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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.

Kidney Cancer Journal | Volume 6, Issue 2

Posted by Kidney Cancer Journal | Jun 2022

Hereditary Renal Cell Carcinoma Abstract BACKGROUND:Hereditary renal cell carcinoma (RCC) is a...

Highlights from the 5th Global Summit on Precision Diagnosis and Treatment of Prostate Cancer

Posted by Faina Shtern, MD | Jun 2022

Faina Shtern, MD, President and CEO of the AdMeTech Foundation, presents key highlights from the 5th Global Summit on Precision Diagnosis and Treatment of Prostate Cancer, a virtual event organized by the AdMeTech Foundation and held from September 23 through September 25, 2021. After introducing the AdMeTech Foundation, Dr. Shtern goes over the rationale for the annual summit and brain trust, explaining that the goal is for multi-disciplinary key opinion leaders to address fundamental challenges in patient care by: developing accurate diagnostic tools; integrating anatomic, biologic, and histologic diagnostics; and integrating precision diagnosis with precision treatment. She discusses the AdMeTech Foundation’s approach, which includes reaching consensus on the best emerging clinical practices, identifying clinical needs and related research priorities, educating the medical community and general public, and expediting the transfer of promising diagnostics and therapeutics to patients. Dr. Shtern then considers the 5th Global Summit specifically, noting that it focused on integrating precision diagnostics and therapies and addressing fundamental problems in prostate cancer care. She summarizes key points from the four meeting sessions, which focused on: the population of men prior to diagnosis with prostate cancer (Session I); the population of men with newly diagnosed localized disease (Session II); precision oncology of advanced prostate cancer (Session III); and image-targeted, minimally-invasive focal procedures. Dr. Shtern concludes by summarizing the key findings of the 2021 meeting’s Panel on Health Disparities and Panel on Bioinformatics, Machine & Deep Learning, and Artificial Intelligence.

Contemporary Management of Recurrent Idiopathic Priapism

Posted by John P. Mulhall, MD | Jun 2022

John P. Mulhall, MD, Director of the Male Sexual and Reproductive Medicine Program at Memorial Sloan Kettering Cancer Center in New York City, defines recurrent idiopathic priapism (RIP) (repeated priapism events without an overt cause) and explains that management follows all the tenets of ischemic priapism treatment. He explains the focus of treatment should be to give a patient tools to avoid an emergency room (ER) visit. Dr. Mulhall advises clinicians to begin treatment for persistently rigid pharmacologically-induced erections no later than four hours after the onset of symptoms and to counsel all patients with persistent ischemic priapism that there is the chance of erectile dysfunction. Further, Dr. Mulhall advises clinicians to counsel patients with a priapism event >36 hours that the likelihood of erectile function recovery is low. He states that clinicians should manage acute ischemic priapism with intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as the first line of therapy and prior to operative interventions. Dr. Mulhall then displays a graphic showing that pathway dysregulation of the enzyme PDE5 may result in, or contribute to, RIP; he concludes that this is not a complete explanation of the condition. Next, Dr. Mulhall outlines emergency maneuvers that he advises practitioners to train their patients to undergo, using in-home intracavernosal phenylephrine for erections lasting more than one to two hours and visiting a clinic or ER if the at-home treatment is unsuccessful. He highlights the importance of educating patients regarding hypertension/reflex bradycardia when using intracavernosal phenylephrine. Next, he explains that mitigation strategies revolve around the use of PDE5i, ketoconazole/prednisone, anti-androgens, and LHRH agonists. He then cites a 2005 publication stating that phosphodiesterase-5A dysregulation in penile erectile tissue is a mechanism of priapism, pointing out that this is different from sickle-cell disease, and qualifying once again that this does not explain the condition completely. Dr. Mulhall then cites a case report on long-term oral phosphodiesterase-5 inhibitor therapy and its alleviation of recurrent priapism, pointing out that with just a few patients involved, the report, while thought-provoking, is not definitive. He reviews an article that lists various treatments and addresses their degrees of efficacy, highlighting one—ketoconazole with prednisone—that he calls his “go-to strategy.” Dr. Mulhall cites a study of 114 men diagnosed with RIP whereby 42 were initiated on PDE5i therapy and 24 were evaluable; of them, 22 reported improvement in priapism, but Dr. Mulhall explains the limitations of this particular trial and asserts more studies are needed. He explains a related concept, sleep-related painful erections (SRPE), explaining that some treatments for RIP are used with SRPE and he posits that these patients may be on the lower end of the RIP spectrum. He then summarizes his talk, highlighting key points: there is an unclear mechanism of action in RIP; practitioners should treat these episodes like ischemic priapism; patients should receive training in at-home phenylephrine injection (including a discussion of its risks); and mitigation strategies include the use of ketoconazole/prednisone treatment.

Saw Palmetto for BPH, Prostate Cancer, or Prostatitis?

Posted by J. Curtis Nickel, MD, FRCSC | Jun 2022

J. Curtis Nickel, MD, FRCSC, the Canada Research Chair in Urologic Pain and Inflammation and Professor of Urology at Queen’s University in Kingston, Ontario, discusses research on the herbal medicine saw palmetto and its efficacy as an alternative therapy for benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS), prostatitis, and prostate cancer. He relates the history of saw palmetto, explaining that it has been used to treat urinary problems for centuries, but fell out of widespread use in North America at the start of the the modern pharmaceutical era in the 1920s, though physicians in Europe continued prescribing it. Dr. Nickel notes that there are two primary forms of saw palmetto products in North America: saw palmetto extract, which is high in fatty acids; and saw palmetto ground berry powder, which is low in fatty acids. Dr. Nickel emphasizes that the presence of fatty acids is important since prostate cells preferentially take up fatty acids and sterols. He highlights the difference between the North American guidelines, which state that “the available data do not suggest that saw palmetto has a clinically meaningful effect on LUTS secondary to BPH,” and the European guidelines which recommend using saw palmetto on the “basis of its long-standing use.” Dr. Nickel then considers the evidence, explaining that a literature review of 1575 research publications on saw palmetto and LUTS indicates saw palmetto extracts are safe, improve symptoms, and improve quality of life. He then looks at the potential role of saw palmetto in treating prostatitis, a prevalent condition in North American men. Dr. Nickel explains that until recently, researchers could not find evidence from randomized placebo-controlled trials to substantiate findings that the hexanic extract of saw palmetto reduces prostate inflammation. However, he notes, a recent trial suggests saw palmetto extract is effective, safe, and clinically superior to placebo for the treatment of chronic prostatitis/chronic pelvic pain syndrome. Dr. Nickel then turns to the question of whether or not saw palmetto could have a role in managing prostate cancer. He explains that saw palmetto seems like it could have value in preventing or managing prostate cancer since it antagonizes 5ɑ-reductase to reduce DHT production, inhibits DHT binding to androgen receptors, inhibits the expression of Cox-2, inhibits prostate cell growth, etc. However, studies have not found any association between use of saw palmetto and risk of prostate cancer development, nor any correlation with increasing frequency or duration of use. Dr. Nickel concludes that saw palmetto extract is a valuable alternative therapy for men with mild to moderate LUTS/BPH, that it is potentially a useful alternative therapy for prostatitis, and that it does not play a role in prostate cancer prevention or treatment in 2022.