Video 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.

Racial Justice and Prostate Cancer

Posted by Christopher J. Kane, MD, FACS | Jul 2022

Christopher J. Kane, MD, FACS, the Dean of Clinical Affairs at the University of California San Diego School of Medicine, and the CEO of the UC San Diego Health Physician Group, discusses the role of race in prostate cancer mortality among Black men. Dr. Kane presents data showing that both the incidence and rate of death from prostate cancer are significantly higher in Black men, and that this ratio has remained consistent over time. Referencing the SEER database, Dr. Kane notes that Black men were twice as likely to die of prostate cancer. While there are claims that biologic differences between Black and White men are to blame for the rate of death, Dr. Kane points out that the genetic differences between Black men are similar to the genetic difference between White men. He further adds that inheritance patterns of Black Americans are highly variable and cannot be considered a homogenous biological construct. Beyond genetic factors, Dr. Kane mentions other possible causes for the disparity including environmental factors, care dynamics, care quality, and availability. He then reviews a study that analyzed three cohorts to determine whether Black race was associated with inferior prostate cancer outcomes if patients had similar access to care and standardized treatment. The results indicate that Black men were not at higher risk of prostate cancer mortality when they had access to better healthcare. He concludes that physicians can save nearly 4,000 Black men who would otherwise die of prostate cancer each year. Regardless of potential factors impacting disease risk and progression in Black men, Dr. Kane maintains that providing superb screening, detection, and treatment can reduce the observed racial difference in prostate cancer outcomes.

Industry Perspective: ConfirmMDx and Improving the Identification of Men at Risk for Clinically Significant Prostate Cancer

Posted by Wim Van Criekinge, PhD | Jun 2022

Wim Van Criekinge, PhD, Professor of Computational Genomics and Bioinformatics at Ghent University in Ghent, Belgium, and Chief Scientific Officer for MDxHealth in Ghent, discusses ConfirmMDx, a test for prostate cancer from MDxHealth which uses tissue from a negative biopsy. He explains that prostate biopsies have a false negative rate of 25% since they only sample a very small percentage of the prostate and can miss the cancer entirely. ConfirmMDx, Dr. Van Criekinge notes, leverages the fact that cancer originates from changes in DNA which create a halo or field effect around the actual tumor. He details the specific ConfirmMDx genes, all of which were previously cited in a prognostic context, and explains that negative cores that are proximal to cancer will show up positive on ConfirmMDx. Dr. Van Criekinge highlights that ConfirmMDx, which has a negative predictive value of 96%, outperforms traditional methods like age, PSA, atypia, and the PCPT Risk Calculator 2.0 in identifying men harboring aggressive cancer. He also emphasizes the test’s accessibility and low cost, noting that the vast majority of patients are responsible for paying $250 or less. Dr. Van Criekinge concludes by detailing the clinical information required for the ConfirmMDx test, including PSA and DRE result, PSA and DRE date, and the pathology report, adding the caveat that tissue more than 30 months old may be rejected.

