Latest Videos

Active Surveillance: Who Qualifies, Who Does Not and How Should it be Monitored

Posted by | Mar 2022

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, outlines recent progress in active surveillance (AS), highlighting molecular genetics of Gleason Grade (GG) 1 vs. higher grade cancers, patient selection, germline testing, imaging, biomarkers, predictive nomograms, modeling, long-term outcomes, follow-up strategies, the tumor microenvironment, and dietary modifications. Dr. Klotz explains that AS is now the standard of care for GG1 prostate cancer, supported by professional organizations internationally. He displays data on the diverse genetic landscape of clinically low-risk prostate cancer, pointing out that just two percent of patients with GG1 cancer are in the highest quartile in terms of their genetic aberrancy and aggressivity. Dr. Klotz cites a study involving nearly 6,000 patients on AS that examined genetic factors associated with prostate cancer conversion from AS to treatment, explaining that 18 variants were found to be associated with conversion, 15 of which were not previously associated with prostate cancer risk. Dr. Klotz cites research involving nearly 10,0000 patients that studied metastasis and mortality in men with low- and intermediate-risk prostate cancer on AS; prostate cancer–specific mortality at 10 years was 1.1 percent in patients with GG1 cancer, 3.7 percent in patients with GG2, and then 12 percent in patients with GG3 disease. He displays a risk nomogram, the Canary PASS Biopsy Risk Calculator, pointing out that ordinary parameters such as age, body mass index (BMI), prostate-specific antigen (PSA) volume, time since diagnosis, and maximal core ratio can be powerful predictors of the likelihood of higher-grade cancer. Dr. Klotz addresses MRI, explaining it does not reliably indicate disease progression; he cites a study that showed 31 percent of men on AS with stable MRI upgraded to ≥GG2. He cites another study that emphasizes systematic biopsy must be performed whether MRI is positive or negative and explains a systematic review of 15 studies of patients on AS that indicated MRI sensitivity is just ~60 percent—a rate Dr. Klotz characterizes as unreliable. Dr. Klotz then addresses high-resolution micro-ultrasound as a complementary tool, before turning to simple heart- and prostate-healthy advice for patients on AS: stop smoking; make dietary modifications to reduce obesity, and get regular exercise. He cites a study on obesity and the tumor immune microenvironment and explains that in obese men, the tumor cells become acquisitive of free fatty acids and essentially the immune cells are deprived of free fatty acids. This leads to altered fatty acid partitioning, impairing CD8+ T cell infiltration and function. He surmises that this altered tumor microenvironment causes obese men to have worse outcomes. Dr. Klotz concludes with a summary of current AS follow-up strategy and explains that an emerging strategy is dynamic risk profiling with accurate biomarkers that will replace most serial biopsies.

Read More

LUTS: Latest in Prevention, Clinical Trials, and Approved Treatments

Posted by | Mar 2022

Michael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, gives an overview of how to assess and treat lower urinary tract symptoms (LUTS) in men. He presents a case of a 65-year-old patient referred to a urologist due to benign prostatic hyperplasia (BPH). Dr. Albo explains that in the old treatment algorithm, the question of how to treat this patient would have been simple: urinary symptoms would be treated with a non-specific Alpha blocker, and then if symptoms persisted, the urologist would offer transurethral prostatectomy (TURP) or a simple prostatectomy. However, Dr. Albo notes, the updated treatment algorithm currently in use is far more complex and features many options. This is due in part, he observes, to the realization that LUTS is not just related to the prostate, but rather has a complicated etiology related to other parts of the body including the bladder and urinary tract. Dr. Albo returns to the example of the 65-year-old referred for BPH, and explains that based on the new algorithm, initial evaluation of this patient will likely feature taking his medical history, giving him a physical examination, getting his International Prostate Symptom Score (IPSS), performing urinalysis, having him keep a 3-day voiding diary, and counseling him on options for intervention. Dr. Albo explains that determining prostate size is important as well since volume predicts symptom progression and risk of complications, and can inform treatment selection. He also observes that when selecting a treatment, a treatment’s effect on sexual function is an important factor for most men, regardless of age. Dr. Albo then lists additional suggested evaluation techniques for patients with LUTS, including assessment of prostate size and shape, checking post-void residual (PVR) volume, and performing uroflowmetry and urodynamic testing. He notes that none of these has enough data to prove they should be used in everybody. Dr. Albo moves on to how to treat LUTS, explaining that the goals of treatment include alleviation of bothersome symptoms, prevention of complications, prevention of progression, and minimization of complications of treatment. He discusses watchful waiting for LUTS, highlighting that 85% of men with mild LUTS are stable at one year, but 36% of men with moderate LUTS cross over to surgery within 5 years. Dr. Albo concludes that the complicated new guidelines are helpful, but far from where they need to be.

