Mitchell O. Finkelstein (high school research intern), presented this presentation during the 31st Annual International Prostate Cancer Update in July 2021, in Snowbird, Utah.
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Steven N. Gange, MD, FACS, Director of Research and Education at Granger Medical Clinic/Summit Urology Group, reviews a propensity score-matched study comparing focal therapy (FT) for localized prostate cancer to radical prostatectomy (RP). Dr. Gange explains that, until now, this information has never been reported, as randomized controlled trials (RCTs) comparing RP to FT methods such as high-intensity focused ultrasound (HIFU), brachytherapy, or cryotherapy have historically failed to enroll and could be considered unethical given the disparity of risk. By using propensity score matching, the researchers for this study roughly simulated an RCT by selecting patients with matching entry criteria from a diverse dataset, ultimately testing 246 patients on each respective side. The primary outcome was failure-free survival, and Dr. Gange notes that at 3, 5, and 8 years the results were similar for both cohorts. Each cohort also had similar biochemical and histopathological outcomes. Dr. Gange concludes that this appears to be a reasonable comparison between RP and FT, but observes that there are some limitations to the study, including an inability to account for confounding variables and to adjust for baseline urinary and sexual function, as well as a lack of long-term outcomes.
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J. Kellogg Parsons MD, MHS, FACS, Professor of Urology at the University of California, San Diego, explains why neoadjuvant therapy prior to surgery may not be the best option for prostate cancer patients. He reviews findings from definitive randomized clinical trials that show ADT does not improve survival, and addresses common side effects, such as cognitive impairment and loss of testosterone function. Dr. Parsons then explains AUA Clinical Guidelines published in alignment with SUO and ASTRO that strongly recommend against routine neoadjuvant therapy prior to surgery. Lastly, he gives examples of when physicians can consider the option despite such caveats.
Read MoreL. Michael Glodé, MD, FACP, Professor Emeritus of Medical Oncology and the former Robert Rifkin Chair for Prostate Cancer Research at the University of Colorado Cancer Center in Aurora, Colorado, presents the case for standard imaging over second-generation technology in urologic oncology. One compelling reason to consider standard imaging like bone scans is the extensive data that have culminated in criteria on when to order routine scans such as these. Advanced imaging currently lacks both the wealth of data and scanning criteria, leading to questions about the frequency of false positives and false negatives and whether radiologist training is consistent. Dr. Glodé observes that we understand the limitations of conventional imaging, adding that there is insufficient data to make any such determination about the accuracy of second-generation scans. Since trials studying second-generation anti-androgens over the last few years have employed conventional imaging, Dr. Glodé suggests the more sensitive second-generation imaging could potentially deny patients with now-visible metastases access to some drugs based on eligibility criteria. The cost of newer imaging techniques is also prohibitive, especially if they do not replace current scans or change approaches to treatment. He concludes that the level 1 evidence on treatment of non-metastatic castration-resistant prostate cancer using conventional scans weighed against the cost of second-generation scans and the potential for inconsistent application of newer technology suggest that doctors should better utilize current standard imaging.
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This Commentary will addresses the guidance from four clinical trials regarding patient selection and imaging choices to best select patients most likely to benefit from MDT.
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