MRI-guided Transurethral Ultrasound Ablation (TULSA) for Prostate Cancer

Posted by Laurence Klotz, MD, FRCSC | Jun 2022

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, discusses the technology, procedure, outcomes, and regulatory environment surrounding MRI-guided transurethral ultrasound ablation (TULSA) treatment for patients with prostate cancer. He begins by displaying a chart of multiple minimally invasive treatment options for prostate cancer. Dr. Klotz lists prospective studies of focal therapy that found relatively few adverse quality-of-life (QOL) effects. He goes on to compare five ultrasound-based technologies in terms of biopsy and prostate-specific antigen (PSA) outcome, concluding that data demonstrates these therapies work. Dr. Klotz emphasizes that there is not currently a way to differentiate the oncological efficacy of these treatments, citing the number of variables and reiterating that they all are reasonably effective. Dr. Klotz then turns the discussion to MRI-guided transurethral ultrasound ablation (TULSA), explaining the function of the technology and the system components involved, explaining that the energy delivered is controlled by a closed-loop control system. He outlines the key features of the TULSA system, explaining that it delivers transurethral directional ultrasound ablation which is incision and radiation free, and there is no energy coming through the rectum and there is no volume limitation. Further, real-time MRI thermal dosimetry and ablation control means temperature is measured in real time and the system adjusts the amount of energy delivered to the tissue, providing precision, actively compensating for tissue and blood flow changes during the treatment. Finally, the system offers thermal protection of important anatomy (i.e., urethra and rectum cooling). Dr. Klotz then outlines the evolution of the TULSA technology, including technical studies, canine studies, first-in-man treatment, and feasibility studies. He describes the TULSA-PRO Ablation Clinical Trial (TACT), which involved 115 patients across 13 institutions in five countries, with safety (frequency/severity of adverse events) and efficacy (PSA reduction ≥75 percent in >50 percent of patients) being the primary endpoints at 12 months. Ninety-six percent of patients had a PSA reduction ≥75 percent at 12 months and at the 12-month MRI the median prostate volume had decreased from 41 to 4 cc (a decrease of 90 percent). Further, the treatment preserved continence and erectile function. In a three-year follow-up among men who underwent the treatment, just 11 percent needed salvage treatment. Dr. Klotz explains the challenges involved in demonstrating level-one evidence for the benefit of new technologies since benefits tend to be incremental and gradual. He cites the da Vinci robot as an important example and explains that the U.S. Food and Drug Administration (FDA) has acknowledged this in its approval of high intensity focused ultrasound (HIFU) and TULSA (for tissue ablation). Dr. Klotz concludes with a summary of the TULSA technology, procedure, outcomes, and regulatory considerations, explaining that this new technology is being offered in the US and Europe and is pending in Canada.

Socioeconomic Aspects of Prostate Brachytherapy

Posted by Peter F. Orio III, DO, MS | Jun 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Peter F. Orio III, DO, MS, Vice Chair of Network Operations for Dana-Farber/Brigham and Women’s Cancer Center Department of Radiation Oncology and Associate Professor of Radiation Oncology at Harvard Medical School in Boston, Massachusetts, discusses socioeconomic influences on the use of prostate brachytherapy. He begins by listing nine factors that he believes have led to a decline in the use of prostate brachytherapy: (1) a decrease in PSA screening and prostate cancer diagnosis; (2) an increase in patients electing active surveillance; (3) Nuclear Regulatory Commission requirements; (4) an increase in the number of robotic prostatectomies; (5) a suboptimal volume of prostate brachytherapy procedures being performed; (6) negative press about brachytherapy from procedures performed at the Philadelphia VA; (7) the increased technical sophistication of external beam radiation technologies; (8) a lack of knowledge of brachytherapy’s efficacy; and, most significantly, (9) markedly decreased reimbursement rates for brachytherapy. Focusing on this last point, Dr. Orio considers a report by the Government Accountability Office which found that if there was a self-referring interest in a center that offered intensity-modulated radiation therapy (IMRT), use of IMRT would increase by about 50%, while radical prostatectomies would decrease by 27% and brachytherapy procedures would decrease by 50%. He explains that in a fee-for-service model, a treatment like brachytherapy which requires one implant is reimbursed for far less than a treatment like IMRT which requires weeks of treatment over the course of multiple sessions. This creates, Dr. Orio argues, a disincentive to perform brachytherapy even though it is less expensive and results in better quality of life than IMRT. He suggests that implementation of the radiation oncology alternative payment model (RO-APM) may solve this problem. Dr. Orio explains that the RO-APM, which is being tested in certain zip codes, represents a shift to value-based care and is intended to simplify coding and reduce Medicare costs. Under the RO-APM, he notes, regardless of the modality of treatment, the payment is the same, so brachytherapy monotherapy will likely benefit from an increase in payment. Dr. Orio concludes that the RO-APM may lead to a resurgence in prostate brachytherapy by removing financial disincentives to performing the procedure.