Video Archives

Active Surveillance in Favorable Intermediate-Risk Prostate Cancer

Posted by James A. Eastham, MD, FACS | Oct 2021

James A. Eastham, MD, FACS, the Peter T. Scardino Chair in Oncology and Chief of the Urology Service in the Department of Surgery at Memorial Sloan-Kettering Cancer Center in New York, discusses the process of selecting intermediate-risk patients with prostate cancer for active surveillance (AS). He explains how active surveillance serves as an alternative to direct treatment that helps reduce cases of overtreatment, and notes that it is now considered an option for intermediate-risk (IR) patients across many guidelines. However, no process for patient selection is outlined, despite evidence that AS used indiscriminately with all IR patients is harmful. Dr. Eastham cites the PIVOT, ProtecT, and PREFERE trials, all of which show that when looking at the IR population as a whole, treatment is preferred based on increased rates of survival and decreased rates of disease progression. He raises the question of why AS is recommended for such patients when this data exists and summarizes the results of 14 series’ on AS for men with favorable IR compared to low-risk (LR) patients, finding equivalent survival rates in the two groups with estimated metastasis-free survival and prostate cancer-specific survival of 90% at 15-year follow up. Despite these positive results, Dr. Eastham states that there is no set definition of a “favorable” IR patient and looks to more trials to fill in this gap. He summarizes data from Göteborg and Sunnybrook, with Göteborg’s cohort showing 90% prostate cancer-specific survival and Sunnybrook’s showing 89%. Dr. Eastham details how Sunnybrook’s data includes information on Gleason pattern 4 being a major driver of high rates of metastases, leading him to then look at data from the Martini Klinik, the University of Michigan, and Memorial Sloan Kettering Cancer Center supporting the idea that choosing patients with lower volume of Gleason pattern 4 will lead to greater success of AS in IR patients.

PSMA PET Imaging at Time of Diagnosis

Posted by Peter R. Carroll, MD, MPH | Oct 2021

Peter R. Carroll, MD, MPH, Professor of Prostate Cancer and Urology at the University of California, San Francisco, discusses PSMA PET imaging and compares it to conventional imaging at the time of diagnosis. He states that conventional imaging has insufficient sensitivity when staging men with high-risk localized prostate cancer at the time of diagnosis, therefore providing the rationale for using PSMA PET. Dr. Carroll then summarizes data demonstrating PSMA PET’s sensitivity. He begins with the OSPREY trial, which shows overall pelvic lymph node sensitivity of 40.3% and specificity of 97.9% for 18F-DCFPyL PSMA PET, and then looks at a meta-analysis of Gallium-68 PSMA-11 PET that found a sensitivity of 74% and specificity of 96%. He also cites a multicenter, two-arm, randomized study in Australia as proof of PSMA PET’s superiority to conventional imaging due to evidence of lower radiation exposure and higher specificity. Dr. Carroll discusses how PSMA PET impacts treatment planning, looking at a study on the impact of staging PSMA PET scans on radiation treatment plans that found major changes in 30% of patients and minor changes in 13-15%. He believes that the field is moving towards intraoperative imaging and outlines a study he is currently working on that is using an advanced firefly camera for intraoperative imaging and testing to see if the process will result in more therapeutic interventions. Dr. Carroll states that so far the study has been able to identify tumor fluorescence of all patients, has been very effective at identifying residual disease at surgical margins, and has had only one adverse effect: transitory green urine. He concludes that PSMA PET imaging is more sensitive than standard imaging and will soon replace conventional methods, although the impact on long-term outcomes remains to be determined.

