E. David Crawford, MD; Alan H. Bryce, MD; and Bryan A. Mehlhaff, MD discuss Lutetium Lu-177, its effectiveness, manufacturing challenges, and clinical effects of today’s shortage.
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Phillip J. Koo, MD, advises urologists and oncologists on prostate-specific membrane antigen (PSMA)-positron emission tomography (PET) imaging.
Read MoreChristopher J. Kane, MD, FACS, the Dean of Clinical Affairs at the University of California San Diego School of Medicine, and the CEO of the UC San Diego Health Physician Group, discusses the role of race in prostate cancer mortality among Black men. Dr. Kane presents data showing that both the incidence and rate of death from prostate cancer are significantly higher in Black men, and that this ratio has remained consistent over time. Referencing the SEER database, Dr. Kane notes that Black men were twice as likely to die of prostate cancer. While there are claims that biologic differences between Black and White men are to blame for the rate of death, Dr. Kane points out that the genetic differences between Black men are similar to the genetic difference between White men. He further adds that inheritance patterns of Black Americans are highly variable and cannot be considered a homogenous biological construct. Beyond genetic factors, Dr. Kane mentions other possible causes for the disparity including environmental factors, care dynamics, care quality, and availability. He then reviews a study that analyzed three cohorts to determine whether Black race was associated with inferior prostate cancer outcomes if patients had similar access to care and standardized treatment. The results indicate that Black men were not at higher risk of prostate cancer mortality when they had access to better healthcare. He concludes that physicians can save nearly 4,000 Black men who would otherwise die of prostate cancer each year. Regardless of potential factors impacting disease risk and progression in Black men, Dr. Kane maintains that providing superb screening, detection, and treatment can reduce the observed racial difference in prostate cancer outcomes.
Read MoreAlan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic Arizona in Scottsdale, discusses genetic testing, next generation DNA sequencing, and the genetic diversity of prostate cancer (PCa) in regard to treatment. He begins by reviewing the germline BRCA mutations, stating that BRCA1 and BRCA2 mutations individually make up fewer than 1.3% of all cases of localized PCa. Dr. Bryce then discusses BRCA2 in detail, focusing on how BRCA2 carriers are considered high risk by the NCCN guidelines, which recommend PSA screening discussions to start at age 45. He evaluates traditional guidelines in the context of germline mutations, finding that genetic testing and Gleason score guidelines do not reliably identify PCa patients for the presence/absence of high-risk germline mutations. Dr. Bryce then discusses the mutational landscape by disease state, displaying how PCa evolves as it advances to become metastatic and castration resistant and supporting the idea that a genomic understanding of an individual’s disease is key to treatment. He reviews the approval of olaparib, a PARP inhibitor, and the PROfound trial. Dr. Bryce concludes that inherited prostate cancer risk syndromes are under-recognized, both in practice and in research, that PCa is genetically diverse, that the impact of treatments on tumor evolution should be evaluated, and that multiple new pathways for therapeutic targeting have been identified.
Read MoreMichael E. Albo, MD, Vice Chair of the Department of Urology at the University of California, San Diego, compares the efficacy, safety, and considerations for a variety of treatment options—both traditional surgical and newer, minimally-invasive therapies—for patients with benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). He begins by outlining the surgical management of LUTS attributed to BPH before discussing the goals and selection of treatment. He explains the patient and urologist perspectives in terms of evaluating minimally invasive therapies before summarizing the various treatment options as a whole. The first are resection treatments, including transurethral resection of the prostate (TURP) (which Dr. Albo calls “the gold standard”) and transurethral incision of the prostate (TUIP). Next he describes enucleation technologies, including simple prostatectomy, laser enucleation of the prostate (using holmium [HoLEP] or thulium [ThuLEP] lasers), and bipolar enucleation. Dr. Albo explains that while simple prostatectomy should be considered only for patients with large to very large prostates, laser enucleation options are size-independent options for the treatment of LUTs/BPH; additionally, the HoLEP and ThuLEP options have more favorable perioperative safety and he advises these be considered as treatment options in patients at higher risk of bleeding. Dr. Albo then addresses vaporization procedures, including bipolar transurethral vaporization of the prostate (TUVP) and photoselective laser vaporization of the prostate (PVP), explaining that PVP is likely safe for patients on anticoagulants. At this juncture he turns to the minimally-invasive prostatic urethral lift (PUL), citing studies showing this is less effective than TURP but with similar quality of life improvements. Dr. Albo makes the point that trials need to better evaluate minimally invasive interventions in terms of whether patients are able to discontinue medication and therefore whether that intervention can be considered successful. He discusses water vapor thermal therapy (WVTT), citing data supporting the preservation of erectile and ejaculatory function and five-year data showing sustained changes in International Prostate Symptom Score (IPSS) and Qmax. Robotic waterjet treatment (RWT) has been shown to be effective and safe, with the main drawback being bleeding; Dr. Albo predicts that, while more needs to be learned as far as RWT for larger prostates, this procedure could be game-changing. He mentions two additional procedures, transurethral microwave therapy (TUMT) and prostate artery embolization (PAE) (which currently is not recommended outside the context of clinical trials) as well as an investigational treatment with nitinol struts to remodel the bladder neck. He concludes by asserting that the field has come a long way in terms of the sophistication of the surgical treatment algorithm, emphasizing the importance of a discussion with the patient in terms of side effects, the availability of technology at the institution, and the surgeon’s skill level in the decision-making process.
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