be detected with PSMA PET imaging, as the majority of cases have PSMA-avid lesions present. Dr. Carroll further notes typical and atypical regional and local areas of recurrence. He also describes a new disease management algorithm for deciding between further radiation therapy or monitoring & localized treatment.

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Treating a Patient Denied Coverage Based on Not Conforming to NCCN Guidelines

James L. Mohler, MD, Chair of the National Comprehensive Cancer Network (NCCN) Prostate Panel, discusses approaches for urologists dealing with insurance coverage denial for patients who do not fit within NCCN guidelines for prostate cancer. He outlines the iterative, bias-free process of creating the guidelines, which allows for a quick response to the latest research. Dr. Mohler further details how the guidelines value efficacy, quantity/quality of evidence, consistency of evidence, and safety above affordability, and how this can lead to denial of coverage. He then outlines talking points for overcoming guideline-based reasons for rejection from insurance providers.

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Molecular Imaging of Prostate Cancer

Wolfgang Weber, MD, Professor and Chair of the Department of Nuclear Medicine at the Technical University of Munich in Germany, discusses the changes in molecular imaging over the last 7 years and their impact on staging and re-staging of prostate cancer. Dr. Weber discusses how PSMA PET imaging works by binding with the ligands of antigens present in cells affected by prostate cancer. He also describes studies in which molecular imaging has been useful in reclassifying nmCRPC by identifying metastases not visible using conventional imaging, specifically in bones and lymph nodes. This has led to novel theranostic approaches where imaging closely intertwines with surgery or chemotherapy to potentially improve treatment outcomes.

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Considerations for the Clinical Impact of Next Generation Imaging in Prostate Cancer

Ashley Ross, MD, PhD, Executive Medical Director of the Mary Crowley Cancer Research Center in Dallas, discusses the current and potential impact of PSMA PET imaging on the identification and treatment of localized prostate cancer. He notes how PET PSMA and fluciclovine imaging can increase the accuracy of detecting clinically significant localized disease. Dr. Ross further discusses how PET imaging assists in risk stratification of candidates for treatment of HSPC, nmCRPC using salvage local therapy, metastasis-directed therapy, or intensification of systemic therapy. He also discusses how PET imaging can help identify candidates for cure with local treatments.

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Prostate Cancer Screening and Early Detection: Should We Follow the NCCN Guidelines? Con Argument

Robert E. Donohue, MD, argues against urologists adhering to the National Comprehensive Cancer Network (NCCN) Prostate Cancer Screening and Early Detection Guidelines. He proposes his own definitive answers to controversial questions relating to the use of digital rectal exams and PSA tests in baseline evaluation, indications for biopsy and biopsy technique, the age for initiation and discontinuation of testing, the frequency of testing, screening in high-risk populations, and which biomarkers to use. 

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Prostate Cancer Screening and Early Detection: Should We Follow the NCCN Guidelines? Pro Argument

A. Karim Kader, MD, PhD, argues that although PSA-based prostate cancer screening is flawed, urologists should adhere to the National Comprehensive Cancer Network (NCCN) Prostate Cancer Screening and Early Detection Guidelines. He outlines how, in order to avoid overdiagnosis and other issues, urologists can be more judicious as to which patients are offered screening, biopsy, and treatment, while not abandoning the use of PSA as a marker for prostate cancer altogether.

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