Updates in Radiation Oncology: A View From ACRO

Posted by Steven E. Finkelstein, MD, FACRO | Oct 2021

Steven E. Finkelstein, MD, FACRO, a radiation oncologist with Florida Cancer Affiliates in Panama City, Florida, discusses the American College of Radiation Oncology (ACRO) and their goals for leadership, education, advocacy, and recognition in their field. He explains that they want to be the most inclusive physician-driven organization in radiation oncology and want to drive professional and personal development for their members. He then outlines ACRO’s leadership-focused committees and their accomplishments. Dr. Finkelstein states that ACRO’s education goals are being reached by providing cutting-edge educational programming at a reasonable cost. He then lists the involved committees and shares some of the accomplishments of the organization in education, including free self-assessment modules sufficient to reach maintenance of certification requirements and inclusion of administrators in a business track during conferences. Dr. Finkelstein then explains that, through advocacy, ACRO aims to make the practice of radiation oncology better for physicians. He discusses ACRO’s advocacy-oriented committees, and then cites the development of an alternative payment model, and addressing widespread concern with the eviCore treatment guidelines as some of ACRO’s advocacy-based accomplishments. Dr. Finkelstein then looks at ACRO’s progress in getting recognition for radiation oncology, explaining that recognizing professional success helps advance practice excellence. He goes over some of ACRO’s accomplishments in this area, including the development of a comprehensive physics review and a robust and modern virtual medical chart review that eliminates reviewer bias. He concludes with a list of 10 reasons why a practice should undergo accreditation that includes improving practice quality by external review, ensuring that the most up-to-date question and answer techniques and standards as well as the most up-to-date policies are in place, and more.

Updates in ADT: Managing Adverse Effects

Posted by Laurence Klotz, MD, FRCSC | Oct 2021

Laurence Klotz, MD, FRCSC, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research at Sunnybrook Health Sciences Centre, reviews simple interventions physicians can use to improve quality of life and survival as well as to ameliorate unwanted side effects in prostate cancer patients undergoing androgen deprivation therapy (ADT). He explains that there are many commonly known and relatively manageable adverse effects to ADT, but that many family practitioners may not be aware of or interested in dealing with them. The responsibility therefore falls to urologists. Dr. Klotz then discusses the available and developing interventions, as well as the mechanisms of action that underlie them. First, he looks at how statins reduce the adverse effects of metabolic syndrome related to ADT by inhibiting cellular uptake of androstenediol and therefore reducing the substrate available for testosterone synthesis in the castrate environment. Dr. Klotz then considers the benefits of bisphosphonates and monoclonal antibodies like denosumab in helping with osteoporosis, another common side effect of ADT. He also looks at metformin, an inexpensive drug that appears to reduce weight gain in men on ADT, and notes that exercise is an effective way to delay progression of prostate cancer. Dr. Klotz then presents evidence supporting the use of GnRH antagonists to reduce cardiovascular events in men on ADT and discusses new research regarding the role of FSH in obesity.

Efficacy of Enzalutamide Plus ADT in Men with De Novo (M1) mHSPC Versus Progression to mHSPC: Post Hoc Analysis of the Phase III ARCHES Trial

Posted by Daniel P. Petrylak, MD | Oct 2021

Daniel P. Petrylak, MD, Director of Genitourinary Oncology, Professor of Medicine and Urology, Co-Leader of Cancer Signaling Networks, and Co-Director of the Signal Transduction Program at Yale University Cancer Center in New Haven, Connecticut, presents data analysis from the phase III ARCHES trial showing the efficacy of enzalutamide (ENZA) plus androgen deprivation therapy (ADT) in men with metastatic hormone-sensitive prostate cancer (mHSPC). He asserts that urologists should be using next generation anti-androgens more often, citing the fact that only about half of patients are being offered such therapies at the time of mHSPC diagnosis. Dr. Petrylak outlines three reasons for this, including lack of access (driven by high cost and staffing availability), lack of understanding of the data, and lack of education. He then summarizes the ARCHES trial specifications, patient characteristics, and the primary endpoint radiographic progression-free survival (rPFS) data, which demonstrate favored outcomes with ENZA combined with ADT, while specifying that mature overall survival (OS) data is not yet available. Dr. Petrylak then discusses secondary endpoint data, which demonstrate that time to prostate-specific antigen (PSA) progression was significantly better in patients who received ENZA and ADT; similarly, ENZA and ADT reduced the risk of starting a new antineoplastic therapy by 72 percent compared with a placebo and ADT. Data also showed patient benefit in terms of time to first symptomatic skeletal event (SSE) as well as time to castration resistance. Dr. Petrylak addresses the question of disease volume in determining which patients ought to receive these next-generation treatments. He examines rPFS across patient subgroups, from patients with just one metastasis all the way up to those with over six metastases, and asserts that all patients across these groups benefited from the ENZA and ADT therapy, dispelling myths that low-volume patients should not be receiving next-generation treatments. Dr. Petrylak concludes that, for patients with castration-sensitive prostate cancer (CSPC), ENZA used with ADT improves rPFS over ADT alone and that the effect is consistent over all volumes of disease, again stipulating that the OS data is maturing, with additional data expected later this year.