Charlottesville Archives

Expectations for Mentorship Among APPs: What Urologists Should Know

Posted by Mikel L. Gray, PhD, FNP, PNP, CUNP, CCN-AP, FAANP, FAAN | May 2024

Mikel L. Gray, PhD, PNP, FNP, CUNP, CCCN, FAANP, FAAN, provides guidance on how Urologists and APPs can get the most out of mentorships. Dr. Gray begins by reviewing the critical importance of APPs in Urology, and highlighting the AUA’s history of explicit support of APPs in urologic practice.

Dr. Gray then outlines the general experiences of APPs regarding training and fellowship in urology practices, and the lack of available structure for advancement. He outlines the various paths for APPs to enter into practice, and the challenges they represent.

Dr. Gray then turns to the role of the Urologist in mentoring urologic APPs. He explicitly highlights the “4 Cs” that the Mentor Urologist must actively facilitate for a successful mentorship: Connection, Conversation, Community, and Culture.

Dr. Gray concludes by providing guidance on what an APP should actively seek out in a mentor. He underscores the importance of finding the right mix of subspecialty and general urology in a practice, and seeking both Urologist and APP mentors.

Long-Term Outcomes with Monotherapy for LR and fIR Prostate Cancer

Posted by Timothy N. Showalter, MD, MPH | Mar 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Timothy N. Showalter, MD, MPH, Associate Professor of Radiation Oncology at the University of Virginia in Charlottesville, discusses long-term outcomes of and recent advances in brachytherapy monotherapy for low-risk (LR), favorable intermediate-risk (fIR), and selected unfavorable intermediate-risk (uIR) prostate cancer. He begins by listing potential advantages of brachytherapy monotherapy, highlighting that it features a single episode of care, is cost-effective, is multidisciplinary, has excellent long-term outcomes, features established technology to support tailored dosimetry and quality, and has been the subject of recent advances that enhance implant quality and reduce toxicity. Dr. Showalter then considers patient selection for brachytherapy monotherapy, noting that MRI may be useful in selecting patients with LR, fIR, and selected uIR disease. He emphasizes the importance of assessing whether a patient’s anatomy is suitable for implant based on gland size and arch interference, as well as the need to determine whether a patient has adequate baseline urinary function. Dr. Showalter also lists contraindications to brachytherapy monotherapy, including relative contraindications such as a large TURP defect, a large gland, and a large median lobe, as well as absolute contraindications such as inability to tolerate anesthesia, unacceptable operative risk, and the absence of a rectum. He then moves on to consider long-term outcomes of brachytherapy monotherapy, noting that for LR, fIR and selected uIR, follow-up data indicates biochemical progression-free survival of greater than 90%. Dr. Showalter also observes that outcomes are favorable in terms of toxicity, although there are some declines in urinary and sexual function. Finally, Dr. Showalter briefly summarizes recent advances in brachytherapy, emphasizing the role of advanced imaging such as MRI in helping to tailor brachytherapy dose and increase the personalization of care.

Updates in mpMRI

Posted by Kirsten L. Greene, MD, MAS, FACS | Jan 2022

Kirsten L. Greene, MD, MAS, FACS, the Paul Mellon Professor and Chair of Urology at the University of Virginia School of Medicine, gives an update on multiparametric (mp) MRI’s current role in prostate cancer detection, surveillance, staging, and recurrence. She defines mpMRI as featuring diffusion weighted images and being dynamic contrast enhanced (DCE), but also notes that biparametric MRI, which omits DCE, appears to be an effective option as well. Dr. Greene goes over the different MRI-targeted biopsy trials for prostate cancer detection, including PROMIS, PRECISION, MRI FIRST, 4M, TRIO, and PRECISE, and she explains that all of these show that mpMRI has superior sensitivity to transrectal ultrasound (TRUS) for high-grade disease, but that mpMRI alone does miss anywhere from 5 to 10% of clinically significant cancer. For this reason, Dr. Greene says, the recommendation is to use MRI prior to biopsy and use image-guided techniques, but also keep systemic biopsy. She then briefly discusses the NCCN 2021 guidelines for use of mpMRI for initial biopsy, confirmatory biopsy, prior to second biopsy, and for recurrence. Dr. Greene also looks at mpMRI for serial imaging during active surveillance, explaining that it is useful for identifying missed or anterior lesions and for delaying the next biopsy after confirmatory biopsy, but also that when to stop active surveillance based on MRI alone is controversial. She also considers the future of mpMRI in combination with PSMA PET. Dr. Greene concludes that there is a clear role for MRI (multi and biparametric) in detection, active surveillance, pre-treatment staging, and recurrence, and she reminds viewers that MRI accuracy depends upon the equipment and the experience of the radiologist.

