Ann Arbor Archives

Bone Health and ADT

Posted by Mark A. Moyad, MD, MPH | Jul 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, interviews Celestia S. Higano, MD, FACP, Adjunct Professor in the Department of Urologic Sciences at the University of British Columbia and Medical Director of the Prostate Cancer Supportive Care Program at the Vancouver Prostate Centre, about the importance of dual-energy X-ray absorptiometry (DEXA) screening to preserve bone health in men initiating androgen deprivation therapy (ADT). Dr. Moyad begins by highlighting the findings of an article recently published in JAMA which showed that while DEXA screening was associated with a decreased risk of osteoporotic fracture, only 7.9% of older men starting ADT received this screening. Dr. Moyad argues that this demonstrates that while many focus on calcium and vitamin D deficiency as the causes of bone issues in men on ADT, the real deficiency is in DEXA screening. Dr. Higano concurs, explaining that the only good way to monitor bone density in men on ADT is to get a baseline, and noting that every patient in her practice undergos DEXA screening before initiating ADT unless they are on a bone health agent already. She also mentions that she performs a repeat DEXA after a year. Dr. Moyad then considers whether quantitative computed tomography (QCT) is a reasonable alternative to DEXA, arguing that it is not since it is more expensive, uses a lot of radiation, and overestimates bone health issues. Dr. Higano agrees, observing that QCT was designed as a research tool rather than a diagnostic one, while DEXA is the “gold standard” in this area. They then hypothesize that some clinicians are switching from DEXA to QCT because of higher reimbursement rates. Drs. Moyad and Higano conclude by underscoring that wider DEXA screening is the most significant change needed to preserve bone health in men on ADT.

Overactive Bladder vs. Interstitial Cystitis: Overlapping Conditions?

Posted by John Thomas Stoffel, MD | May 2022

John Thomas Stoffel, MD, Associate Professor of Urology and Chief of the Division of Neurourology and Pelvic Reconstruction within the University of Michigan Department of Urology in Ann Arbor, Michigan, discusses how to differentiate overactive bladder (OAB) from interstitial cystitis (IC), as well as how to appropriately treat both conditions. He begins with some background, explaining that OAB is common and affects 30 to 50 million women worldwide. IC is also common, and may affect between 2 and 17% of US adults. Dr. Stoffel argues that despite this prevalence, clinicians do not understand the depth of these conditions nor how to differentiate them. He then defines OAB as “[urinary] urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia,” whereas IC is an unpleasant sensation (pain, pressure, discomfort) perceived to be related in the urinary bladder, associated with LUTS, of greater than 6 weeks duration in the absence of infection. Dr. Stoffel posits that IC is more associated with sensory symptoms while OAB more associated with motor symptoms. He then discusses the work-up for OAB and IC, explaining that the work-up for the former should include a physical exam, urine analysis, and a voiding diary, while the work-up for the latter should feature a physical exam, a history of symptoms, urinalysis, urine culture, and urine cytology. Dr. Stoffel moves on to treatment strategies, describing the treatment of OAB as like a ladder, moving sequentially from behavioral therapy to medications to neuromodulation/onabotulinum toxin. He recommends tracking outcomes for OAB with patient reported outcome measures (PROMS), and highlights the effectiveness of behavioral therapies such as timed voiding/fluid management, weight loss, and biofeedback. Dr. Stoffel also notes that there are no clear winners among OAB medications, and he emphasizes the need to define patients’ expectations. He describes the treatment strategy for IC as less like a ladder than a grab bag, explaining that “initial treatment type and level should depend on symptom severity, clinician judgment, and patient preferences.” Dr. Stoffel briefly considers the evidence for neuromodulation and onabotulinum toxin, concluding that they are effective for OAB, but there is little extended data in IC.

