International Prostate Cancer Update Archives

Integrating Theranostics Into a Group Practice

Posted by David M. Albala, MD | Oct 2021

David M. Albala, MD, Chief of Urology at Crouse Hospital in Syracuse, New York, discusses theranostics and the role it will play in the future of prostate cancer treatment. He explains that theranostics is a management strategy involving the integration of therapeutics and diagnostics that specifically uses targeting molecules labeled with either diagnostic radionuclides or with therapeutic radionuclides for diagnosis of and therapy for a particular malignancy. Dr. Albala states that theranostics works to overcome trial and error methods of finding “one-size-fits-all” solutions in medicine in order to produce personalized medicine. Dr. Albala also discusses PSA and PSMA, explaining that PSMA is used with different ligands such as PSMA-11 and PSMA-617 to treat specific individuals. He reviews how theranostics are used with radionuclide agents to determine localization, examine molecular biodistribution, aid in determining optimal therapeutic dosage, and monitor the patient’s response to treatment. Dr. Albala then reviews data from a trial of Lutetium-177 and PSMA-617 for metastatic castration-resistant prostate cancer that showed Lutetium-based treatment outdoing standard-of-care in median overall survival by 4 months and skeletal event occurrence by 3%. He concludes with a summary of the implications of theranostics for patient care, stating that theranostics leads to more effective disease management and eliminates unnecessary treatments, enhances diagnosis and disease staging, and reduces costs associated with suboptimal diagnostics and treatments.

Treatment for Prostate Cancer with MRI-Guided Transurethral Ultrasound

Posted by Laurence Klotz, MD, FRCSC | Oct 2021

Laurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, discusses MRI-guided transurethral ultrasound ablation (TULSA) in patients with localized prostate cancer. He characterizes this energy-based therapy as one that meets a need for patients with intermediate-risk prostate cancer, offering a less-invasive therapy with fewer quality-of-life effects than radiation and radical prostatectomy. Dr. Klotz explains the closed-loop controlled system and lays out the TULSA-PRO system components, emphasizing the power of the real-time thermal map when using thermal energy to heat tissue to destroy it. He then outlines the MRI-guided treatment workflow before listing the key features of TULSA: since it is a transurethral directional ultrasound ablation, it is incision- and radiation-free, with no energy being delivered through the rectum (thus avoiding rectal injury) and no volume limitation; the automated, closed-loop system eliminates guesswork and allows for precision, measuring temperature in real time, adjusting the amount of energy delivered to the tissue, and actively compensating for tissue and blood flow changes during the treatment; the therapy also offers thermal protection of important anatomy, including the urethra and rectum. Dr. Klotz then reviews previous TULSA technical and canine studies and the first-in-man treat and resect study for feasibility. This research led to a phase one safety and precision study that showed a 90 percent prostate-specific antigen (PSA) reduction. Dr. Klotz then reviews the TULSA-PRO Ablation Clinical Trial (TACT), which demonstrated a median PSA reduction of 95 percent, with consistent rates of biopsy-based improvement in 75-80% of men one year after TULSA therapy; data also show that TULSA therapy is easily tolerated and that most patients recover continence and erectile function within the year after therapy. Indeed, three-year follow-up data for TACT demonstrate that PSA response has been durable over time. Dr. Klotz concludes with a summary of TULSA, emphasizing the newness of this complex technology that is safe, precise, and has low toxicity. He highlights that it has been approved by the FDA and Health Canada and is emerging as a novel alternative to conventional therapy.

