2021 Archives

Considerations to Improve Screening for Prostate Cancer

Posted by Gerald L. Andriole, Jr., MD | Dec 2021

Gerald L. Andriole, Jr., MD, outgoing Robert K. Royce Distinguished Professor and Chief of Urologic Surgery at Barnes-Jewish Hospital, the Siteman Cancer Center, and Washington University School of Medicine in St. Louis, Missouri, and incoming Director of Urology in the National Capital Region at the Brady Urologic Institute at Johns Hopkins University, reviews current guidelines for prostate cancer screening and considers how screening can be improved. After an introduction from E. David Crawford, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, Dr. Andriole summarizes the AUA, EAU, and NCCN prostate cancer screening guidelines, highlighting the NCCN’s recommendation that men get an early-in-life PSA test to obtain a baseline, and interrogating the validity of the age cut-offs for testing in the AUA and EAU guidelines. He then proposes a series of concepts to improve screening, starting with recommendations on how to better identify which men are at above average risk. Dr. Andriole particularly emphasizes the utility of polygenomic risk scores, which have a high negative predictive value and can focus attention on which patients need to be further screened. He suggests that another key way to improve screening is to reduce confusion about the PSA test among patients and primary care providers by setting a cut-point of 1-1.5 as a threshold for referral to a urologist. Dr. Andriole then considers how to identify patients with clinically-significant prostate cancer earlier, focusing on the need for better biopsies. He also notes the importance of reducing unnecessary repeat and initial biopsies and suggests potentially using biomarkers, MRI, and PSMA-PET to decide whether a biopsy is necessary. After concluding his talk, Dr. Andriole further discusses polygenic risk score, the pros and cons of multiparametric MRI, the benefits of micro-ultrasound, transrectal versus transperineal biopsy, and the future of screening with Dr. Crawford.

Final Results from ACIS Trial of Apalutamide Plus Abiraterone/Prednisone in Patients with Chemo-Naive mCRPC

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

Raoul S. Concepcion, MD, FACS, Chief Science Officer of U.S. Urology Partners in Nolensville, Tennessee, presents the final results of the ACIS trial, a random double-blind phase III study examining concomitant treatment with apalutamide and abiraterone plus prednisone against abiraterone and androgen deprivation therapy (ADT) in patients with chemotherapy-naïve metastatic castrate-resistant prostate cancer (mCRPC). He provides background, describes the study design and baseline characteristics, and reviews the findings. Dr. Concepcion explains the role of activated androgen receptors and intratumoral androgens in mCRPC. He also describes the concept of androgen annihilation, essentially blocking androgen at both the production and receptor level. The ACIS trial met its primary endpoint, radiographic progression-free survival (rPFS), at a median of 25.7 months of follow up, representing a 31% reduction in risk of radiographic progression or death. The risk reduction was maintained at 30% in long term follow-up at 54.8 months. However, overall survival was similar between treatment arms. Likewise, the secondary endpoints, time to initiation of cytotoxic chemotherapy, time to pain progression, and time to chronic opioid use, were also similar. Lastly, Dr. Concepcion notes that no new safety signals were observed and patient quality of life was comparable between treatment arms.

Updates of Changes in the Early Detection of Prostate Cancer NCCN Guidelines 2021

Posted by Preston C. Sprenkle, MD | Dec 2021

Preston C. Sprenkle, MD, Associate Professor of Urology at Yale University School of Medicine in New Haven, Connecticut, offers an update of changes in the National Comprehensive Cancer Network (NCCN) guidelines for 2021 regarding the early detection of prostate cancer. Dr. Sprenkle first explains the rationale behind the early detection of prostate cancer guidelines, with the NCCN recognizing that prostate cancer is a spectrum of disease, that early detection is for men who opt-in to screening, and that early detection allows for treatment of aggressive cancer, realizing the challenge of not treating indolent disease. Dr. Sprenkle then displays a schematic to outline the format and elements of the NCCN guidelines before highlighting some changes made since 2020. The revised guidelines clarify language regarding race and ancestry as well as germline mutations. The revisions strengthen statements supporting the use of magnetic resonance imaging (MRI), reflecting an understanding that the benefit of MRI fusion prostate biopsy is clear and that data on multi-parametric (mp)MRI are no longer simply “emerging.” Additionally, the new recommendations remove the prostate cancer antigen 3 gene (PCA3) from the list of recommended biomarkers that further define risk. Guidelines now also recommend that high-grade prostatic intraepithelial neoplasia (HGPIN) be treated as benign disease. Dr. Sprenkle emphasizes that while these 2021 guidelines do not introduce major changes, the addition in 2020 of intraductal carcinoma (IDC) as a concerning pathological feature was a major change that merits continued attention.

