In this discussion, E. David Crawford, MD, Professor of Urology and Jack A. Vickers Director of Prostate Research at the University of California, San Diego, leads a discussion of the case study of a healthy 80-year-old male with a history of BPH presenting with a rapid rise of PSA from a PSA of 3-4 ng/ml to 9.7 ng/ml and increased urgency and perception of difficulty fully voiding.
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E. David Crawford, MD, Editor-in-Chief at Grand Rounds in Urology, leads a discussion on Androgen Deprivation Therapy (ADT) as the foundation for advanced prostate cancer treatment, supported by Verity Pharmaceuticals. Joining him in this discussion is:
Scott B. Selinger, MD – President of the Advanced Urology Institute, Chair of the Advanced Urology Institute’s Advanced Prostate Cancer committee, and President-Elect of the Large Urology Group Practice Association (LUGPA),
David S. Morris, MD, FACS – President and Director of Advanced Therapeutics Center for Urology Associates
Dr. Crawford begins with a brief overview of the history of ADT and the current options available for hormone-based therapies. Dr. Sellinger notes that with the introduction of more accurate assays, the targeted post-operative levels of testosterone (T) should be less than half of the 50 ng/dl that he had been originally taught. Dr. Morris points out that there is no one-size-fits-all level of testosterone, but agrees that post-op T levels should be as low as possible.
Dr. Crawford presents the group with data from the U.S. Prostate Cancer Conference indicating that just under a third of the experts present believed that the target for post-operative T levels should be 50 ng/dl or lower. Dr. Sellinger points out that 50 ng/dl or lower is the current target held by the FDA, but that active practitioners should be targeting 20 ng/dl or lower, which Dr. Crawford supports with data.
Dr. Crawford shifts the discussion from the ideal post-op T target to the importance of ADT scheduling, pointing out that the current acceptable dose delay is within two weeks. Dr. Crawford asks Dr. Morris for his input on the importance of a consistent administration schedule for interval dosing, and Dr. Morris acknowledges that the available medications provide varying levels of leeway between doses, though keeping the schedule as consistent as realistically possible is always best. Dr. Sellinger chimes in with real-world factors that impact clinicians’ ability to adhere to a strict dosing schedule.
Dr. Sellinger identifies that many of the studies which examined the impact of late dosing used an unrealistic 28-Day month cycle, pointing out that there are no months which consistently have only 28 days. Dr. Crawford follows up this point by presenting a review comparing the impact of late dosing on a 28-Day month against a 30-31-Day month, illustrating a significant spike in the rate of T breakthroughs when dosing was late in the 30-31-Day cycle. The group concludes that monitoring T is the most important factor in evaluating the effectiveness of ADT.
Dr. Crawford then asks the group if failure to monitor T could lead to an erroneous diagnosis of castrate-resistant prostate cancer. Dr. Morris and Dr. Sellinger agree that failure to monitor T could cause a clinician to misdiagnose castrate-resistant prostate cancer, especially when different ADT medications have differing effectiveness and administration procedures.
The group concludes with a discussion of EMBARK results, and the potential impact of newer therapies added to ADT. Dr. Morris focuses on how the EMBARK data suggests better treatment results from intensifying the therapy at first, then de-escalating the therapy once the patient becomes responsive. Dr. Sellinger highlights that many oncologists are still using monotherapy to treat prostate cancer, and expresses optimism at the expanding treatment options for prostate cancer.
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E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology, sits down to talk about how patients and their loved ones can best navigate a prostate cancer diagnosis with David Mobley, MD, FACS, co-author of the book, “Prostate Cancer: Expert Advice for Helping Your Loved One.” They begin by referencing how the idea for the book came about between Dr. Mobley and Contributing Editor for Grand Rounds in Urology, Neil H. Baum, MD, after they saw a similar book intended for the partners of women with breast cancer. They discuss how Dr. Mobley and Dr. Baum, teamed up to address the questions and concerns patients and their partners often have that medical doctors rarely have time to answer in detail.
Dr. Mobley then discusses how Dr. Richard G. Key, MD, a specialist in treating the psychological effects of cancer diagnoses, joined the author team to provide guidance to the man and his partner on how to handle the emotional and psychological symptoms of prostate cancer. They discuss how the inclusion of Dr. Key’s expertise elevated the book by humanizing each case.
Finally, Dr. Crawford and Dr. Mobley discuss how the book relays information in the context of the experience of a couple navigating prostate cancer treatment. The format of each chapter is a vignette of a real prostate cancer patient, followed by an explanation for the questions raised in the vignette, and ending with further questions a man and his partner may have.
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In this discussion, the third in a trilogy on PSMA PET supported by Blue Earth Diagnostics, E. David Crawford, MD, Editor-in-Chief at Grand Rounds in Urology, leads a discussion of the case study of a 60-year-old male presenting with a PSA of 10.5 ng/ml and a Gleason score of 7 after 6 months of ADT and Proton Therapy.
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