International Prostate Cancer Update Archives

Presentations from the 31st Annual International Prostate Cancer Update

Posted by David Utz | Aug 2021

These lectures were presented during the 31st Annual International Prostate Cancer Update in July 2021, in Snowbird, Utah.

Genetic Testing and Prostate Cancer

Posted by Raoul S. Concepcion, MD, FACS | Aug 2021

Raoul S. Concepcion, MD, FACS, Chief Science Officer of U.S. Urology Partners in Nolensville, Tennessee, discusses genomics and DNA repair within the context of prostate cancer treatment to demonstrate the ability of next generation sequencing (NGS) to improve patient outcomes. He begins by giving basic definitions of genetics, genomics, and the genome before sharing data that supports an argument for performing genetic testing. Dr. Concepcion reviews studies on several related topics that all show higher rates of germline mutations in patients with metastatic and/or high-grade cancer. Dr. Concepcion explains that the link between germline mutations and higher rates of metastatic and higher-grade cancer shows that understanding DNA mutations and genomics can improve treatment. He then gives an overview of genomics, explaining how genetic code is formed and behaves and the different types of DNA mutations. He also gives an example of a pathogenic report expressing a nonsense mutation. Dr. Concepcion reviews the American College of Medical Genetics and Genomics (ACMG) classification system and how including testing as a part of treatment plans will improve that system. He then discusses the Knudson “two-hit” model hypothesis, presents data demonstrating that 60% of metastatic cancer patients do not undergo molecular testing, and explains that patients treated with targeted therapies based on genetic testing have 63% longer overall survival than other metastatic patients. Dr. Concepcion concludes by observing that an understanding of modern-day genomics and DNA repair is crucial to improving treatment.

What’s New in Active Surveillance for Prostate Cancer in 2021

Posted by Laurence Klotz, MD, FRCSC | Aug 2021

Laurence Klotz, MD, FRCSC, Professor of Surgery at the University of Toronto and the Chair of Prostate Cancer Research at Sunnybrook Health Sciences Centre, discusses what is new with active surveillance (AS) for prostate cancer, presenting various recent studies. He begins by considering the role of molecular genetics and observes that patients with certain kinds of disease are very safe candidates for AS noting, for instance, that only 2% of patients with Gleason grade 1 cancer are in the highest average genetic risk quartile, and that long-term outcomes for patients with Gleason grade 1 disease on AS are excellent. Dr. Klotz then looks at the safety of AS for younger patients, a group that has often been encouraged to get radical treatment, and highlights studies showing that younger men have a lower risk of upgrading while on AS and that AS is as safe for men over 60 as it is for men under 60. He comments on some other commonly-cited risk factors, noting that, with the exception of patients with BRCA mutations, a family history of prostate cancer does not increase a patient’s risk of having more aggressive prostate cancer, and also that while Black men experience higher rates of progression and treatment on AS, there is no difference in metastasis or mortality compared to White men on AS. Dr. Klotz acknowledges that radical treatment is likely necessary for patients with the BRCA2 mutation, but mentions that there is some controversy in this area. He then touches on the limitations of MRI, emphasizing that MRI progression does not correlate with upgrading and that MRI does not contribute significantly to the identification of higher-grade cancer, and that biopsy compliance is important for identifying progression. Dr. Klotz also briefly notes that active surveillance is a safe option for well-selected patients with intermediate-risk disease. He then looks at some recent research indicating a relationship between obesity and prostate cancer progression. Dr. Klotz concludes with the observation that while there is still a lot of variation in the use of active surveillance, as well as room for growth, there has been increased uptake overall in the US.

How to Optimize a Telehealth Visit

Posted by Evan R. Goldfischer, MD, MBA | Aug 2021

Evan R. Goldfischer, MD, MBA, FACS, urologist and Director of the Research Department at Premier Medical Group in Poughkeepsie, New York, and President-Elect of LUGPA, discusses how a medical practice can adapt to telehealth by adopting certain procedures for patients, doctors, and staff. He suggests that even if COVID-19 goes away, telehealth is here to stay because it produces high satisfaction rates amongst patients, is good for periods of inclement weather, can allow for weekend and evening billing of patient calls, can extend a practice to other regions, can be used for inpatient consults, and can be used for ER visits. Dr. Goldfischer acknowledges that working with new telehealth technology can be challenging for staff and recommends that staff are made familiar with the technology so that they in turn can instruct patients on its use. He also recommends that telehealth visits are scheduled during a dedicated block of time and aren’t interspersed with inpatient visits, that charts are prepped with all necessary lab results and notes, and that there is no need for a physical exam or any in-person sample collection. He also encourages video over audio visits. Dr. Goldfischer says that schedulers can help patients prepare for a telehealth visit by testing a patient’s ability to use the necessary technology and by having family members or nursing home staff present with the patient for the visit 10 minutes of the appointment. He suggests that doctors prepare by having 2 computers set up (1 for video and 1 for the electronic medical record), reviewing records ahead of time, being in a quiet and isolated room to preserve confidentiality, looking professional and not being distracted, and checking computer connectivity ahead of time. Dr. Goldfischer stresses the importance of focusing on the patient, engaging family members, taking in the patient’s surroundings, and making sure that the patient is engaged during the appointment. He recommends scheduling any follow-ups immediately after the visit and sending a letter or copy of the office notes if the doctor is unsure whether the patient processed all the information.

Next Generation Imaging for Prostate Cancer

Posted by Phillip J. Koo, MD | Aug 2021

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, gives an overview of the current state of next generation imaging (NGI) for prostate cancer and how it compares to conventional imaging, i.e., bone scans and CT scans. He begins by noting that while there are strengths to conventional imaging and the NCCN clinical guidelines still recommend its use, it misses a lot of cancer, especially in patients with low PSA or biochemical recurrence (BCR). Dr. Koo suggests that NGI is to conventional imaging as a high-definition television is to a conventional one: both show a picture, but one shows a clearer one. He briefly looks at how NGI for prostate cancer works, explaining that NGI takes advantage of unique biological aspects of prostate cancer carcinogenesis and that increased metabolism and vascular changes in prostate cancer cells can be evaluated with radiolabeled analogs of choline, acetate, glucose, amino acids, and nucleotides. Dr. Koo then goes over the different approved NGI PET/CT options, including 11C-choline, 18F-fluciclovine, 68Ga-PSMA-11, and PyLARIFY PSMA. He particularly focuses on the 2 PSMA ligands, since data indicates that PSMA PET/CT performs better than anything used in the past, detecting more cancer at lower PSA levels than other techniques and in places where prostate cancer has rarely been seen before. Dr. Koo notes that PSMA is not infallible though, highlighting a study showing that while 68Ga-PSMA-11 generally has better detection rates than fluciclovine, fluciclovine has a higher detection rate in the prostate bed, suggesting that each radiopharmaceutical has its own strengths and weaknesses. He concludes with a summary of when and how clinicians should use NGI, emphasizing that NGI is here to stay and the field of urologic oncology should be prepared for rapid change.