Video Archives

Management of BCG-Unresponsive Cystectomy-Ineligible Bladder Cancer Patients: Pembrolizumab

Posted by Daniel P. Petrylak, MD | Feb 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, discusses alternatives to bacillus Calmette-Guerin (BCG) immunotherapy for non-muscle invasive bladder cancer (NMIBC), focusing on pembrolizumab. Dr. Petrylak gives an overview of NMIBC and of NMIBC management with BCG immunotherapy. He explains that BCG immunotherapy is standard of care for this difficult-to-treat disease state and has proven capable of reducing recurrence, progression, and death rates, but that there is a subset of patients who experience BCG failure. Dr. Petrylak describes the different kinds of BCG failure, including BCG-relapsing, BCG-intolerant, BCG-refractory, and BCG-resistant disease, and then discusses the limited treatments currently available for these patients. He observes that intravesical chemotherapies have not proven highly efficacious for NMIBC, but that immune checkpoint inhibitors like pembrolizumab show significant promise. Dr. Petrylak reviews the KEYNOTE-057 trial, which found that immune checkpoint therapy with pembrolizumab can lead to complete responses in 40% of patients, and the SWOG S1605 trial, which did not reach its endpoint but found a complete response to immune checkpoint therapy with atezolizumab at 6 months in 27% of patients. He concludes by discussing other ongoing and future trials to further evaluate checkpoint inhibitors for NMIBC.

Liquid Diagnostics and Prostate Cancer

Posted by E. David Crawford, MD | Feb 2021

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, discusses how to use liquid diagnostics in combination with PSA testing to reduce unnecessary prostate biopsies. Dr. Crawford explains that while PSA is a good, inexpensive test of the relative risk of prostate cancer, better guidance is needed for application, especially because 90% of PSA tests are ordered by general practitioners rather than specialists. He suggests that medical practitioners consider a PSA of >1.5 to 4 as the danger zone where further evaluation is indicated. These patients should not be immediately sent for a prostate biopsy, but should instead be evaluated for benign prostatic hyperplasia and then for prostate cancer risk using liquid diagnostics. Dr. Crawford recommends following a diagnostic pathway, like the one at pcmarkers.com, to determine which patients need treatment.

The Future of Medicine: At-Home Testing

Posted by Neil H. Baum, MD | Jan 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, examines the burgeoning field of at-home testing, outlining its pros and cons and discussing its urologic application. At-home testing has become increasingly attractive during the pandemic as patients are able to minimize their possible exposure to COVID-19. It is also more convenient for patients and less expensive than lab testing, the latter being particularly important for uninsured Americans. Dr. Baum notes that some test providers offer telemedicine support to review test results, but also cautions that it is important not to over-promise, as not all at-home tests are FDA-approved and not all types of tests can be run with a small blood sample. Additionally, some home tests require patient history or necessitate a doctor to explain the results. The most familiar types of at-home tests include those for pregnancy or genetics, but there are now a number of new tests available such as IBS or celiac testing, BRCA-focused genetic testing, and fructose and lactose intolerance. For urologists, at-home testing for hematuria workup, semen analysis for infertility evaluation, UTI diagnosis, urine biopsy for PSA, screening for bladder cancer, and follow-up hormone testing are all on the horizon. Dr. Baum concludes that at-home testing is a proactive approach to patient care that further improves telemedicine.

New Advances in Next-Generation Imaging: PyL PSMA PET/CT

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

Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, Professor of Urology at UC San Diego, interviews Peter R. Carroll, MD, MPH, Professor of Urology and Prostate Cancer at UC San Francisco, about PSMA PET/CT imaging for prostate cancer, focusing particularly on a promising new PSMA agent called PyL. The only PSMA agent currently approved for use in the United States is 68Gallium, which has a very short half-life and must be manufactured on-site. In part for this reason, 68Gallium PSMA can only be used at UCSF and UCLA. Dr. Carroll explains that PyL PSMA PET behaves similarly to 68Gallium PSMA PET, with greater sensitivity and capacity to trigger a change in treatment plans than standard imaging, but that the PyL agent is more stable, which should make it an easier product to distribute. Drs. Crawford and Carroll then consider the benefits of PSMA testing in general, noting how it could soon replace technetium bone scans as well as choline and axumin PET scans. Dr. Carroll also emphasizes PSMA PET’s role in defining the oligometastatic state. They conclude by discussing PSMA PET and theranostics.

Universal Germline Screening in Prostate Cancer: The Argument Against

Posted by Alan H. Bryce, MD | Jan 2021

Alan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic in Scottsdale, Arizona, argues against universal germline screening in prostate cancer in a point-counterpoint debate. While he agrees that identifying germline mutations is important and can have important implications for therapy and for patients’ families, Dr. Bryce observes that very few carriers are identified through germline testing. Approximately ⅔ of carriers are identified through family history-based screening, and while germline mutations are more common in men with metastatic cancer, they are uncommon in the total prostate cancer population. This means that among low- and intermediate-risk patients, 200-300 people must be screened to find one additional carrier, and among high-risk patients, approximately 50 people must be screened to find an additional carrier. Genetic testing costs money and takes up valuable counseling time, so Dr. Bryce argues that testing all patients is not a sensible allocation of resources.