Prostate Biopsy Considerations – Transrectal vs. Perineal
Dr. Guilherme Godoy discusses research on prostate biopsy considerations, weighing both transrectal and transperineal approaches.
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Talks by Guilherme Godoy, MD, MS
When is Radical Cystectomy Indicated for NMIBC?
Guilherme Godoy, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine, in Houston, Texas, discusses the role of cystectomy in non-muscle invasive bladder cancer (NMIBC). He begins by describing the management options for NMIBC, including transurethral resection of the bladder tumor (TURBT), intravesical treatment, systemic therapy, and radical cystectomy. Dr. Godoy then explains the importance of re-TURBT, stating that it is one of the most critical steps in management for reducing understaging and improving intravesical therapy response in patients. He summarizes the indicators for cystectomy, including failure to resect, adverse pathology, and treatment failures. Dr. Godoy reviews data from a large single-institution retrospective study showing a significant difference in recurrence-free survival, cancer-specific survival, and overall survival in favor of the primary muscle invasion at presentation group vs. the progressive MIBC group. He then discusses data from a systematic review and meta-analysis of 14 studies on oncological outcomes of primary and secondary MIBC, finding worse outcomes overall for secondary muscle invasive cystectomy. Dr. Godoy looks at the European and AUA risk stratification tables, focusing on how both support aggressive management of high risk disease. He shows data from a study of the impact of variant histology on outcomes with intravesical immunotherapy, finding 40% progression-free survival compared to 17.5% in conventional bladder cancer. He states that all of this data supports cystectomy as an important and integral tool in the management of NMIBC due to its excellent oncological outcomes and potential benefit of abbreviated management and follow-up for aggressive NMIBC despite its morbidity, though the treatment may not be appropriate for everyone.
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Decisional Tools to Determine Need for Biopsy and Re-Biopsy in Men with Elevated PSAs
Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology at Baylor College of Medicine, in Houston, Texas, discusses how and when to use elevated PSA and other markers to determine whether a biopsy is needed. Dr. Godoy cautions that relying solely on an abnormal level for a sensitive biomarker like PSA can lead to false positives and overtreatment, noting that an elevated PSA is an indicator of the prostate but not necessarily of cancer. He reminds physicians to consider the PSA level related to the size of the prostate before jumping ahead to other steps. Dr. Godoy describes how oft-overlooked PSA derivatives in conjunction with family history and other risk factors can be used to individualize risk and personalize assessments for a patient. He then presents an array of current and emerging molecular, genetic, and imaging-based testing options. The 4Kscore assesses the probability of high-risk cancer (Gleason 7 or higher) in the biopsy and informs risk of metastatic disease in 20 years. This test can also indicate risk stratification for mortality. Urine-based tests such as SelectMDx and EPI ExoDx Prostate Intelliscore similarly provide risk stratification for biopsy-naïve men, while tissue-based tests such as ConfirmMDx are useful when a patient has had a previous negative prostate biopsy. He summarizes with a diagram of the clinical integration of MRI and molecular markers illustrating how these testing options should be used.
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Active Surveillance – When Can You Continue Watching and When Do You Intervene?
Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology, Dov Kadmon, MD, Professor of Urology, and Michael A. Brooks, MD, Assistant Professor of Urology and Oncology, all at Baylor College of Medicine in Houston, Texas, discuss active surveillance (AS) for prostate cancer by using numerous case studies outlining patient characteristics, evaluation methods and diagnosis, the discussion and decision-making process, treatment, and outcome data to illustrate best practices. Their panel discussion covers magnetic resonance imaging (MRI)-fusion biopsy and systematic biopsy and highlights the need to use both as they are complementary. The doctors also discuss risk-benefit analysis; the role of urine, blood, and genomic testing; treatment algorithms, and important considerations such as those surrounding the patient’s overall health and life expectancy. Dr. Kadmon highlights the importance of integrating experience, common sense, and research. He emphasizes that integrating prostate MRI in AS protocol is imperative and MRI is important both when starting AS and in follow up. The doctors caution that MRI is not infallible; if the follow-up MRI is negative but there is strong suspicion for progression, a regular follow-up biopsy is justified. They advise that these follow-up biopsies be done for a reason and not just not based on an arbitrary time interval. Dr. Kadmon reiterates the point that a fusion biopsy and a systematic biopsy are complementary and should be carried out simultaneously and concludes by reviewing success elements involved in prostate MRI, including the equipment and protocols used, the experience of the radiologist, and whether the radiology program includes a quality improvement feedback loop, emphasizing that all these factors are important.
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Urologic Debate Part 1: MRI vs. Molecular Markers – Which One Should I Use? MRI Perspective
In the first part of this urologic debate, Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology at Baylor College of Medicine in Houston, Texas, argues for multiparametric MRI (mpMRI) as the better diagnostic tool for finding prostate cancer as compared to molecular markers. He observes that while there are many different commercial markers available to aid decision-making before diagnosis, at initial diagnosis, and after treatment, mpMRI can help in all three of these prostate cancer management spaces. Dr. Godoy also argues that while molecular tests may inform risk, a biopsy preceded by MRI will still be necessary, and that biopsy can be improved and optimized by mpMRI. He then discusses different techniques and equipment that can be used with mpMRI, how to interpret and report the results from mpMRI, and the trial evidence for mpMRI’s effectiveness. Dr. Godoy concludes that mpMRI functions as “the ideal biomarker,” as it increases accuracy and decreases the number of biopsies and helps to optimize care after cancer diagnosis.
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