Latest Videos

Neoadjuvant vs. Adjuvant vs. None – “Perioperative Therapy”

Posted by | Feb 2022

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, summarizes research on perioperative therapies for bladder cancer and how they compare to each other. He begins with an overview of the current standard of care for muscle-invasive bladder cancer (MIBC), citing a Swiss study showing that after radical cystectomy there is still a problem of incurable disease relapse through overall survival rates below 63%, and another study showing that neoadjuvant cisplatin-based chemotherapy (NAC) combinations improve survival for MIBC by 5-8%. Dr. Yen then overviews NAC, highlighting the VESPER trial that compared cisplatin-gemcitabine (GC) and dose-dense MVAC (ddMVAC) in the perioperative MIBC setting and found that more patients were able to follow through with NAC than adjuvant chemotherapy (AC) by 21%. He discusses multiple immunotherapy trials that together show that patient responses seem better with chemo-immunotherapy than they do with immunotherapy alone. Dr. Yen then reviews the CheckMate-274 trial that found that adjuvant nivolumab treatment-related adverse effects were tolerable due to a 7% rate of being severe enough to end treatment vs. a 1.4% rate in the placebo arm. He also summarizes the IMvigor trial, which did not meet its primary endpoint of disease-free survival but found that positive ctDNA patients had an improvement from atezolizumab that was not seen in other patients. Dr. Yen concludes that GC and ddMVAC remain important perioperative chemotherapy regimens, that neoadjuvant and adjuvant therapies have situational uses, and more research will be key to refining these treatments further.

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PSMA: Current State of the Art and Future Vision

Posted by | Feb 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses current and possible future applications for prostate-specific membrane antigen (PSMA) as both a diagnostic and a theranostic radiopharmaceutical for prostate cancer. He begins by considering PSMA in the diagnostic setting and explains that its current state-of-the art use is in the area of detection of metastatic disease. Dr. Koo particularly highlights its role in detecting oligometastatic disease in cases of biochemical recurrence. He also notes that PSMA currently has a role in initial staging, and that this role is likely to expand in the future. He predicts that other future diagnostic applications of PSMA will include restaging/treatment response, primary lesion characterization, and potentially prognosis. Dr. Koo then moves to discussing PSMA in the theranostic setting, mentioning the current role of Lu-177 PSMA on the “thera-” side and looking at PSMA, FDG, and PSMA plus FDG on the “-nostic” patient selection side. He also considers the question of whether imaging is even needed considering the large percentage of patients who are PSMA-positive, though he argues for the benefits of imaging. Dr. Koo lists some potential future therapeutic applications of PSMA, such as in earlier treatment, retreatment, combination therapy, dosimetry, and with alpha particles. He concludes that there are many unanswered questions, that conventional wisdom and anecdotes are not evidence-based, and that there is a need for more clinical trials and more disease site specialization within nuclear medicine.

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Conducting Patient Surveys

Posted by | Feb 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives recommendations on how urologists can improve their practices by conducting patient surveys. He notes that one of the key needs and wants of urologists is to monitor the urologist-patient encounter, and he highlights two pathways to success in this area: (1) find out what the patient wants and give him/her more of it; and (2) find out what the patient does not want and avoid it. Dr. Baum explains that the best way to identify what patients do and do not want is to conduct patient surveys. He recommends using a suggestion box and notes that in his own practice, he gives patients a card with six yes-or-no questions on the front and space on the reverse side for patients to write out the three questions they would like to have answered during their visit. Dr. Baum also suggests creating online surveys with questions such as “How likely are you to recommend this practice to others?” and “How responsive were the staff and the doctors to your questions?” He concludes that urologists need to listen to their patients and need to ask them how they can serve them better.

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Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making

Posted by | Feb 2022

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine in Houston, Texas, discusses the evolving standard of care for renal tumors, and how to determine whether someone should have nephron-sparing surgery. He provides some history, explaining that radical nephrectomy used to be standard for all patients with renal tumors, but that due to improvements in technology and technique, partial nephrectomy is now used in a large percentage of cases. Dr. Link argues that with this great power to perform partial nephrectomies on almost all renal tumors comes a great responsibility to make sure that patients receive appropriate care for their individual cases. He observes that this can be complicated for multiple reasons, including that: decision-making about suitability for nephron sparing is not solely an oncologic decision; resecting more complex tumors may be associated with higher perioperative complication risks and likely results in more renal function loss; older or sicker patients tolerate complex or more lengthy surgery less well and may be less ideal candidates; and older patients likely have less to gain from nephron-sparing due to life expectancy. Beyond those concerns, Dr. Link lists and discusses several fundamental oncologic questions to consider in determining whether a patient is a good candidate for partial nephrectomy or not. These include assessing the risk of pathologic upstaging of “resectable appearing” tumors, the impact of tumor complexity on positive margins and how positive margins after partial nephrectomy alter outcome, the risk of de novo ipsilateral second primary tumors in the future and whether pathology and stage alter this risk in some fashion, and whether the patient would benefit more from a radical nephrectomy. Dr. Link concludes that: upstaging of cT1 tumors to pT3a at partial nephrectomy is relatively rare and portends a statistically significant if rather modest negative impact on recurrence free survival; risk of upstaging appears to be higher for larger tumors, higher RENAL scores, higher grade tumors, and those with irregular morphology; renal sinus fat invasion does not appear to be higher risk for poor oncologic outcomes than perinephric fat invasion; there is little data supporting better oncologic outcomes for radical nephrectomy as compared to partial nephrectomy for completely resected pT3 renal cell carcinoma; true positive surgical margins after partial nephrectomy have a significant negative impact on oncologic outcomes; larger tumors with higher RENAL scores raise the risk of positive margins at partial nephrectomy; and since little data exists about risk of second ipsilateral primary tumor development this should not drive decision making today outside of a genetic “diagnosis.”

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Brachytherapy for Prostate Cancer

Posted by | Feb 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society and Grand Rounds in Urology, Mira Keyes, MD, FRCPC, FABS, Clinical Professor at the University of British Columbia (UBC) and a radiation oncologist at the Vancouver Centre of the British Columbia Cancer Agency (BCCA), gives an overview of brachytherapy for prostate cancer (PCa), making a case against its declining use based on its efficacy. She begins by introducing the American Brachytherapy society, which was founded in 1978 to provide insight, rationale, and research into the use of brachytherapy in the treatment of both malignant and benign conditions. Dr. Keyes then describes how brachytherapy was performed with radium tubes when it was invented in 1901, and was then subsequently done with needles beginning in 1915. She concludes her short history by marking 1983 as the beginning of the modern era of prostate brachytherapy, thanks to advances in imaging capabilities. Dr. Keyes discusses data showing that brachytherapy is associated with better survival in patients with local to advanced cervical cancer. She then goes over the processes for high dose rate and low dose rate brachytherapy for PCa, focusing on the quick recovery, high cure rates, and minimal to no incontinence or sexual dysfunction as benefits for both treatments. Dr. Keyes shows data on brachytherapy utilization for PCa depicting its decline since 2003 due to robotic prostatectomy use, PSA screening changes, active surveillance low-risk treatment recommendation changes, and higher reimbursement for IMRT and robotic surgery. She also discusses data showing that 10% of US cancer care spending is on prostate cancer, with the highest procedure cost per patient going to robotic surgery. Dr. Keyes compares the use of brachytherapy in the US to that of Canada, stating that Canada’s increasing use is due to a reimbursement system that incentivizes brachytherapy, and the education of the public, residents, general practitioners, and urologists. She concludes that the benefits of brachytherapy support its use for localized PCa in the US.

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