Managing the Man with Ejaculatory Dysfunction

Jesse N. Mills, MD, presents management strategies for men presenting with ejaculatory dysfunctions, ranging from premature ejaculation to ejaculodynia. He begins by acknowledging that there is no current FDA-approved treatment specifically for any kind of ejaculatory dysfunction.

Dr. Mills then separates men presenting with ejaculatory dysfunction into distinct categories based on the symptom they are experiencing, and follow-up questions to ask these patients. These five main groups are Premature Ejaculation, Delayed Ejaculation, Anejaculation, Ejaculodynia, and Post-Orgasmic Illness Syndrome.

Throughout the presentation, Dr. Mills discusses each category of dysfunction and available treatment options. He concludes by highlighting the need for further study of post-orgasmic illness syndrome.

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The Who and Why of Focal Therapies

Abhinav Sidana, MD, MPH, discusses the selection processes, objectives, and data supporting the use of focal therapy to treat prostate cancer. He begins with an overview of the state of focal therapy, and how it can be used to provide more personalized prostate cancer treatment to patients.

Dr. Sidana then compares the weaknesses of focal therapy to those of radical surgery and surveillance. He notes that while focal therapy has been criticized for its shortcomings in addressing “invisible” and multifocal cancers, radical surgery has permanent negative effects on patient QOL and that many patients on active surveillance drop out after a certain length of time.

Dr. Sidana then addresses recent advances in focal therapy which can partially mitigate some of the shortcomings of focal therapy. He focuses on advancements in MRI accuracy and specificity which makes treating multifocal and previously invisible clinically significant cancers using focal therapy effective.

Dr. Sidana concludes by outlining strategies for patient selection for focal therapy. He presents examples of ideal patient and disease characteristics for focal therapy treatment and lists relevant contraindications.

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Active Surveillance of Renal Mass

Frances M. Alba, MD, discusses the benefits of active surveillance of small renal masses (SRM) as a treatment option. Dr. Alba begins by presenting data that most SRM have low or very low malignant potential. Despite this, SRM are removed routinely without preoperative pathologic diagnosis and Dr. Alba asserts this raises the question of significant overtreatment.

Dr. Alba then addresses metastasis, explaining that risk of metastases is exceedingly low for SRM. She describes a prediction calculator to support personalized-treatment selection and explains that regardless of treatment, the vast majority of patients will die of other causes. She emphasizes overall survival is influenced by patient risk factors.

Dr. Alba addresses quality-of-life issues for patients being treated with active surveillance, including the impact of illness uncertainty. She covers trends in active surveillance before outlining her recommendations, suggesting an initial period of six months to establish a trend. She advises asking patients about fears, concerns, and life events. She points out that active surveillance can be used to delay intervention in patients with competing medical or life issues and delayed intervention is safe.

Dr. Alba concludes by emphasizing that active surveillance is the ultimate nephron-sparing management modality and patients can be managed conservatively with serial imaging. Dr. Alba reminds practitioners that intervention for SRM imposes physical, emotional, mental, and financial burdens on patients and families, and that active surveillance can alleviate many of these concerns.

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Conquering the Curve in Peyronie’s Disease

Ryan P. Terlecki, MD, FACS, discusses risks and benefits of Peyronie’s disease treatments, advocating for surgery as a definitive treatment. Dr. Terlecki asserts the condition is poorly understood with a “lot of garbage” in print and online. (e.g., advice not to operate early on, assumptions the injury is from tunical damage, and problematic data on intralesional injections).

From a treatment standpoint, Dr. Terlecki addresses treatment dogma he sees as problematic. He debunks claims for various treatments, like vitamin E, colchicine, Xiaflex, and pentoxifylline, and makes a case against extracorporeal shock wave therapy.

Dr. Terlecki addresses surgery and explains that, for patients with adequate rigidity, plication or grafting is effective. However, patients with inadequate function require inflatable penile prosthesis (IPP) and curvature correction. He cautions against degloving, tunical excision, and plicating for implant cases.

Dr. Terlecki concludes that Peyronie’s patients are often distressed and need clear communication and a realistic understanding of treatment risks and benefits. He calls surgery the gold standard, and says plication should be considered first for potent patients without complex defects.

