PCa Commentary | Volume 195 – November 2024
PCa Commentary | Volume 195 – November 2024 Posted by Edward Weber | November 2024 NEW...
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Topic: Biomarkers
Overview of Liquid Biomarkers
E. David Crawford, MD, professor of Urology at the University of California, San Diego, discusses advancements in risk stratification and biomarkers for prostate cancer detection. In his 10-minute presentation, he highlights the challenges of inconsistent screening guidelines, criticizing the current fragmented approach to PSA screening and underscoring the need for simplified, standardized messaging for primary care providers.
He advocates using a PSA cutoff of 1.5 ng/mL as a threshold for identifying at-risk individuals. Molecular markers, combined with PSA levels, improve precision in detecting clinically significant cancers and reducing overtreatment. Dr. Crawford outlines the complementary roles of PSA testing, molecular diagnostics, and multiparametric MRI in refining prostate cancer risk assessments.
Dr. Crawford introduces novel liquid biomarkers and their evolving role in guiding treatment decisions, cautioning that they serve as data points rather than definitive answers. Drawing analogies, he illustrates the multifactorial approach required for accurate prostate cancer diagnosis, akin to assessing risk in complex scenarios.
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Optimizing MRI Techniques for Prostate Cancer Diagnosis
Fergus Coakley, MD, Portland Health and Science University, Portland, Oregon, delivers a 10-minute presentation on optimizing MRI for prostate cancer diagnosis, addressing key shifts in diagnostic paradigms. He explains the transition from systematic biopsies following PSA screening to a targeted approach using multiparametric MRI (mpMRI) and in-bore biopsies. He highlights the superior signal-to-noise ratio of endorectal coils, emphasizing their role in enhancing tumor detection and staging. Through case studies, Dr. Coakley demonstrates the efficacy of high-quality MRI in identifying clinically significant cancers that were missed by traditional methods. Data supporting targeted-only biopsies for positive MRI findings are presented, with discussions on the low yield and increased complications of systematic sampling. Dr. Coakley challenges conventional views on multifocality and secondary foci, showing minimal impact on prognosis. He urges the adoption of advanced MRI-guided techniques while acknowledging the need for further research. This insightful presentation invites viewers to explore evolving strategies in prostate cancer diagnostics and their implications for patient outcomes.
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Update of Changes in the Early Detection of Prostate Cancer NCCN Guidelines 2024
Preston C. Sprenkle, MD, Associate Professor of Urology at Yale University, delivers a comprehensive update on the 2024 National Comprehensive Cancer Network (NCCN) guidelines for early detection of prostate cancer.
In this 9-minute presentation, Dr. Sprenkle highlights the importance of early detection in identifying aggressive cancers while avoiding overtreatment of indolent disease, with shared decision-making and individualized risk assessment remaining central to guiding screening and treatment decisions. Refinements include clearer recommendations for younger patients with low PSA levels and adjusted screening intervals for men over 75. Genetic risk assessment and counseling are emphasized.
Sprenkle shares that the guidelines now recognize MRI as the standard of care for pre-biopsy evaluation. High-quality MRI imaging and expert interpretation are underscored to address variability in diagnostic practices. Systematic and MRI-targeted biopsies are preferred for improved accuracy in cancer detection. Dr. Frankel underscores the importance of integrating advanced imaging and equitable access to care to transform prostate cancer outcomes.
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Results from the Norwegian Prostate Cancer Consortium (NPCC)
Jan Oldenburg, MD, PhD, presents a detailed exploration of findings from the Norwegian Prostate Cancer Consortium, focusing on the predictive value of baseline PSA levels for prostate cancer risk and mortality. In this 10-minute presentation, Dr. Oldenburg analyzes the data from the NPCC study, revealing that PSA levels strongly correlate with long-term outcomes over an 18-year follow-up period.
Dr. Oldenburg calls for tailored screening protocols to balance early detection with minimizing unnecessary interventions. With comprehensive data and practical implications, his talk offers critical insights into PSA screening, making it an essential watch for clinicians focused on advancing prostate cancer management.
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Update on PROBASE Trial: Baseline PSA in Young Men (Aged 45 and 50)
Peter Albers, MD, highlights key findings from the ongoing PROBASE screening trial, which began in 2014 to evaluate prostate cancer detection in younger men. The trial focuses on identifying low-risk individuals to minimize harm while more effectively targeting high-risk groups.
In this 12-minute presentation, Dr. Albers shares data from PROBASE showing that identifying a baseline PSA low-risk cutoff PSA value of less than 1.5 ng/mL safely reduces unnecessary testing for five years. The strategy could reduce overtesting by broadening the low-risk group definition while ensuring early detection of clinically significant cancers.
Albers shares that MRI also plays a critical role, especially in refining high-risk group identification. PROBASE findings suggest strict biopsy criteria, such as PIRADS 4 thresholds, enhance specificity and reduce unnecessary procedures.
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MRI-Based Prostate Cancer Screening in an Era of MCEDs
Mark Emberton, MD, FRCS, discusses advancements in prostate cancer screening, emphasizing the limitations of current methods and the potential of innovative approaches.
In this 9-minute presentation, Emberton discusses emerging technologies, such as polygenic risk scoring and advanced biomarkers, that hold promise for enriching high-risk populations. Imaging, particularly bi-parametric MRI, is presented as a leading tool.
Emerton introduces TRANSFORM, a prostate cancer screening study funded by Prostate Cancer UK and the NHS. Developed through a collaborative, multidisciplinary approach, the study incorporates randomization to minimize bias and contamination. Adaptive trial design ensures underperforming methods are replaced, and novel tests can be incorporated as they emerge. Emerton expresses optimism that this innovative approach will shape the future of prostate cancer screening, addressing equity, efficiency, and scientific rigor.
