United States Archives

PSMA Targeted Therapies and the Role of the Urologist

Posted by Phillip J. Koo, MD | May 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses PSMA targeted therapies for prostate cancer and the urologist’s role in using radiotherapy. He begins by looking at the results of the VISION trial of lutetium-177 PSMA-617 for metastatic castration-resistant prostate cancer (mCRPC), explaining that radioligand therapy significantly increased overall survival and radiographic progression-free survival. Dr. Koo then considers the TheraP trial of lutetium-177 PSMA-617 versus cabazitaxel which saw far better PSA response in PSMA arm than in the cabazitaxel one. He notes that the amount of imaging used in patient selection for TheraP would be impractical in a real-world setting. Dr. Koo also looks at the slate of upcoming clinical trials of PSMA, highlighting the number of combination therapy trials in the CRPC setting, as well as the number of trials looking at PSMA’s potential role in earlier phases of the disease. Finally, Dr. Koo discusses the role of the urologist in the new PSMA era, arguing that urologists need to understand and be comfortable with PSMA since it is an increasingly important tool for treating advanced prostate cancer. He recommends that urologists create advanced prostate cancer clinics featuring targeted radiotherapy clinics.

Physician Burnout, and Life After Death

Posted by Peter C. Fisher, MD | Apr 2022

Peter C. Fisher, MD, Chief of Surgery and Director of Men’s Health Services at St. Mark’s Hospital in Salt Lake City, Utah, begins his talk on physician burnout with a personal story that changed his life. His hope is that in sharing what he learned through this experience, he can help those in his field become more integrated, less individual, more committed, and less comparative. Dr. Fisher experienced sudden cardiac arrest (SCA) while playing basketball at age 45. SCA (called sudden cardiac death in those who do not survive) carries a 90 percent mortality and 95 percent morbidity rate. Dr. Fisher discusses the experience of being pulseless for 11 minutes and the actions of the people who, collectively, saved his life. Dr. Fisher has now experienced what he calls “life after death,” which has led him to shift priorities, find greater joy, and recognize the failures of the pre-dying life, which he describes as ambitious, strategic, and independent. Conversely, he characterizes his life after death as relational, intimate, and relentlessly grateful. Dr. Fisher shares several observations, explaining that before the experience, he defined success according to his contribution to various projects and was addicted to the praise that “success” garnered. Now, he recognizes that the quality of his relationships defines his success. This near-death experience allowed Dr. Fisher to more clearly see the distinction between where he is wanted versus where he is needed. Dr. Fisher shares that, in his new life after death, his wants and desires have shifted from independence to interdependence. He explains the recognition that comparison is the “robber of joy” and describes how freeing it has been to no longer carry the weight of that comparison. Dr. Fisher emphasizes that in his life after death, he has been more honest, patient, and focused on long-term gains; he characterizes life as a qualitative, rather than a quantitative, endeavor. In conclusion, Dr. Fisher explains that vulnerability can result in tremendous strength and result in warmer, joyful relationships.

Comparative Outcomes: Prostate Brachytherapy vs. EBRT vs. SBRT for Low/Intermediate Risk Disease

Posted by Michael J. Zelefsky, MD | Apr 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Michael J. Zelefsky, MD, Vice Chair of Clinical Research in the Department of Radiation Oncology and Chief of the Brachytherapy Service at Memorial Sloan Kettering in New York City, compares outcomes for prostate brachytherapy vs. external-beam radiation therapy (EBRT) vs. stereotactic body radiotherapy (SBRT) for patients with low- and intermediate-risk disease. Dr. Zelefsky explains that when comparing outcomes, the focus is on toxicity after therapy and the efficacy of therapy. He also notes several limitations in comparing different radiotherapeutic modalities as well as dramatic technological innovation over the last 10 years that have greatly improved radiotherapy delivery. While this has been revolutionary in the treatment of disease, it creates what he calls “a moving target” when comparing outcomes because of the difficulty in comparing studies completed at various points in this technological revolution. Dr. Zelefsky cites a comparative study of patient-reported quality-of-life (QOL) outcomes after SBRT, low-dose-rate (LDR) brachytherapy, and high-dose-rate (HDR) brachytherapy for prostate cancer. Another study compared patient-reported QOL following SBRT and conventionally fractionated EBRT compared with active surveillance in those with localized prostate cancer. He reviews highlights from five-year outcomes of the HYPO-RT-PC randomized, non-inferiority, phase 3 trial that examined ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer, including that the estimated failure-free survival at five years was 84 percent in both treatment groups. Dr. Zelefsky notes that genitourinary and gastrointestinal toxicity were similar in both groups as well. He presents a chart illustrating urinary symptoms post-therapy which shows that while LDR has a higher rate of acute grade two urinary symptoms, late urinary toxicity and late urinary incontinence are similar across LDR, EBRT, and SBRT. Dr. Zelefsky outlines the benefits of prostate brachytherapy for favorable and intermediate-risk disease, pointing out that it has the most ablative potential, prostate-specific antigen nadirs are generally significantly lower than with EBRT, and post-treatment biopsy outcomes are positive in just seven percent of patients. He compares this with data showing that EBRT results in post-treatment positive biopsy outcomes of approximately 25-30 percent and data showing that SBRT with a dose of 40 Gy results in post-treatment positive biopsy outcomes of 11 percent. Dr. Zelefsky suggests then that SBRT has more ablative potential than EBRT but that brachytherapy has even more ablative potential than either of these. Finally, Dr. Zelefsky summarizes by explaining how these findings help inform patient decisions and treatment selection, pointing out that prostate brachytherapy may be preferable for the younger patient with few urinary symptoms, while patients with significant urinary symptoms may prefer SBRT. Patients with a larger prostate who may otherwise require downsizing with ADT may opt for SBRT over brachytherapy.

PCa Commentary | Volume 164 – April 2022

Posted by Edward Weber, MD | Apr 2022

This Commentary looks at an emerging management trifecta for recurrent prostate cancer: PSMA PET, oligometastatic cancer & focal therapy.

Off-Label Use of Xiaflex for Peyronie’s Disease

Posted by Jesse N. Mills, MD | Apr 2022

Jesse N. Mills, MD, Associate Clinical Professor and Director of the Men’s Clinic at UCLA, discusses techniques for Xiaflex on and off label, and when and how it can be used to treat Peyronie’s disease. These include alternative injection techniques, plaques involving the penile urethra, use for men on anticoagulation treatments, and non-goniometric deformity.