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Focal Cryoablation

Michael A. Gorin, MD, discusses the value of focal cryoablation as a treatment option for prostate cancer in modern practice. He begins by providing a brief overview of negative patient outcomes after whole-gland treatment, and the benefits of subtotal gland treatments in the form of focal ablation therapies like cryoablation and High Intensity Focused Ultrasound (HIFU) therapy.

Dr. Gorin notes that HIFU and cryoablation are the two most commonly used and studied modalities for prostate cancer treatment. He discusses the benefits and weaknesses of focal HIFU, with particular focus on the possibility of incomplete cancer treatment, and compares them to those of focal cryoablation.

Dr. Gorin presents the elements of focal cryoablation which reduce the risk of incomplete treatment. He presents current guidelines and devices for performing focal cryoablation which protect the patient against side effects, like urethral sloughing, which had been previously associated with cryotherapy.

Dr. Gorin concludes by demonstrating the long-term success rate for patients treated using focal cryoablation. He compares the QOL outcomes of focal cryoablation to those of HIFU, and presents a recording of a real focal cryoablation procedure.

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Focal HIFU

Arvin K. George, MD, discusses the use of Focal High Intensity Focused Ultrasound (HIFU) ablation for prostate cancer treatment. He begins by listing the indicators and guidelines for Focal HIFU, particularly after failed radiation therapy.

Dr. George then walks through the selection process for Focal HIFU. He presents the ideal patient and disease characteristics for HIFU ablation therapy, and contraindications for the treatment, including tumor size.

Turning to complications associated with HIFU ablation therapy, Dr. George discusses the common early-, medium-, and late-stage complications associated with Focal HIFU. The most common complications for Focal HIFU ablation therapy being urinary retention and erectile dysfunction. He discusses strategies for avoiding common complications from HIFU.

Dr. George concludes by reviewing patient outcomes of Focal HIFU ablation compared to other treatments for prostate cancer. He presents studies comparing failure-free survival outcomes between patients treated with Focal HIFU over three, five, and eight years compared to other established prostate cancer treatments.

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Point Counterpoint: Micro Ultrasound

Gerald L. Andriole, Jr., MD, presents the benefits of including micro ultrasound (microUS) in prostate imaging. He begins by noting that microUS is a relatively new technology compared to multiparametric magnetic resonance imaging (mpMRI).

Dr. Andriole presents examples of the detailed prostate images produced by microUS. He discusses the Prostate Risk Identification using MicroUltraSound (PRIMUS) classification system, intended as an analog to PRI-RADS, and the training required for practitioners using microsUS. He presents video examples of microUS-guided versus MRI-guided biopsies.

He concludes by comparing the specificity, sensitivity, and NPV of mpMRI and microUS biopsies in identifying clinically significant cancer. He presents recent studies which indicate that microUS alone may be as effective as mpMRI alone in the context of biopsies.

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Point Counterpoint: MRI

Thomas P. Frye, DO, argues in favor of multiparametric magnetic resonance imaging (mpMRI) over micro ultrasound (MicroUS) for prostate imaging. He begins by stating the underlying goals of prostate imaging in the context of triaging in urologic oncology.

Dr. Frye then turns to the lack of data in support of microUS over mpMRI. He highlights that prostate imaging from MicroUS lacks the scale and reliable interpretability of mpMRI.

Dr. Frye supports the effectiveness of mpMRI in detecting clinically significant prostate cancer with data from the PROMIS and PRECISION studies. He notes that the use of mpMRI in screening can prevent unnecessary biopsies of insignificant cancers.

He concludes by reviewing weaknesses in recent studies of mircoUS. He presents a clinical analysis of microUS which demonstrated the superiority of conventional imaging (TRUS) and mpMRI over microUS.

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PSMA PET for Prostate Cancer: Primary Staging, Recurrent Disease Localization

Steven P. Rowe, MD, PhD, discusses the strengths of Prostate-Specific Membrane Antigen (PSMA) PET in PCa staging and localization. Dr. Rowe begins with a brief overview of PSMA PET and its correlation with metastases and tumor aggressiveness.

Dr. Rowe focuses on the sensitivity and specificity of PSMA PET for identifying metastases. He establishes that PSMA PET has high specificity, regardless of metastatic tumor size, but that the sensitivity to tumors below 5 millimeters in diameter is low. For treatment of the primary disease in the prostate, Dr. Rowe discusses the role of PSMA PET in tumor segmentation.

