Guidelines and Practical Applications: Erectile Dysfunction
William O. Brant, MD, FACS, FECSM explores the latest clinical guidelines and their application in managing erectile dysfunction (ED).
Read More
Utah
Physician Burnout, and Life After Death
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.
Read More
Real World Utilization of Guideline Based Therapy in mCSPC: Update From the 2021 ASCO Annual Meeting
Neeraj Agarwal, MD, Professor of Medicine and Presidential Endowed Chair of Cancer Research at the Huntsman Cancer Institute at the University of Utah in Salt Lake City, examines the underutilization of effective intensified androgen deprivation therapy (ADT) for patients with metastatic castration-sensitive prostate cancer (mCSPC). He begins by emphasizing the unprecedented efficacy of intensified ADT in improving survival for patients with mCSPC. Dr. Agarwal then asserts that, despite those findings, less than a third of patients are being offered intensified ADT therapies as first-line (1L) treatment for mCSPC, even four to five years after data has become available. Dr. Agarwal supports this argument by citing three studies from the 2021 ASCO Annual Meeting: real-world utilization of advanced therapies and racial disparity among patients with mCSPC, a Medicare database analysis of over 35,000 patients (2009-2018); real-world 1L treatment patterns in patients with mCSPC in a U.S. health insurance database (2014-2019); and real-world treatment patterns among patients diagnosed with mCSPC in community oncology settings (2014-2019). Dr. Agarwal summarized the most salient finding: less than one-third of men received intensified treatment (ADT combined with docetaxel or with a novel hormonal therapy) as their first-line treatment for mCSPC. Additionally, most men received ADT alone or ADT combined with a nonsteroidal antiandrogen as their 1L treatment, even as recently as 2019, with Black and Hispanic men even less likely than White men to receive an intensified treatment. Further, most men whose cancer had spread to soft organs (e.g., liver, lungs) had received ADT alone. Dr. Agarwal concludes by reemphasizing that the vast majority of patients are not receiving intensification therapy which is backed by level-one evidence. Dr. Agarwal points to the importance of education, awareness, and access as critical to developing better science around implementation and leading to more patients being able to receive these transformative treatments.
Read MoreTITAN Phase 3 Trial with Apalutamide in Metastatic Castration Sensitive Prostate Cancer
Neeraj Agarwal, MD, Professor of Medicine and Presidential Endowed Chair of Cancer Research at the Huntsman Cancer Institute at the University of Utah in Salt Lake City, summarizes results from the phase 3 TITAN trial of apalutamide in metastatic castration-sensitive prostate cancer (mCSPC), focusing on patient-reported quality of life outcomes. He briefly discusses the design of the study, explaining that it featured a 1:1 randomization of over 1000 patients to apalutamide plus ADT or placebo plus ADT and had dual endpoints of overall survival (OS) and radiographic progression-free survival (rPFS). Dr. Agarwal notes that both primary and final analysis found significant improvements in both OS and rPFS. Surprisingly, adjusting for the approximately 40% crossover from the placebo arm to the apalutamide arm actually led to an even greater reduction in risk of death (48% compared to 35%). Dr. Agarwal notes that this is an unprecedented improvement in survival with mCSPC, and also that rapid and deep PSA decline with apalutamide and ADT was associated with improved OS. He also considers quality of life (QoL) measurements, describing the assessment tools for evaluating pain, fatigue, and health-related QoL, and then highlighting that neither primary nor final analysis saw declines in any of these with apalutamide as compared to placebo. In fact, patients on apalutamide reported experiencing less pain. Dr. Agarwal concludes that in men with mCSPC treatment with apalutamide significantly improved survival outcomes without adversely affecting quality of life and fatigue.
Read More
Management of Recurrent Prostate Cancer After Focal Therapy
Kelly L. Stratton, MD, Assistant Professor of Urologic Oncology in the University of Oklahoma (OU) Department of Urology in Oklahoma City rationalizes the implementation of Focal Therapy despite chances of recurrence and discusses salvage therapy. He characterizes Focal Therapy as an option between radical treatment and active surveillance, which preserves quality of life. The perfect candidate is hard to achieve, according to Dr. Stratton, due to the rarity of a patient with intermediate-risk cancer, lesion localization, intact erections, and minimal urinary tract symptoms; however, he states that the ideal candidate doesn’t have to be perfect. Dr. Stratton overviews the two main types of recurrence: in-field recurrence and contralateral recurrence, through patient examples, which display how recurrence may occur post Focal Therapy and the abilities of high intensity focused ultrasound, prostatectomy, and cryoablation as salvage therapies. A multicentre study of five year outcomes post Focal Therapy found a failure free survival rate of 88% with 25% of patients having had undergone retreatment, data that Dr. Stratton states to suggest a need for providers to openly discuss the chances of repeat focal therapy against having a more aggressive treatment. He reviews data that supports implementation of Focal Therapy and displays the impact of different salvage therapies. Dr. Stratton concludes by stating that Focal Therapy’s success requires adherence to the principles of active surveillance, follow-up biopsies, and a willingness to provide definitive local therapy when focal treatment fails.
Read More