Frontiers in Oncologic Prostate Care and Ablative Local Therapy Archives

Optimal Surveillance Algorithm Following Focal Therapy of Prostate Cancer

Posted by Herbert Lepor, MD | Dec 2024

In this 13-minute presentation, Herbert Lepor, MD, focuses on the development and implementation of an evidence-based surveillance algorithm following focal therapy for prostate cancer. Dr. Lepor highlights the fundamental role of longitudinal PSA testing, imaging, and biopsy in monitoring patients. Key findings from his cohort of over 500 patients include:

PSA Trends as Predictors: Longitudinal consecutive PSA rises are the strongest predictors of clinically significant recurrence.
MRI Utility: Positive MRIs are associated with a 30-40% likelihood of detecting cancer, but the overall frequency of positive MRIs remains low, justifying their use selectively.
Biopsy Strategies: The cohort’s data indicate that systematically performing biopsies on patients with negative MRIs yields low detection rates, and most findings represent low-volume or less concerning disease.

Dr. Lepor concludes that the current algorithm incorporates PSA testing, selective MRI, and biopsy based on imaging or PSA trends, reducing unnecessary procedures while maintaining effective cancer surveillance. However, further data, especially at the five-year mark, are needed to refine this approach further. This pragmatic and evolving strategy balances oncologic safety with patient quality of life.

The Changing Landscape of Focal Therapy for Prostate Cancer

Posted by Herbert Lepor, MD | Dec 2024

In this 20-minute presentation, Herbert Lepor, MD, reflects on a 40-year journey in prostate cancer management and emphasizes the evolving role of focal therapy. Having performed over 5,000 radical prostatectomies, outcomes like continence, potency, and complications are critically evaluated. Challenges such as climacturia, penile shortening, and recurrence prompt the exploration of focal therapy as a patient-centered alternative. The shift towards minimally invasive options like cryoablation reflects efforts to balance cancer control with improved quality of life.

Early studies demonstrate that focal therapy effectively ablates targeted lesions with minimal in-field recurrence. MRI is a cornerstone in lesion identification and treatment planning, ensuring precision in disease localization and minimizing overtreatment. Functional outcomes from focal therapy show marked improvements, particularly in preserving sexual function and reducing urinary symptoms. Focal therapy’s growing adoption, bolstered by robust evidence and improved techniques, positions it as a transformative approach in prostate cancer care. This evolution marks a paradigm shift, with patients increasingly opting for therapies prioritizing oncologic control and quality of life.

Patient Selection: How to Pick a Focal Therapy Candidate

Posted by Derek Lomas, MD | Dec 2024

Derek Lomas, MD, outlines a comprehensive approach to patient selection for focal therapy in prostate cancer in this 12-minute presentation. The overarching criteria emphasize that focal therapy is suitable for patients with localized, clinically significant disease, distinct from candidates for active surveillance or those unsuitable for surgery or radiation. Two key dimensions, patient and disease characteristics, guide decision-making, balancing individualized patient factors with disease-specific metrics like tumor location and grade.

Patient health status is central, with functional baseline metrics, particularly urinary and sexual function, critical for setting realistic expectations. Patients must be well-informed about focal therapy’s pros, cons, and guideline limitations.

Disease characteristics identify the ideal focal candidate as patients with low- and intermediate-risk cancer. Multiparametric MRI and systematic and targeted biopsies, sometimes repeated, ensure comprehensive mapping.

Dr. Lomas emphasizes the importance of tailoring treatment to available modalities, such as HIFU for posterior lesions or cryoablation for anterior challenges. Critical to the most successful strategy is patient understanding and a willingness to decline unsuitable candidates, reinforcing a commitment to patient-centered care and optimal outcomes.

Urologist Led Advanced Prostate Cancer Practice Tips, Tricks and Pitfalls

Posted by Aaron Berger, MD | Dec 2024

Aaron Berger, MD, delivers an in-depth discussion on the evolution and importance of urology-led advanced prostate cancer practices. In this 21-minute presentation, Dr. Berger traces the transformation of urological management from limited ADT to a multidisciplinary and pathway-driven approach today. Berger highlights the pivotal moments, such as the introduction of immunotherapy, effective oral options, and advancements in imaging guidelines, which allowed urologists to retain and expand their roles in treating advanced prostate cancer. He emphasizes the establishment of specialized clinics as critical, enabling comprehensive care through navigation systems, in-office dispensaries, and dedicated teams. Collaboration with radiation and medical oncologists is vital for managing complex cases and adopting innovations like PSMA-based therapies and triple therapy.

Metastatic Castrate Resistant Prostate Cancer – Immunotherapy and PARP Inhibitors

Posted by Alan Tan, MD | Dec 2024

Alan Tan, MD, discusses multiple advanced treatment options for prostate cancer, focusing on genomic testing, PARP inhibitors, and emerging immunotherapy strategies. His 26-minute presentation begins with data indicating that 12% of prostate cancer patients carry germline mutations, predominantly in the BRCA family, emphasizing the prognostic significance of BRCA alterations. Genomic testing advancements, particularly in homologous recombination repair (HRR) alterations, reveal actionable pathways in approximately 25-27% of cases. PARP inhibitors are highlighted for their efficacy in BRCA-mutated cancers, with the latest trials—PROpel, TALAPRO-2, and MAGNITUDE—demonstrating survival benefits in combination therapies.

Dr. Tan also addresses immunotherapy, with a compelling clinical example underscoring the transformative impact of pembrolizumab in an ultra-high tumor mutation burden case. He also examines T-cell engagers, which show promise in overcoming downregulated MHC expression, and early-phase trials for bispecific antibodies. Toxicity management in PARP inhibitors is discussed in detail.