Dr. Rowe concludes by addressing the use of PSMA PET in identifying recurrent disease and salvage therapy candidates. He discusses the design and results of the CONDOR trial, and the lesion-level positive predictive value of PSMA PET in recurrent disease.

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Learning HoLEP Once Already in Practice: Value, Learning Curve, and Tips/Tricks

Rebecca C. Gerber, MD, presents practical guidance on the use of Holmium Laser Enucleation of the Prostate (HoLEP) in clinical practice. Dr. Gerber begins by enumerating the benefits of HoLEP as a treatment, and pre-operative requirements for patients.

Dr. Gerber then provides an overview of perioperative considerations and the steps for the procedure. She presents a video demonstration of the procedure in practice, providing her clinical perspective for each step.

Dr. Gerber concludes by presenting examples of past HoLEP procedures, and providing her perspectives on which cases are better for practitioners with less HoLEP experience. She highlights the benefits of using HoLEP to treat catheter-dependent patients.

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Antibiotic Stewardship for Procedures and Patients with Recurring Infections

Brian J. Flynn, MD, presents guidance on effective UTI management while minimizing antibiotic resistance. Dr. Flynn begins with an overview of recurring UTI pathogenesis and diagnosis.

Dr. Flynn then addresses common treatment options for recurrent UTI management, like Fosfomycin. He reviews the common first-line antibiotics, highlighting the importance of short-duration antibiotics after non-antibiotic treatments have failed.

Dr. Flynn then delves into other prophylactic strategies for treating recurrent UTIs. He discusses prophylactics relating to cleanliness, specific cranberry products, water intake, and methanamine hippurate.

Dr. Flynn concludes by addressing the social and psychological impact of recurrent UTIs, particularly in post-menopausal women. He stresses the importance of discussing contributing factors frankly, but empathetically, with patients to achieve the desired treatment outcome.

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Optimizing Perioperative Nutrition and Assessing Frailty

Jennifer M. Taylor, MD, MPH, discusses interventions for optimizing perioperative outcomes surrounding patient frailty and nutrition. Dr. Taylor begins by defining the causes of frailty and acknowledging that most cancer patients will have a certain level of frailty.

Dr. Taylor presents tools for the assessment of frailty that medical practitioners can use to evaluate frailty-based risks of invasive treatments. She notes that frail patients have a higher risk of mortality after surgery, and demonstrates a prototype of a Risk Analysis Index that is currently being trialed at multiple VA hospitals.

Dr. Taylor concludes by discussing the importance of having a multidisciplinary team that includes a dietician to support the frail patient pre- and post-operatively. She highlights that preoperative nutritional interventions, particularly in malnourished patients, are effective in reducing frailty in a short amount of time.

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Integrated Diagnostics (Radiogenomics) and Patient Selection and Monitoring for Active Surveillance, Surgical, and Radiation Treatment

Sanoj Punnen, MD, MAS, discusses the use and benefits of integrated diagnostics for monitoring prostate cancer during Active Surveillance (AS). He begins by noting that AS is becoming a popular treatment for a wide range of low-risk prostate cancers, thanks to more granular risk-stratification methods and an increasing clinical emphasis on lowering patient burden during treatment.

Dr. Punnen then discusses lowering the frequency of serial biopsies as a means of lowering patient burden during treatment. He explores studies which indicate that MRI and Gleason scoring alone are insufficient for monitoring prostate cancer progression.

Dr. Punnen concludes with an exploration of the ongoing Miami MRI-Guided Active Selection for Treatment of Prostate Cancer (MAST) trial examining the use of MRI, 4Kscore, and Decipher scores during AS. The data thus far indicates that MRI alone is not predictive of progression, and that clinicians should consider integrating other prognostic data into their AS treatment protocols.

