Harvard Medical Center Archives

Current State of the Art in Bladder-Preserving Trimodality Therapy for Muscle-Invasive Bladder Cancer

Posted by Jason A. Efstathiou, MD, DPhil | Nov 2024

Jason A. Efstathiou, MD, DPhil, FASTRO, FACRO, emphasizes the growing interest in bladder preservation therapies as an alternative to radical cystectomy for muscle-invasive bladder cancer (MIBC). While cystectomy remains an effective treatment, it is not performed in about half of eligible patients. Trimodality therapy (TMT), combining maximal transurethral resection (TUR), chemotherapy, and radiation, offers a promising bladder-sparing approach.

In this 11-minute presentation, Dr. Efstathiou compares outcomes between TMT and cystectomy, showing no significant difference in metastasis-free or cancer-specific survival. A shift toward biomarker-driven management is also highlighted, with specific markers, such as MRE11 and immune signatures, indicating better responses to chemoradiation. Immunotherapy is increasingly integrated into treatment regimens, with promising trials like SWOG 1806 exploring the addition of immune checkpoint inhibitors to chemoradiation.

TMT, now recognized by major guidelines, offers patients a viable option with preserved bladder function, improved quality of life, and less life interference. The presentation stresses the need for improved staging, expanded access to bladder-sparing options, and informed decision-making to optimize outcomes for MIBC patients.

Advances in Treating the Primary and Sites of Metastases in Oligometastatic Prostate Cancer

Posted by Jason A. Efstathiou, MD, DPhil | Sep 2024

Jason A. Efstathiou, MD, DPhil, FASTRO, FACRO, highlights the evolving landscape of prostate cancer management, emphasizing the impact of new data, technologies, and clinical trials. A key focus is on the role of radiation therapy in treating metastatic and oligometastatic prostate cancer, particularly in combination with systemic therapies such as androgen deprivation therapy (ADT) and next-generation agents like abiraterone.

In this 11-minute presentation, Dr. Efstathiou reviews studies like the STAMPEDE and the P1 trials, suggesting that radiation combined with intensified systemic therapy can delay disease progression. The presentation also highlights advancements in imaging, such as trials like STOMP and ORIOLE.

Dr. Efstathiou emphasizes the integration of advanced imaging and genomics into clinical practice, allowing better patient selection and risk stratification. The discussion touches on the importance of multidisciplinary care to ensure optimal treatment strategies, particularly as prostate cancer management becomes increasingly complex.

New Spacer Technology for Prostate Cancer Radiation Therapy

Posted by Peter F. Orio III, DO, MS | Oct 2023

Peter F. Orio III, DO, MS, discusses the critical role of rectal spacing in reducing the toxicity associated with radiation therapies in the treatment of prostate cancer. While not yet FDA approved, Dr. Orio reviews several pivotal trials on SpaceOAR and Barrigel which support the use of rectal spacing technology in prostate cancer treatment.

Dr. Orio underscores the role of rectal spacing technology in a patient-centric approach to cancer care. Throughout his presentation, Dr. Orio focuses on the mechanisms behind rectal spacing technology which preserve patient quality of life more effectively than traditional approaches when done correctly.

Dr. Orio then reviews the weaknesses and dangers of rectal spacer technology and analyzes reports in the FDA MAUDE database for SpaceOAR Classic, SpaceOAR Vue, and Barrigel. He cautions physicians and surgeons to know their own skill-level and to always choose the safety of the patient.

Treatment of Localized Disease

Posted by Peter F. Orio III, DO, MS | Sep 2023

Peter F. Orio III, DO, MS, discusses the treatment of localized prostate cancer, with emphasis on maximizing the value for the patient. Dr. Orio explains Michael Porter’s equation for determining patient value: patient-relevant outcomes, divided by the cost to achieve the outcomes.

Dr. Orio then reviews the benefits and limitations of common treatments for prostate cancer, including:

External Beam Radiation Therapy with and without Androgen Deprivation Therapy
Brachytherapy
Radical Prostatectomy with and without Pelvic Lymph Node Dissection
Focal Therapies

Dr. Orio concludes by emphasizing that the goal of treatment is to cure the patient and avoid reducing QoL as much as possible. As long as the physician keeps that goal top of mind, the journey to remission will be different for every patient

Identification of Localized Disease

Posted by Peter F. Orio III, DO, MS | Jul 2023

Peter F. Orio III, DO, MS, discusses the process of identifying localized prostate cancer. Dr. Orio emphasizes that prostate cancer is a spectrum of disease, rather than a binary, as prostate cancer is not necessarily confined to the prostate organ alone, and that the ultimate goal of treatment is reduction of harm to the patient’s future self.

Dr. Orio reviews the current screening, imaging, and testing steps to identifying localized prostate cancer, including the best candidates for screening. He notes that mandatory DREs discourages patients from coming in to the urologist, and suggests that screening should eliminate them.

Dr. Orio offers the more sensitive and less invasive PSA tests in combination with MRIs as an alternative first step in screening. He concludes by offering PSA – MRI – Fusion Biopsy – Germline Testing – FHX – FNX Imaging as the new path for screening and identifying localized prostate cancer.