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Counseling Men with Favorable Intermediate Risk Disease- How to Advise, What Evidence Do You Share?
Dov Kadmon, MD, provides a comprehensive overview of managing favorable intermediate-risk prostate cancer, focusing on patient counseling, treatment decisions, and long-term outcomes.
In this 21-minute presentation, Dr. Kadmon begins by defining favorable intermediate-risk prostate cancer as grade group 2 (Gleason 3+4), with PSA levels under 10 and limited tumor burden based on biopsy. Patients are reassured that this type of cancer is common, typically indolent, and confined to the prostate, with a slow doubling time of three to five years, allowing a broad window for therapeutic intervention.
The discussion then shifts to treatment options, emphasizing the choice between active surveillance and curative interventions like radical prostatectomy or radiation therapy. Surgery’s side effects, including urinary incontinence and erectile dysfunction, are acknowledged. Radiation therapy, while sparing immediate surgery, carries risks of chronic toxicity.
Dr. Kadmon shares insights from the UK-based ProtecT trial, comparing active monitoring, surgery, and radiation therapy. The trial shows similar overall survival rates across treatment arms, but highlights increased rates of metastasis and disease progression in the active monitoring group. He underscores that while surveillance may be appropriate for select patients, curative treatment offers a more definitive approach, especially in younger individuals or those with a longer life expectancy.
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Biomarkers for Radiation Therapy
Peter F. Orio III, DO, MS, focuses on the evolving role of biomarkers in radiation oncology, particularly for prostate cancer. He asserts that biomarkers serve as biological indicators that help predict and monitor responses to treatment, thereby optimizing therapeutic outcomes and reducing toxicity.
In this 12-minute presentation, Dr. Orio categorizes radiation biomarkers into diagnostic, predictive, prognostic, and monitoring types, emphasizing their distinct roles in disease prediction, treatment response, and patient prognosis. Orio provides examples and discusses how these tools influence radiation planning and decision-making across various medical disciplines, including radiation oncology, medical oncology, and surgery.
The presentation underscores that while many biomarkers are prognostic, the future lies in their predictive capabilities, which are crucial for truly personalized treatment.
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Cardiometabolic Health for Men with Advanced Prostate Cancer: Lessons Learned and Future Directions
Andrew W. Hahn, MD, addresses cardiometabolic health in men with advanced prostate cancer, focusing on the impacts of hormone therapy and strategies for managing cardiovascular risks.
In this 10-minute talk, Dr. Hahn highlights the common overlap of prostate cancer and cardiometabolic risk factors and underscores the necessity of evaluating cardiovascular risk in prostate cancer patients. He reviews data indicating that androgen deprivation therapy (ADT) can indirectly increase cardiovascular risks by altering body composition and intensifying metabolic syndrome. Adding androgen receptors nearly doubles cardiovascular event risk. Despite FDA advisories, guidelines, and the availability of cardiovascular risk assessments, many patients undergoing ADT lack appropriate cardiovascular monitoring.
Dr. Hahn highlights future directions in identifying men at heightened risk for cardiovascular events using imaging and genomic biomarkers. Promising approaches include myocardial perfusion PET scans and exploring genomic markers that correlate with cardiovascular toxicity in hormone therapy. Managing cardiometabolic health in advanced prostate cancer requires careful risk assessment and personalized approaches. Biomarkers are needed to effectively predict cardiovascular complications from hormone therapy.
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Advances and Controversies in Theranostic Approaches to Prostate Cancer
Eric M. Rohren, MD, PhD, analyzes how theranostics—combining therapeutic and diagnostic processes—are reshaping prostate cancer management. For example, prostate-specific membrane antigen (PSMA), used as a biomarker for both imaging and targeted therapy in PSMA-targeted PET scans, offers precise tumor localization, significantly enhancing diagnostic accuracy. PSMA-targeted radiopharmaceuticals such as 68Ga-PSMA-11 for PET imaging and 177Lu-PSMA-617 for therapy have been shown to improve detection rates and treatment outcomes, particularly in metastatic and castration-resistant prostate cancer.
Despite these advancements, Dr. Rohren acknowledges the challenges in theranostic approaches. The variability in PSMA expression among patients can impact the effectiveness of both imaging and therapy. Additionally, he discusses the potential side effects and toxicity associated with radioligand therapy, emphasizing the need for careful patient selection and monitoring.
Dr. Rohren also explores the ethical and regulatory considerations in the adoption of theranostics. He highlights the need for standardized protocols and guidelines to ensure consistent application and patient safety.
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KEYNOTE LECTURE: Too Little or Just Enough? The Role of Focal Therapy in ProtecT Era
Freddie Hamdy, MD, presents an insightful analysis of the role of focal therapy in the treatment of prostate cancer within the ProtecT era. He explores the balance between overtreatment and undertreatment, emphasizing the need for tailored approaches that maximize patient outcomes while minimizing unnecessary interventions.
Dr. Hamdy discusses the ProtecT trial’s findings, which highlight the benefits and limitations of active monitoring, surgery, and radiotherapy for localized prostate cancer. Focal therapy emerges as a promising middle ground. His presentation covers various focal therapy techniques, including high-intensity focused ultrasound (HIFU), cryotherapy, and focal laser ablation.
Dr. Hamdy stresses the importance of accurate patient selection, including diagnostic evaluations, multiparametric MRI, and targeted biopsies, for focal therapy. He also addresses the necessity of follow-up protocols including regular PSA testing and imaging.
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