Updates in Treatment of Renal Cell Carcinoma

Posted by Robert Dreicer, MD, MS, MACP, FASCO | Dec 2021

Robert R. Dreicer, MD, MS, MACP, FASCO, Associate Director for Clinical Research and the Deputy Director of the University of Virginia Cancer Center, discusses the challenges in picking an optimal front-line regimen for the treatment of renal cell carcinoma and the impact of adjuvant immuno-oncology (IO) therapy. He cites data from four trials (CheckMate 214, Keynote-426, CheckMate 9ER, and CLEAR) before outlining the challenges in choosing an optimal front-line regimen. Dr. Dreicer points out that there is no comparative data currently available before explaining that tyrosine kinase inhibitors (TKIs, formerly the standard of care for kidney cancers) are toxic, challenging drugs that impact a patient’s quality of life. Dr. Dreicer outlines the therapies available today, including ipilimumab plus nivolumab (IPI-NIVO) which he characterizes as challenging for the first couple of months but well-tolerated in the last ~20 months during which patients undergo a maintenance regimen of nivolumab. He points out that treatment can be stopped after two years for patients that respond well. Dr. Dreicer asserts there is no equivalent conclusion with a TKI checkpoint. Dr. Dreicer then turns his discussion to the KEYNOTE-564 study on pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for patients with renal cell carcinoma. He outlines the study design and eligibility criteria before displaying the disease-free survival (DFS) data showing the adjuvant therapy resulted in a 32 percent reduction in recurrence or death. Dr. Dreicer argues that for patients who can access an IO-based regimen, IPI-NIVO should be the standard of care, advising that while there is not one “right answer” to the optimal treatment question, practitioners ought to use one regimen, figure out what it’s toxicities are, and learn how to use it well. Dr. Dreicer then outlines questions that will emerge if an adjuvant checkpoint inhibitor becomes a standard of care, citing disruption to the front-line paradigm, the role of subsequent IO therapy, progression while on adjuvant therapy, and progression following adjuvant therapy. Dr. Dreicer emphasizes the need for other trials and the need to develop therapeutics that work in immune-checkpoint resistance.

Neoadjuvant Cisplatin-Based Chemotherapy for Muscle-Invasive Bladder Cancer

Posted by Robert Dreicer, MD, MS, MACP, FASCO | Mar 2021

Robert Dreicer, MD, MS, MACP, FASCO, Associate Director for Clinical Research and the Deputy Director of the University of Virginia Cancer Center, discusses phase 3 study evidence in support of cisplatin-based chemo which he argues is a secure alternative to immune-checkpoint inhibition, a more experimental treatment. He begins by paralleling support of immune-checkpoint inhibition to other oncological examples of physician claims of “I already know the answer.” Dr. Dreicer reflects on the 90s, specifically on the recommendation of high dose chemo for advanced breast cancer prior to the completion of studies. Once the studies were completed it became clear that high dose chemo did not demonstrate an improvement in treatment and may in fact have proved itself mostly harmful. He continues by reviewing a randomized trial comparing long-term survival results of patients treated with gemcitabine plus cisplatin against methotrexate, vinblastine, doxorubicin, and cisplatin in patients with bladder cancer. The trial found that cisplatin-based chemo had a 15.3% response rate. Dr. Dreicer overviews a phase 3 trial which found that cisplatin-based therapy reduced risk of death by 16%, corresponding to an increase in 10-year survival from 30% to 36%. He concludes with an argument for cisplatin-based treatment due to the availability of higher-quality evidence for its use than immune-checkpoint inhibition.