2021 Archives

Castration Resistant Prostate Cancer – Developments and Challenges from 2020

Posted by Emmanuel S. Antonarakis, MD | Mar 2021

In this Platinum Lecture, Emmanuel S. Antonarakis, MD, Professor of Oncology and Urology as well as Director of Prostate Cancer Medical Oncology Research and the Co-Director of the Prostate Cancer Multidisciplinary Clinic at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, summarizes developments from 2020 in mutation-targeted treatments for metastatic castration-resistant prostate cancer (mCRPC). He considers the successes of PARP inhibitors, especially for patients with the BRCA2 mutation, and the limitations of PD1 inhibitors. Dr. Antonarakis concludes by looking at promising research into B7-H3 and PSMA.

Neoadjuvant Cisplatin-Based Chemotherapy for Muscle-Invasive Bladder Cancer

Posted by Robert Dreicer, MD, MS, MACP, FASCO | Mar 2021

Robert Dreicer, MD, MS, MACP, FASCO, Associate Director for Clinical Research and the Deputy Director of the University of Virginia Cancer Center, discusses phase 3 study evidence in support of cisplatin-based chemo which he argues is a secure alternative to immune-checkpoint inhibition, a more experimental treatment. He begins by paralleling support of immune-checkpoint inhibition to other oncological examples of physician claims of “I already know the answer.” Dr. Dreicer reflects on the 90s, specifically on the recommendation of high dose chemo for advanced breast cancer prior to the completion of studies. Once the studies were completed it became clear that high dose chemo did not demonstrate an improvement in treatment and may in fact have proved itself mostly harmful. He continues by reviewing a randomized trial comparing long-term survival results of patients treated with gemcitabine plus cisplatin against methotrexate, vinblastine, doxorubicin, and cisplatin in patients with bladder cancer. The trial found that cisplatin-based chemo had a 15.3% response rate. Dr. Dreicer overviews a phase 3 trial which found that cisplatin-based therapy reduced risk of death by 16%, corresponding to an increase in 10-year survival from 30% to 36%. He concludes with an argument for cisplatin-based treatment due to the availability of higher-quality evidence for its use than immune-checkpoint inhibition.

Building Your Urologic Castle: Barriers to Exit (Part 2 of 2)

Posted by Neil H. Baum, MD | Feb 2021

In the second part of this two-part series, Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives suggestions on how urologists who have already successfully attracted patients by removing barriers to entry can then keep those patients in their practice by building barriers to exit. He explains that the goal is for each patient to have a stellar experience and then share their feedback with others. Dr. Baum emphasizes the importance of a robust, regularly updated website and active social media pages. He also highlights the importance of practice accessibility, from having online scheduling and communication via email and text, to having same-day appointments available, keeping office wait times as short as possible, and supplying accessible, validated parking. He suggests that doctors call patients at home after they have had a procedure, both to demonstrate care and to reduce incoming calls from patients. Dr. Baum also notes the importance of having transparent pricing and insurance assistance, and of providing translators for patients who do not speak English. He concludes by encouraging urologists to make their USP (unique service proposition) visible and obvious to patients, by noting that there are riches in the niches, and by reiterating the importance of eliminating negative barriers and fortifying positive ones in a medical practice.

Neoadjuvant Immune-Checkpoint Inhibition for Muscle-Invasive Bladder Cancer

Posted by Petros Grivas, MD, PhD | Feb 2021

Petros Grivas, MD, PhD, Associate Professor of Oncology at the University of Washington School of Medicine in Seattle, argues for the use of immune-checkpoint inhibition over cisplatin-based chemotherapy for muscle-invasive bladder cancer (MIBC) based on promising level 1 evidence. He begins with an overview of the PURE-01 trial, which found that single-agent pembrolizumab safely achieved a pTO of 42% and a down-staging rate of 54%. Dr. Grivas continues by discussing the possibility of imaging endpoint use, reaching the conclusion that more validation is necessary before progress can be made in this area. He then returns to the PURE-01 trial, reviewing the surgical safety data which demonstrate high-grade complications post-pembrolizumab in 34% of patients, a significant minority. Dr. Grivas follows this by looking at the wider landscape of phase 2 trials in MIBC beyond just PURE-01, noting that they have shown promising pathologic complete response rates and rates of pathologic downstaging to non-muscle invasive disease. He looks to the future, suggesting that with more data and validation physicians will be able to treat patients based on their individual biology. Dr. Grivas concludes by arguing that it may be possible to use immune-checkpoint inhibition in patients who are unfit for cisplatin or to even avoid using cisplatin altogether, but notes that there is a need for more high-quality studies to inform discussions.

Active Surveillance 2021 – Imaging and Biomarkers

Posted by Laurence Klotz, MD, FRCSC | Feb 2021

In the second part of a Platinum Lecture trilogy on active surveillance, Laurence Klotz, MD, FRCSC, Professor of Surgery and holder of the Sunnybrook Chair of Prostate Cancer Research at the University of Toronto, outlines recent developments in imaging and biomarkers and discusses how these are changing active surveillance for prostate cancer. He reviews the benefits and limitations of MRI targeting, considers the potential of high resolution micro-ultrasound, looks at how biomarkers that provide a continuous risk index might be more useful in active surveillance than most currently-available biomarker tests, and contemplates a future of data integration and artificial intelligence in active surveillance.