Semaglutide as a Game Changer for Weight Loss

Posted by Mark A. Moyad, MD, MPH | Feb 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, discuss the potential benefits of semaglutide, a newly approved weight-loss drug. Dr. Moyad begins by summarizing the damage done by past weight-loss drugs, noting that they inevitably came with a huge catch and were never heart-healthy. He then introduces semaglutide, a recently-approved drug which has been shown to result in 15% weight loss over 2 years. Dr. Miner elaborates, explaining that there have been 4 studies of semaglutide featuring over 4500 individuals and that it is extremely safe. He highlights that the smaller dose in diabetics has also been shown to improve renal and cardiovascular outcomes, and that these outcomes are now being studied in non-diabetics. Dr. Miner argues that these results suggest semaglutide is a game changer. Dr. Moyad then discusses potential catches, noting that while the side effect profile seems good, the cost is very high at nearly $900 per month, and it is not covered by most insurance. Dr. Miner suggests that the price will go down once some time has passed from the initial approval. He does highlight as a negative the fact that semaglutide is given once per week as a subcutaneous injection, and suggests that it will be beneficial if the oral version currently under investigation is found to be effective. Drs. Miner and Moyad also ponder the long term impacts of semaglutide and sustained weight loss on testosterone levels, blood pressure, and depression. Dr. Moyad concludes by discussing his curiosity about the potential impact of semaglutide in a urologic setting.

GU ASCO Symposium 2022 Summary

Posted by Ulka Vaishampayan, MD | Feb 2022

Ulka Vaishampayan, MD, Professor of Medicine and Genitourinary (GU) Oncology at the University of Michigan’s Rogel Cancer Center in Ann Arbor, Michigan, discusses highlights from the 2022 GU ASCO Symposium, focusing on advanced prostate cancer treatment research. She begins by discussing the phase 3 ARASENS trial, which looked at overall survival with darolutamide versus placebo in combination with androgen deprivation therapy (ADT) and docetaxel for metastatic hormone-sensitive prostate cancer (mHSPC). Dr. Vaishampayan explains that the investigators found that darolutamide significantly reduced the risk of death by 32.5%, and that this means that an overall survival benefit has now been seen with treatment intensification in 2 separate trials: PEACE-1 (docetaxel plus abiraterone) and ARASENS (docetaxel plus darolutamide). She argues that these results indicate that a triplet regimen with ADT, docetaxel, and darolutamide is the new standard of care in men with mHSPC. Dr. Vaishampayan then moves on to discuss the phase 3 PROpel trial of olaparib and abiraterone versus placebo and abiraterone as first-line therapy for patients with metastatic castration-resistant prostate cancer (mCRPC). She notes that PROpel found 34% risk reduction of progression or death with olaparib plus abiraterone, and that while overall survival data is fairly immature, the trend seems to favor olaparib plus abiraterone over placebo plus abiraterone. She also highlights that the safety profile of olaparib plus abiraterone was consistent with the safety profile for the individual drugs and there was no detriment to quality of life. Finally, Dr. Vaishampayan considers first results from the phase 3 MAGNITUDE study of niraparib with abiraterone acetate and prednisone as first-line therapy in patients with mCRPC with and without homologous recombination repair (HRR) gene alterations. She explains that MAGNITUDE showed a benefit to niraparib in the HRR arm, but no benefit in the non-HRR arm. Dr. Vaishampayan concludes that MAGNITUDE demonstrates the importance of testing for HRR gene alterations in patients with mCRPC to identify who will optimally benefit from the combination of niraparib and prednisone and also supports niraparib plus prednisone as a new first-line treatment option for patients with mCRPC and alterations in genes associated with HRR.

Testosterone, Weight Loss / Weight Gain, and Testosterone Replacement Therapy (TRT)

Posted by Mark A. Moyad, MD, MPH | Feb 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, investigate the ways in which body mass index (BMI) correlates with testosterone levels and how this knowledge can be used in a medical setting. Dr. Moyad begins the discussion with Dr. Miner’s presentation on the possibility of testosterone needs increasing as BMI increases, wherein Dr. Miner found that obese men required higher doses of testosterone to reach eugonadal levels than men who were not obese. Dr. Miner states that he expects the results of a long-term safety study of testosterone will soon show that testosterone therapy is safe over the long term, allowing physicians and researchers to focus on the symptomatic benefit of testosterone in areas such as mood and cardiovascular risk. Dr. Moyad asks if weight loss and increased fitness could possibly reduce the need for testosterone therapy, to which Dr. Miner responds that it may be possible if both weight loss and a reduction in comorbidities occur but it is unlikely in patients over 60. They conclude that weight loss can help make testosterone therapy more effective but it is unclear if it would be enough to reduce testosterone therapy altogether because of a multitude of genetic variables.