Video Archives

Role of Prostate Brachytherapy in Gleason 8-10 Disease

Posted by Peter F. Orio III, DO, MS | May 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 brachytherapy’s role in treating high-risk prostate cancer (PCa). He shares the largest prostatectomy series to report cause-specific survival (CSS) by biopsy Gleason score (and the largest prostatectomy series to report CSS in the prostate-specific antigen [PSA] era), highlighting data that demonstrate that men with T3 disease have a 38 percent chance of prostate-cancer-specific mortality (PCSM) and men with a Gleason score of 8-10 have a 34 percent chance of PCSM. Further, long-term surgical biochemical progression-free survival (bPFS) among men with a Gleason score of 8-10 is on the order of 30-40 percent. Dr. Orio then displays data from a comparative analysis of PSA-free survival outcomes for patients with high-risk PCa by radical therapy. It shows that external-beam radiation therapy (EBRT) with brachytherapy (with or without androgen-deprivation therapy [ADT]) has better PSA-free progression than do other radical therapies. He cites data that show when brachytherapy is added to EBRT, patient outcomes improve. He then introduces three clinical trials examining EBRT with and without brachytherapy to examine more closely. In the first trial, at a median follow-up of 8.2 years, patients treated with EBRT with a brachytherapy component had half the biochemical failure compared with patients treated with EBRT alone. Similarly, another randomized trial of EBRT alone or combined with high-dose brachytherapy boost showed similar improved outcomes, with better biochemical relapse-free survival at five, seven, and 10 years for patients who underwent the combined therapy. Dr. Orio then turns to the ASCENDE-RT Trial, which compared a low-dose-rate prostate brachytherapy (LDR-PB) to a dose-escalated EBRT (DE-EBRT) for patients with high- and intermediate-risk PCa. Data showed a benefit to the LDR-PB, with an absolute difference in the proportion of patients free of recurrence of nearly 21 percent at nine years. Similar results occurred among intermediate-risk patients and high-risk patients. Dr. Orio goes on to compare the progression-free survival at seven years among high risk patients who received the LDR-PB (83 percent) with the surgical bPFS of 30-40 percent, concluding that brachytherapy can spare many men the need for salvage therapies. He then addresses toxicity concerns about the LDR-PB, explaining that practitioners should avoid the dragging of seeds to the membranous urethra, where they have the potential to cause a urethral stricture. Dr. Orio explains that doctors can decrease toxicity by identifying the apex of the prostate, making it easier to control placement of the seeds and avoid toxicity. He goes on to explain other solutions to reduce toxicity such as using a gel spacer between the prostate and the rectum. Dr. Orio cites one additional study confirming that EBRT with brachytherapy leads to better patient outcomes compared with radical prostatectomy or EBRT alone. Dr. Orio advises that patients with intermediate- or high-risk PCa receiving EBRT +/- ADT should be offered brachytherapy as a dose escalation strategy because it is proven with Level 1 evidence. He explains that the American Society of Clinical Oncology (ASCO) stated that eligible intermediate- and high-risk PCa patients choosing EBRT with or without ADT should be offered brachytherapy. Dr. Orio states that a rising PSA condemns many men to expensive, toxic, and quality-of-life-reducing treatments and asks if society is prepared for this cost to normalize overall survival. He asserts that we should instead consider using brachytherapy in those with higher-risk disease.

Point-Counterpoint: Neoadjuvant Chemotherapy Prior to Cystectomy (Pro)

Posted by Amirali Salmasi, MD | May 2022

Taking the pro side in a point-counterpoint debate, Amirali Salmasi, MD, Assistant Professor of Urology at the University of California, San Diego, argues that neoadjuvant chemotherapy (NAC) should be offered to any “fit” patient with invasive bladder cancer before radical cystectomy (RC). After noting that survival outcomes for invasive bladder cancer after cystectomy are not great in general, Dr. Salmasi considers decades of trial data on the addition of NAC to RC. He looks at the SWOG-8710 trial, two Nordic trials, the BA06 30894 trial, a trial of ddMVAC, and more, all of which indicate that NAC improves outcomes significantly. Dr. Salmasi also notes that these trials did find that NAC increased perioperative risks. He then considers the potential role of adjuvant chemotherapy, observing that the limited data available suggest that NAC is superior to adjuvant treatment. Dr. Salmasi concludes with a brief discussion of how urologists and oncologists should optimize the use of NAC by researching therapy combinations, duration, patient selection, and biomarkers.

