Latest Videos Archives

Bladder Cancer Journal Vol. 8, Issue 1

Posted by Bladder Cancer Journal | Mar 2022

Sensitivity and Specificity in Urine Bladder Cancer Markers – Is it that Simple? Abstract: Marker...

Industry Perspective: The Oncotype DX Genomic Prostate Score Assay Test

Posted by Daniel Shoskes, MD, FRCSC | Mar 2022

Daniel Shoskes, MD, FRCSC, Medical Director in Medical Affairs for Urologic Oncology at Exact Sciences, and Emeritus Professor of Urology at the Cleveland Clinic, explains how Exact Science’s Oncotype DX Genomic Prostate Score (GPS) assay test works, and considers its utility in guiding treatment decisions. He begins by discussing why genomics are of interest in relation to prostate cancer, highlighting the fact that abnormal gene expression may lead to abnormal/unregulated cell growth, which in turn may lead to irregularity on direct palpation, altered appearance on MRI, elevated PSA, and disordered gland appearance on histology. The researchers at Exact Sciences, Dr. Shoskes explains, hypothesized that these clinical features might not completely capture the prognosis of the patient, and that looking at gene expression directly might give further information. He relates how the researchers selected genes for association with metastasis and then refined the list for associations with death and adverse pathology. They found 17 genes that predicted recurrence in both the primary and highest Gleason patterns, and also had consistent analytical performance and expression in samples as small as 1mm. Dr. Shoskes then discusses how predictive this 17-gene assay is, noting that the GPS assay is an independent predictor of metastasis and prostate cancer death within 10 years of radical prostatectomy and may be associated with prostate cancer outcomes for up to 20 years after diagnosis. He highlights that incorporating the GPS result with NCCN Guidelines can provide a comprehensive risk profile. Dr. Shoskes considers how the GPS assay can be used practically, explaining that for low-risk patients, it can help inform shared decision-making for active surveillance vs. immediate therapy with curative intent, while for higher-risk patients, it can help inform the decision for treatment intensification. He concludes that the Oncotype DX GPS assay provides meaningful, actionable information on the biologic potential of prostate cancer independent of clinical, pathologic, and radiographic data.

Active Surveillance or Focal Therapy as Primary Management

Posted by Laurence Klotz, MD, FRCSC | Mar 2022

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, addresses when it is appropriate to use focal therapy versus active surveillance (AS) for prostate cancer. He observes that focal therapy for prostate cancer is controversial, with some doubting its efficacy entirely, and gives the disclaimer that he approaches the subject as an advocate for focal therapy in certain cases. Dr. Klotz then discusses the goals of AS, explaining that for de novo Gleason grade 1 patients, the purpose is to identify higher grade cancer, and for Gleason grade 2-3, the goal is identification of clinical progression while the disease is still curable. He notes that with AS, historically the risk of ‘progression’ to higher grade cancer has been 40%, while with focal therapy, the risk of failure is 35-40%, meaning that the risk of unrecognized/persistent GG ≥ 2 is similar for both. Dr. Klotz then considers the uses and appeal of focal therapy, emphasizing the benefits of a treatment that preserves the prostate and also allows time to intervene if the cancer returns. He also mentions some of the misuses and risks of focal therapy, arguing that it can be difficult to use in cases of tumor multifocality and heterogeneity and that the significant limitations of imaging and targeting, especially for Gleason grade 2 disease, can be challenging. Additionally, Dr. Klotz highlights the lack of level 1 evidence supporting focal therapy. He goes on to discuss what makes good candidates for partial gland ablation, describing patients with a Gleason grade 2 solitary unilateral lesion as being in the ‘sweet spot’ for focal therapy, while patients with more widespread or slightly higher grade disease may be candidates, but not necessarily. Dr. Klotz would not advise partial gland ablation to young patients with high-volume Gleason grade 1 unilateral disease who have a clear target on MRI, or to patients with Gleason grade 4 disease who have a small solitary lesion on biopsy and MRI. He then discusses the current management protocols for both AS and focal therapy in detail before concluding with a look at the future of focal therapy. Dr. Klotz argues that, despite the controversies, patients will increasingly demand focal therapy and therefore the urology field has a mandate to confirm its oncologic effectiveness and safety, and to determine which of the many methods of focal therapy is best.

Bottom Line Shrinking? Check Your EOBs

Posted by Neil H. Baum, MD | Mar 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the importance of reviewing explanations of benefits (EOBs) in a medical practice to ensure the practice is receiving appropriate compensation. He defines EOBs as feedback on the effectiveness of a practice’s billing/coding, and argues that failing to review EOBs will result in a decrease in cash flow. Dr. Baum claims that reviewing EOBs strengthens management of the billing team and helps practices know why they are or are not successful, since “what gets measured gets managed.” He gives the example of an overwhelmed biller who failed to submit 10% of claims for 12 years and rarely appealed denials. By reviewing EOBs, Dr. Baum explains, the managing partner can identify the problem and gather proof that billing needs improvement. He discusses several other benefits of reviewing EOBs, noting that EOBs show deficiencies and how to correct them, as well as provide tracker data on a practice’s payor mix and frequency of highly paid procedures. Dr. Baum recommends that practices review EOBs approximately every three months, using an exception report to track any deviation in compensation. He says that doing so will take little more than an hour per month and help practices ensure they are paid what they deserve in an era of decreasing reimbursements and increasing overhead expenses.

When is Radical Cystectomy Indicated for NMIBC?

Posted by Guilherme Godoy, MD, MS | Mar 2022

Guilherme Godoy, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine, in Houston, Texas, discusses the role of cystectomy in non-muscle invasive bladder cancer (NMIBC). He begins by describing the management options for NMIBC, including transurethral resection of the bladder tumor (TURBT), intravesical treatment, systemic therapy, and radical cystectomy. Dr. Godoy then explains the importance of re-TURBT, stating that it is one of the most critical steps in management for reducing understaging and improving intravesical therapy response in patients. He summarizes the indicators for cystectomy, including failure to resect, adverse pathology, and treatment failures. Dr. Godoy reviews data from a large single-institution retrospective study showing a significant difference in recurrence-free survival, cancer-specific survival, and overall survival in favor of the primary muscle invasion at presentation group vs. the progressive MIBC group. He then discusses data from a systematic review and meta-analysis of 14 studies on oncological outcomes of primary and secondary MIBC, finding worse outcomes overall for secondary muscle invasive cystectomy. Dr. Godoy looks at the European and AUA risk stratification tables, focusing on how both support aggressive management of high risk disease. He shows data from a study of the impact of variant histology on outcomes with intravesical immunotherapy, finding 40% progression-free survival compared to 17.5% in conventional bladder cancer. He states that all of this data supports cystectomy as an important and integral tool in the management of NMIBC due to its excellent oncological outcomes and potential benefit of abbreviated management and follow-up for aggressive NMIBC despite its morbidity, though the treatment may not be appropriate for everyone.