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Construction and Multi-Center Validation of the Radiomics Model for Non-Invasive Identification of Active Surveillance Candidates

Liang Wang, MD, PhD, presents current data on the use of noninvasive approaches with radiomics models to identify prostate cancer in active surveillance (AS) patients. Dr. Wang begins by sharing data on the risk reduction that early detection provides, but notes risks of overdiagnosis and overtreatment. He then addresses the role of magnetic resonance imaging (MRI) in prostate cancer management, noting improved techniques and better image interpretation by the Prostate Imaging Reporting & Data System (PI-RADS). However, Dr. Wang highlights that other biomarkers along with MRI must guide further diagnosis and treatment.

Dr. Wang discusses the rapidly evolving field of radiomics, explaining it enables the digital decoding of images into quantitative features that may uncover disease characteristics unseen by the naked eye. Further, it assesses a broad set of predefined features to define patterns relevant to pathology using statistical methods.

Dr. Wang concludes by cautioning that current data on the use of radiomics were from single-institution retrospectives with small cohort sizes and an absence of independent, external validation. Dr. Wang mentions broader, ongoing research which may lead to a non-invasive, radiomics-based tool that may be used to identify AS candidates with prostate cancer in the future.

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Physician Coaching and Embracing QI

Ryan P. Terlecki, MD, FACS, presents a model for quality improvement for healthcare providers, drawing from professional sports coaching. He begins by articulating the professional parallels between physicians and quarterbacks, noting that the best performers in each field have strong professional support networks and constant performance evaluation.

Dr. Terlecki then discusses how quality improvement measures used in professional sports apply to medical practice. He supports his points by presenting data from studies where “playbacks” of urologic surgeries were used to effectively improve surgeon performance.

Dr. Terlecki concludes by emphasizing the benefits of being open to feedback and making efforts to improve for both healthcare professionals and patients. He encourages healthcare professionals to be open to both giving and receiving coaching in their practices, and provides actionable advice for implementing these quality improvement measures.

Dr. Terlecki provides guidance on tailoring patient intake questionnaires to keep the focus on the patient’s issue and possible approaches. He gives examples of open and closed questions for male genital pain.

Dr. Terlecki then discusses the importance of setting patient expectations regarding diagnoses and what they should expect from the provider, particularly when the provider does not specialize in pain management. He then discusses common, uncommon, and overlooked causes of male genital pain.

Dr. Terlecki concludes by walking through this algorithm from intake to assessment to diagnosis and treatment. He emphasizes the importance of not dismissing patient input on treatment, but still strictly adhere to evidence-based treatment over unproven or alternative treatments.

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In-office Therapies for Men with Erectile Dysfunction

Jesse N. Mills, MD, discusses the effectiveness of a selection of experimental in-office therapies for erectile dysfunction treatment. Throughout his presentation, Dr. Mills explores the outlook, benefits, and challenges of experimental therapy options currently pushed by external market forces, including:

Low-intensity Shockwave Therapy (LiSWT)
Platelet-Rich Plasma (PRP)
Stem Cell Therapy
Intracavernosal Injection (ICI)
Hyperbaric Oxygen

Dr. Mills concludes by stressing that although these therapy options are still considered experimental, urologists should strive to observe these therapies and hold balanced conversations with patients regarding their efficacy. He encourages urologists to stay optimistic about erectile dysfunction treatment as stewards of male health, suggesting they watch for new data in the world of experimental treatments.

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Biomarkers Made Simple

Peter A. Pinto, MD, presents an overview of the roles of biomarkers in prostate cancer diagnosis and screening. In his presentation, Dr. Pinto covers:

Biomarkers Categorization
Tissue-Based Biomarkers
Emerging Urine-Based Biomarkers
Biomarker Detection
Challenges and Opportunities in Biomarker Research

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Metastatic Prostate Cancer: Can Urologists Work Alongside Medical Oncologists in Advanced Disease?

A. Edward Yen, MD, discusses the importance of collaborating with medical oncologists when using hormone-directed therapy to treat metastatic prostate cancer. He begins by illustrating changes in treatment approach, using a case study to contrast past treatment algorithms with modern treatment approaches.

Dr. Yen presents a treatment algorithm from the early 2000s, calling attention to the isolation of “urologist” versus “oncologist” options in patient treatment and the impact of those isolated treatment approaches on overall survival. Dr. Yen contrasts this approach with modern agents and therapies which require collaboration between urologists, medical oncologists, and other medical disciplines.

Dr. Yen then addresses practical challenges associated with increased multidisciplinary collaboration, including keeping up with rapid advancements, managing treatment toxicities, and sequencing and selecting treatment.