Leaving a Lasting Impression on Your Patients

Posted by Neil H. Baum, MD | Dec 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, gives tips on how urologists can leave a positive lasting impression on their patients. He explains that making a favorable last impression is important since it encourages patients to share their experience. Dr. Baum then gives some suggestions on how a urologist can leave a positive impression, including calling key patients at home to answer any lingering questions patients may have and to remind them of future appointments or procedures. He defines key patients as those who have been recently discharged, those who have recently had an outpatient procedure, those who have received a negative result from recent diagnostics, or new patients. Dr. Baum notes that the doctor should ideally be the one to call the patient and provides some suggestions for scheduling calls and alerting patients ahead of time that the doctor will be calling in order to avoid playing phone tag. He lists the advantages of calling, explaining that it continues the connection between the patient and the practice, reduces the number of calls from patients, improves a practice’s online reputation, and creates “raving fans.” Dr. Baum concludes that last impressions are just as important as first impressions for a practice’s reputation.

2020 AUA Microhematuria Guidelines Update

Posted by Jennifer M. Taylor, MD, MPH | Dec 2021

Jennifer M. Taylor, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine in Houston, Texas, begins by citing the original American Urological Association (AUA) Microhematuria Guideline from 2012, pointing out that the guideline was created in response to a major public health problem. She outlines the benefits and drawbacks of the original guideline, including the benefit that the AUA guideline would miss the fewest number of cancers versus other guidelines. The drawbacks included not being cost-effective, having low-yield and low specificity, being too aggressive for women and for those at low risk of malignancy, and having low rates of adherence. Dr. Taylor concludes that the 2012 guideline’s adverse impacts on patients were too great, citing discomfort, infections, false positives, and radiation exposure. Dr. Taylor then turns her discussion to the Microhematuria: AUA/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Guideline 2020, which took a risk-based, patient-centered approach, aiming to minimize harm and the waste involved in over-evaluation for low-risk patients, thereby improving specificity in those patients while maintaining specificity for those at higher risk for disease. Goals of the 2020 guideline included improving adherence with a more judicious set of guidelines and harmonizing the guidelines to achieve clarity among diverse stakeholders. The systematic review took place between January 2010 and December 2019 and included an evidence base of five systematic reviews and 91 primary literature studies. Dr. Taylor explains that the 2020 guideline maintains that microhematuria is defined as a urinalysis (UA) showing at least three red blood cells per high-powered field (≥ 3RBC/HPF). Dr. Taylor expounds upon the updated guidelines in terms of initial evaluation, diagnosis, and follow-up before confronting the gender gap in bladder cancer diagnosis. She cites a study concluding that treatment without further evaluation in the year prior to a bladder cancer diagnosis occurred 19 percent of the time in men versus 47 percent of the time in women. Further, there were three or more treatments for urinary tract infection (UTI) prior to evaluation by a urologist in 3.8 percent of men versus 15.8 percent of women. Dr. Taylor calls this significant and calls for continued advocacy for fuller symptom evaluation. Dr. Taylor then breaks down risk stratification, emphasizing that risk is highly correlated with known risk factors for urothelial cancer and doctors can tailor the intensity of the patient evaluation based on those risk factors. She presents and explains low-, medium-, and high-risk patient characteristics and evaluation recommendations. Dr. Taylor summarizes the takeaways from the 2020 guideline. For low-risk patients, practitioners should employ shared decision-making with their patients, either opting to repeat the UA or conduct a cystoscopy and renal ultrasound; for intermediate-risk patients, practitioners should conduct a cystoscopy and renal ultrasound; and for high-risk patients, the guideline recommends a cystoscopy with axial imaging. Dr. Taylor emphasizes the importance of the cystoscopy in these evaluations before displaying a summary one-page outline of the 2020 guideline and algorithm.