Active Surveillance in Favorable Intermediate-Risk Prostate Cancer

Posted by James A. Eastham, MD, FACS | Oct 2021

James A. Eastham, MD, FACS, the Peter T. Scardino Chair in Oncology and Chief of the Urology Service in the Department of Surgery at Memorial Sloan-Kettering Cancer Center in New York, discusses the process of selecting intermediate-risk patients with prostate cancer for active surveillance (AS). He explains how active surveillance serves as an alternative to direct treatment that helps reduce cases of overtreatment, and notes that it is now considered an option for intermediate-risk (IR) patients across many guidelines. However, no process for patient selection is outlined, despite evidence that AS used indiscriminately with all IR patients is harmful. Dr. Eastham cites the PIVOT, ProtecT, and PREFERE trials, all of which show that when looking at the IR population as a whole, treatment is preferred based on increased rates of survival and decreased rates of disease progression. He raises the question of why AS is recommended for such patients when this data exists and summarizes the results of 14 series’ on AS for men with favorable IR compared to low-risk (LR) patients, finding equivalent survival rates in the two groups with estimated metastasis-free survival and prostate cancer-specific survival of 90% at 15-year follow up. Despite these positive results, Dr. Eastham states that there is no set definition of a “favorable” IR patient and looks to more trials to fill in this gap. He summarizes data from Göteborg and Sunnybrook, with Göteborg’s cohort showing 90% prostate cancer-specific survival and Sunnybrook’s showing 89%. Dr. Eastham details how Sunnybrook’s data includes information on Gleason pattern 4 being a major driver of high rates of metastases, leading him to then look at data from the Martini Klinik, the University of Michigan, and Memorial Sloan Kettering Cancer Center supporting the idea that choosing patients with lower volume of Gleason pattern 4 will lead to greater success of AS in IR patients.

PSMA PET Imaging at Time of Diagnosis

Posted by Peter R. Carroll, MD, MPH | Oct 2021

Peter R. Carroll, MD, MPH, Professor of Prostate Cancer and Urology at the University of California, San Francisco, discusses PSMA PET imaging and compares it to conventional imaging at the time of diagnosis. He states that conventional imaging has insufficient sensitivity when staging men with high-risk localized prostate cancer at the time of diagnosis, therefore providing the rationale for using PSMA PET. Dr. Carroll then summarizes data demonstrating PSMA PET’s sensitivity. He begins with the OSPREY trial, which shows overall pelvic lymph node sensitivity of 40.3% and specificity of 97.9% for 18F-DCFPyL PSMA PET, and then looks at a meta-analysis of Gallium-68 PSMA-11 PET that found a sensitivity of 74% and specificity of 96%. He also cites a multicenter, two-arm, randomized study in Australia as proof of PSMA PET’s superiority to conventional imaging due to evidence of lower radiation exposure and higher specificity. Dr. Carroll discusses how PSMA PET impacts treatment planning, looking at a study on the impact of staging PSMA PET scans on radiation treatment plans that found major changes in 30% of patients and minor changes in 13-15%. He believes that the field is moving towards intraoperative imaging and outlines a study he is currently working on that is using an advanced firefly camera for intraoperative imaging and testing to see if the process will result in more therapeutic interventions. Dr. Carroll states that so far the study has been able to identify tumor fluorescence of all patients, has been very effective at identifying residual disease at surgical margins, and has had only one adverse effect: transitory green urine. He concludes that PSMA PET imaging is more sensitive than standard imaging and will soon replace conventional methods, although the impact on long-term outcomes remains to be determined.

Updates in Radiation Oncology: A View From ACRO

Posted by Steven E. Finkelstein, MD, FACRO | Oct 2021

Steven E. Finkelstein, MD, FACRO, a radiation oncologist with Florida Cancer Affiliates in Panama City, Florida, discusses the American College of Radiation Oncology (ACRO) and their goals for leadership, education, advocacy, and recognition in their field. He explains that they want to be the most inclusive physician-driven organization in radiation oncology and want to drive professional and personal development for their members. He then outlines ACRO’s leadership-focused committees and their accomplishments. Dr. Finkelstein states that ACRO’s education goals are being reached by providing cutting-edge educational programming at a reasonable cost. He then lists the involved committees and shares some of the accomplishments of the organization in education, including free self-assessment modules sufficient to reach maintenance of certification requirements and inclusion of administrators in a business track during conferences. Dr. Finkelstein then explains that, through advocacy, ACRO aims to make the practice of radiation oncology better for physicians. He discusses ACRO’s advocacy-oriented committees, and then cites the development of an alternative payment model, and addressing widespread concern with the eviCore treatment guidelines as some of ACRO’s advocacy-based accomplishments. Dr. Finkelstein then looks at ACRO’s progress in getting recognition for radiation oncology, explaining that recognizing professional success helps advance practice excellence. He goes over some of ACRO’s accomplishments in this area, including the development of a comprehensive physics review and a robust and modern virtual medical chart review that eliminates reviewer bias. He concludes with a list of 10 reasons why a practice should undergo accreditation that includes improving practice quality by external review, ensuring that the most up-to-date question and answer techniques and standards as well as the most up-to-date policies are in place, and more.