Dr. Yen concludes by presenting a model of collaboration used by his practice which integrates urology, medical oncology, radiation oncology, nuclear medicine, pathology, interventional radiology, palliative/supportive care, genetics, nutrition and dietetics, psychology, and social work in treatment. He notes that the involvement of these specialties in the treatment of advanced prostate cancer leads to comprehensive evaluations, tailored treatment plans, and better outcomes for patients.

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In-Office Management of Female SUI: Optimizing Productivity

Robert J. Evans, MD, FACS, presents guidance on how practice leaders can optimize in-office management of female stress urinary incontinence. He begins with a review of pre-visit intakes, and best-practices for gathering pertinent information in the office intake form.

Dr. Evans then turns to appropriate delegation of tasks within the practice, noting that APPs can evaluate patients in-office and initiate some treatments for female stress urinary incontinence. Additionally, the patient’s gynecologist can provide additional insight into treating female stress urinary incontinence.

Dr. Evans concludes by reviewing best practices for in-office procedures, and reiterates the importance of delegating tasks appropriately. APPs are a practice’s greatest resource for optimizing patient treatment in-office.

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Tips and Tricks for Managing Stones in the Complex Patient

Colin E. Kleinguetl, MD, presents guidance and strategies for kidney stone management in chronically infected and pregnant patients. He begins by discussing challenges to managing kidney stones in the pregnant patient, including:

The weaknesses of kidney stone imaging options
The pros and cons of radiation during diagnosis
The importance of working with the patient’s OBGYN during treatment
The treatment options available to pregnant kidney stone patients

Dr. Kleinguetl concludes by turning to patients with chronic UTIs, acknowledging the circular relationship between recurrent/persistent UTI and kidney stone disease. He then addresses common causes of stones in chronically infected patients and effective treatment options depending on the cause of the infection.

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Gleason 6 (GG1) – Should It Be Called Prostate Cancer?

Jeremy Slawin, MD, MBA, presents arguments for and against the reclassification of Gleason 6 (GG1) as something other than prostate cancer. He begins with a brief overview of the definition and perception of prostate cancer, and the psychological burdens and implications which come with cancer diagnoses.

Dr. Slawin then addresses the growing momentum in favor of a change in nomenclature for Gleason 6 (GG1) that does not include the word “cancer,” as has been done for diseases like noninvasive follicular thyroid neoplasm with papillary-like features (NIFTP), formerly called papillary thyroid cancer. Dr. Slawin presents data supporting the idea that GG1 is closer to pre-cancer in clinical behavior, detection, and management, and that calling it a cancer may drive overtreatment of GG1.

Dr. Slawin then turns to arguments against the reclassification of GG1. He addresses the issue of undersampling in biopsies which lead to GG1 diagnoses, the risk of under-grading, and how failing to call GG1 “cancer” could give a false perception of risk and lower the already-low patient compliance rates in active surveillance treatment.

Dr. Slawin concludes by giving his perspective on the issue of changing the nomenclature for GG1. He, along with most pathologists, is not in favor of reclassifying GG1, and leads a Q&A with the audience to gather their perspectives.

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Selection and Outcomes of Image-Guided, Minimally-Invasive Treatment

Abhinav Sidana, MD, MPH, aims to identify key selection criteria for image guided minimally invasive treatments, also known as focal therapy, for prostate cancer. Dr. Sidana begins by noting that the use of focal therapy for prostate cancer treatment has become widespread in the past decade.

Dr. Sidana then addresses current EAU and NCCN guidelines for focal therapy. He highlights the lack of guidelines specific to focal therapy, and notes that the medical community has been trying to address this deficiency in recent years.

Dr. Sidana concludes by summarizing current best-practices regarding appropriate imaging modalities for screening, appropriate biopsy strategies, and optimal characteristics for determining focal therapy candidacy. He highlights the importance of the correct selection of energy modality in treating prostate cancer, noting that not every surgeon will have access to all the available energy modalities.