Point-Counterpoint: Neoadjuvant Chemotherapy Prior to Cystectomy – Con

Posted by Alan H. Bryce, MD | May 2022

Taking the con side in a point-counterpoint debate, Alan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic Arizona in Scottsdale, argues that offering neoadjuvant chemotherapy (NAC) to patients with invasive bladder cancer prior to radical cystectomy (RC) may not always be the appropriate decision. He begins by considering what the debate even is, explaining that the NCCN considers NAC followed by radical cystectomy a category 1 recommendation based on high level data. Meanwhile, Dr. Bryce notes, adjuvant chemotherapy is only considered a category 2A recommendation. However, he continues, the NCCN guidelines also mention that patients with “hearing loss or neuropathy, poor performance status, or renal insufficiency may not be eligible for cisplatin based therapy,” and if “cisplatin based therapy cannot be given, neoadjuvant therapy is not recommended.” Dr. Bryce also argues that while clinical trial data strongly favors NAC, real-world patient populations are different from trial populations. He cites a study based on real-world data which found that the patients in the SWOG trial of NAC were younger and fitter compared with national numbers, and which found the survival benefit with NAC to be slight in retrospective data. Additionally, Dr. Bryce observes that about 33 to 41% of patients are ineligible for cisplatin due to their baseline renal function status. He notes that those patients might benefit from adjuvant chemotherapy, but acknowledges there have been few randomized controlled trials in this setting. Dr. Bryce then highlights toxicity issues related to NAC, including increased creatinine, decreased neutrophil, peripheral sensory neuropathy, and tinnitus. He concludes that because real-world patients are older and have more comorbidities than trial populations, NAC perhaps should not be used as widely as guidelines indicate.

How to Utilize MRI for Focal Therapy Planning

Posted by Samir S. Taneja, MD | May 2022

Samir S. Taneja, MD, the James M. Neissa and Janet Riha Neissa Professor of Urologic Oncology, Co-Director of the Smilow Comprehensive Prostate Cancer Center, and Vice Chair of the Department of Urology at NYU Grossman School of Medicine, discusses how to use MRI in planning and doing follow-up on focal therapy for prostate cancer. He begins by introducing the critical decisions in focal therapy implementation, including candidate selection, method of disease mapping/identification, choice of energy, and manner of follow-up/verification of efficacy. Dr. Taneja then lists imaging-related factors influencing oncologic efficacy including tumor size/extent, tumor location, focality, energy source, and gland size. He considers biopsy vs. MRI in treatment planning, explaining that systematic biopsy is inadequate for mapping disease, transperineal template biopsy is the gold standard, and MRI/MRI-targeted biopsy is not perfect, but very good. Dr. Taneja notes that MRI misses some clinically significant cancer, but observes that a 9 to 10 millimeter MRI/MRI-targeted biopsy guided focal ablation seems to identify all the index tumors. He also goes over imaging factors such as disease location and volume affect the choice of energy selection for focal therapy. Dr. Taneja then considers the benefits of imaging post partial gland ablation, explaining that very early imaging evaluates the anatomy of ablation but not its efficacy, intermediate interval imaging guides biopsy and identifies need for retreatment, delayed imaging identifies recurrence. He also briefly discusses the use of PET in cases where MRI does not detect recurrence. Dr. Taneja concludes that MRI has the ability to localize the index tumor, that margin considerations should take into account the known limitations of MRI in disease mapping, and that MRI remains the essential mainstay for monitoring following focal ablation.

Lessons from LEGO Blocks

Posted by Neil H. Baum, MD | May 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, considers five lessons medical practices can learn from the successes of the LEGO toy company. He begins with a brief history of the LEGO company, explaining that it started declining in 1992, but was able to reverse this decline in 2014 and is now the largest toy company in the world. Dr. Baum then goes through lessons for medical practices modeled on the success of LEGO, beginning with the idea of connectivity. He observes that each LEGO piece connects to every other piece, with no piece dominating, and he argues that practices must similarly connect with patients, hospitals, other providers, insurance companies, and the community. Dr. Baum’s second lesson is to build the right team, just as LEGO did a decade ago when it looked like the company was on its way to bankruptcy. He suggests that those running a medical practice ask themselves whether they would rehire each employee in their practice, and whether their doctors and staff are practicing at the top of their licenses. Dr. Baum’s third lesson is to create a clear path, much as LEGO did when they reconnected with their signature block and pivoted away from other products like video games. Medical practices, Dr. Baum argues, should be similarly focused on ensuring every patient has a positive experience. The fourth lesson is to create value based on the customer. Just as LEGO works to maintain customer satisfaction by replacing missing pieces from kits for free and using focus groups to develop new products, Dr. Baum suggests medical practitioners should observe how their patients interact with their practice and ensure they are not making assumptions based on outdated or inaccurate information by conducting regular patient surveys. Finally, Dr. Baum recommends that medical practices follow LEGO’s lead in developing strategic partnerships. He explains that LEGO’s partnerships with Star Wars, Harry Potter, and Disney lead to increased visibility, sales, and profits, and argues that medical practices can do much the same by nurturing partnerships with hospitals, payers, and the community.