Read More

Long-Term Outcomes with Monotherapy for LR and fIR Prostate Cancer

Posted by | Mar 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Timothy N. Showalter, MD, MPH, Associate Professor of Radiation Oncology at the University of Virginia in Charlottesville, discusses long-term outcomes of and recent advances in brachytherapy monotherapy for low-risk (LR), favorable intermediate-risk (fIR), and selected unfavorable intermediate-risk (uIR) prostate cancer. He begins by listing potential advantages of brachytherapy monotherapy, highlighting that it features a single episode of care, is cost-effective, is multidisciplinary, has excellent long-term outcomes, features established technology to support tailored dosimetry and quality, and has been the subject of recent advances that enhance implant quality and reduce toxicity. Dr. Showalter then considers patient selection for brachytherapy monotherapy, noting that MRI may be useful in selecting patients with LR, fIR, and selected uIR disease. He emphasizes the importance of assessing whether a patient’s anatomy is suitable for implant based on gland size and arch interference, as well as the need to determine whether a patient has adequate baseline urinary function. Dr. Showalter also lists contraindications to brachytherapy monotherapy, including relative contraindications such as a large TURP defect, a large gland, and a large median lobe, as well as absolute contraindications such as inability to tolerate anesthesia, unacceptable operative risk, and the absence of a rectum. He then moves on to consider long-term outcomes of brachytherapy monotherapy, noting that for LR, fIR and selected uIR, follow-up data indicates biochemical progression-free survival of greater than 90%. Dr. Showalter also observes that outcomes are favorable in terms of toxicity, although there are some declines in urinary and sexual function. Finally, Dr. Showalter briefly summarizes recent advances in brachytherapy, emphasizing the role of advanced imaging such as MRI in helping to tailor brachytherapy dose and increase the personalization of care.

Read More

Emerging Treatments for BCG Unresponsive Non-muscle Invasive Bladder Cancer

Posted by | Mar 2022

Amirali Salmasi, MD, Assistant Professor of Urology at the University of California, San Diego, discusses available and emerging treatments for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC). He begins by giving a brief history of intravesical BCG and explaining how BCG works, before moving on to discuss treatments for BCG-unresponsive NMIBC. Dr. Salmasi observes that valrubicin was the best available treatment for a long time, but suggests that some of the many emerging treatments may prove superior. He then summarizes recent and ongoing research into various potential therapies for BCG-unresponsive NMIBC, including: sequential gemcitabine and docetaxel; intravesical cabazitaxel, gemcitabine, and cisplatin; chemohyperthermia treatment; CG0070, an oncolytic adenovirus; superagonist N-803; intravesical nadofaragene firadenovec gene therapy; and pembrolizumab. Dr. Salmasi concludes that, for the moment, the gold standard treatment for a patient with BCG-unresponsive bladder cancer remains radical cystectomy, but he argues that if someone is not eligible for or turns down cystectomy, pembrolizumab is now the go-to rather than valrubicin, although this may change depending on the results of some of these ongoing trials.

Read More

Representative Murphy’s Vision for Medical Reform

Posted by | Mar 2022

Congressman Gregory F. Murphy, MD, a practicing urologist and the Representative from North Carolina’s 3rd District, shares his vision for medical reform to help cut costs, ensure appropriate physician reimbursement, and improve care with E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego. Dr. Crawford congratulates Rep. Murphy on his recent assignment to the House Ways and Means Committee, where his position on the Subcommittee on Health will allow him to help set the agenda on medical reform. Dr. Murphy lists the top issues he feels need to be addressed to move medicine forward, including cutting regulation, increasing predictability in what doctors are going to get paid, and improving the accessibility of healthcare to the average American. Dr. Crawford and Rep. Murphy elaborate on these topics, first commenting on the rise of middlemen in healthcare, and discussing how this can limit doctors’ ability to make the correct choices for their patients. They then consider causes and potential solutions to high prices, from getting rid of direct-to-consumer advertising of pharmaceuticals to having doctors take the lead on cutting costs by choosing more inexpensive treatments and reducing waste. Rep. Murphy also comments on the current status of the No Surprises Act, which is intended to end high out-of-network medical bills. Dr. Crawford and Rep. Murphy conclude with a brief discussion of the VA.

Read More

Join the GRU Community

- Why Join? -