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Long-Term Care of the Neurogenic Bladder

R. Caleb Kovell, MD, discusses effective treatments for complex neurogenic bladder patients, including early and long-term interventions. He presents several factors physicians should take into account when treating challenging neurogenic bladder patients, including:

Male and Female Sexual Health Issues
Bladder Stones
Urinary Continence
Previous Augmentation Cystoplasty
Previous Diagnosis of Spina Bifida

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PCa Commentary | Volume 186 – February 2024

ACTIVE SURVEILLANCE: Patient Selection, Outcome and Monitoring for Gleason Grade Progression.
Question: Why not be treated at initial diagnosis of prostate cancer— and hope for cure?
Answer: Because all treatments are associated with unwelcome adverse effects that most men would prefer to avoid. Who should receive immediate treatment, and which men may safely delay treatment, preserving quality of life, — and with careful monitoring and timely intervention experience a similar outcome as if treated initially. That is the subject of this Commentary: patient selection for active surveillance (AS) and new techniques for monitoring for progression during AS.

Currently, eligibility for AS is based on clinical/pathological and biomarker features that define low- or favorable intermediate-risk prostate cancer: Gleason score 3+3 (Grade Group1) and Gleason score 3+4 (Grade Group 2); < 20% Gleason pattern 4; less than 50% positive biopsy cores and having only one NCCN intermediate risk factor (i.e., PSA 10-20 ng/ml, Gleason score 7 and cancer limited to the prostate). A PSA Density of <.15 and an MRI PIRAD score of 1 or 2 support AS. Although Gleason Grade Group 1 is to a small extent heterogeneous, the behavioral heterogeneity of Gleason score 7 grouping has led to a sub-classification into “favorable (Gleason 3+4; Gleason Grade Group 2) and unfavorable intermediate-risk cancer (4+3; Gleason Grade Group 3), the latter not advised for AS. The concern regarding the extent of Gleason pattern 4 in Gleason score 3+4 is based on the understanding that prostate cancer cells with pattern 4 characteristics have the potential to invade and metastasize. Patients with <5% pattern 4, are deemed satisfactory for AS, whereas a rise toward 20% increases the advisability for early intervention. The NCCN guidelines “prefer” AS as opposed to initial treatment for low-risk patients and allows consideration of AS for men with favorable intermediate-risk cancer with low PSA density (< .15) and low tumor volume ( i.e., < 2 positive cores), low genomic risk score and low percentage of Gleason pattern 4, i.e., <5%. Brief Summary of Outcome of Trials of Active Surveillance in Patients with Gleason Grade Groups 1 and 2: An extensive current review (Mukherjee et al., Journal Clinical Medicine, Dec. 2023) of outcomes for men with localized cancer (low-risk and favorable intermediate-risk) was based on a review of 712 studies from which 25 provided sufficient detail. Two representative studies will be briefly summarized: Courtney et al., (J.NCCN. 2022): Men on AS [8726 low-risk (LRPC) and 773 favorable intermediate-risk (FIRPC)] patients were followed for a median of 7.6 years. Metastasis-free survival at 10 years was 98.5% vs 90.4%; cancer-specific survival was 99% vs 96%, respectively. Mukhergee et al., (Eur. Urol. Open Sci., 2023): For men on AS (276 LRPC and 96 FIRPC) with median follow-up of 4.5 years. “… there was no significant difference in the median duration of AS between the two groups (32.5 months for IRPCvs 36 months for LRPC, p=0.53.” During the course of AS 30% had disease progression and were offered active treatment. The overall survival probability at 5 years for LRPC and FIRPC was 93% for both, and at 10-years 90% vs 83%s respectively. Studies from John Hopkins and Toronto report 98-99% cancer-specific survival in carefully selected and monitored men with low- and favorable intermediate-risk cancer despite 36% to 50% conversion to treatment during AS due to Gleason grade progression (Data from NCCN 2022 guidelines). The excellent survival figures in all these studies point to the effectiveness of treatment in those men who progressed during AS. The equivalence of outcome at intervention for carefully selected and monitored men on AS compared to those men treated with surgery at diagnosis has been multiply reported. Epstein, Carter et al., (Journal Urology, 2017) reported, ”Patients on active surveillance reclassified to grade group 2 or greater are at no greater risk for treatment failure than men newly diagnosed with similar grades.” Genomic Classifiers (Decipher, Prolaris, OncotypeDx) provide greater prognostic accuracy than standard clinical/pathological classifications (cited above) for estimating progression in men with localized prostate cancer considering AS. At the 2023 meeting the Society of Urologic Oncology Sheng et al. (Abst 237) reported that in a study of 235 men, Decipher Genomic Classifier (range of increasing concern for metastases and mortality extend from 0 -1.0) was associated with an upgrade to adverse pathology in men with a scores above 0.4 (p=.002) and above 0.6 (p=.006) - both values not suitable for men considering AS. A second study by Khandaker based on data from the Miami Active Surveillance Trial reported similar findings: Decipher scores >0.4 and increasingly above 0.6 were associated with adverse Gleason grade progression which would signal early intervention as opposed to AS.

The Next Step Forward: Predicting Future Progression Dynamically During AS as Opposed to Predictions Made Only at Baseline.

The clinical/pathological classification systems cited above offer prognostic (as opposed the predictive) information to guide patient selection but are not patient-specific. For example, a Decipher score of, say, 4.3 establishes a concerning level of risk but leaves the patient and physician a significant management decision about how to incorporate that extent of risk in a management plan. Studies using statistical analysis (see Cooperberg below) and artificial Intelligence (see Lee and Nayan below) provide dynamic patient-specific predictions of adverse grade progression during the course of AS.

Cooperberg et al.,(JAMA Oncol, Aug 2020) addressed this issue in “Tailoring Intensity of Active Surveillance for Low-risk Cancer Based on Individualizing Prediction of Risk Stability.”
The Canary Prostate Active Surveillance Study (PASS) involves 9 academic medical centers and based their study on 850 very explicitly followed patients for at least 5 years following enrollment. Their product provided an individualized prediction at the time of diagnosis or during AS of ‘non-reclassification’ at 4 years – i.e., information that might guide continued participation in AS or a switch to intervention. “The Canary model was built to be calculable at any given landmark time or event in the course of active surveillance.” Their findings suggest that “based on an individual’s risk parameters, that many men may be safely monitored with a substantially less intensive surveillance regimen.”

Two other studies employed AI to predict grade progression during AS [Lee et al. (Nature Prostate Journal, Digital Medicine, Aug 2022) and Nayan et al. (Urol Oncol. Apr 2022)]. Both provided a guideline regarding future progression. Using AI and incorporating interval monitoring data (PSA, MRI and biopsies) each study estimated an ongoing “real life” prediction at any time during AS of the risk of future Gleason grade reclassification, information that could influence the decision to withdraw from AS and switch to active intervention.

BOTTOM LINE:

Active Surveillance is the preferred management option for men with low- and favorable intermediate-risk prostate cancer and has been shown to yield excellent outcomes. Genomic classifiers are further refining patient selection. Statistical analysis and artificial intelligence provide dynamic risk assessment for grade progression during the ongoing course of AS.

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Molecular Imaging: PSMA PET/CT

Michael Hofman, MBBS, FRACP, FAANMS, FICIS, GAICD, compares the effectiveness of PSMA PET with CT against the standard CT and bone scan. He begins by briefly reviewing findings from the ProPSMA study, which indicated that PSMA PET/CT had greater accuracy in identifying prostate cancer than a standard CT plus bone scan, or “conventional imaging.”

Dr. Hofman discusses the adoption of PSMA PET/CT as a standard of care in different international medical guidelines. He notes that some medical communities have embraced PSMA PET/CT as a replacement for conventional imaging in patients who meet the appropriate criteria for PSMA PET/CT, while others have only adopted it as a supplement to conventional imaging.

Dr. Hofman argues against a common argument for keeping conventional imaging scans as part of standard care, the issue of stage migration. Dr. Hofman argues that, while PSMA PET/CT is a more sensitive test, it also has greater specificity and yields fewer false-positives than conventional imaging. He supports this point by evaluating several equivocal studies comparing PSMA PET/CT and CT/bone scans in patients with various metastatic burdens.

Dr. Hofman concludes with a brief discussion on the lower financial burden of PSMA PET/CT, and on the future directions of PSMA PET/CT in detecting quantitative total tumor volume. He acknowledges the lack of standardization in PSMA PET/CT reporting and encourages fellow clinicians and academics to participate in the creation of standard reporting practices for PSMA PET/CT.

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