2021 Archives

Role of ADT with Radiation

Posted by Steven E. Finkelstein, MD, FACRO | Dec 2021

Steven E. Finkelstein, MD, FACRO, a radiation oncologist with Florida Cancer Affiliates in Panama City, Florida, discusses the role of androgen deprivation therapy (ADT) with radiation therapy (RT) in patients with prostate cancer. Dr. Finkelstein first discusses the definitive setting, explaining optimal durations for the addition of ADT to RT under various circumstances. For example, when local control with RT alone is good, ADT is never given; when the risk of local failure is high, ADT is given for 3-6 months as a radiation sensitizer; and when the risk of distant disease is high, ADT treatment is given for 2-3 years. Dr. Finkelstein goes on to illustrate data that show ADT does not improve survival in men receiving RT for low-risk disease, short-term ADT improves survival in men receiving RT for intermediate-risk disease, and ADT was effective in improving survival for patients with “modern” high- and intermediate-risk disease. Dr. Finkelstein discusses dose escalation in RT and cites an ongoing study examining 1520 patients who received either 79.2 Gy alone or 79.2 Gy plus 6 months of ADT, with the primary endpoint being overall survival (OS), asserting that the study will be seminal once the results have been published. He then reviews the current summary recommendations in the definitive setting: for low-risk (NCCN definition) and low-intermediate-risk patients, the recommendation is surveillance, brachytherapy (BT), or external beam radiation therapy (EBRT) with no recommendation for ADT; for high-intermediate risk patients, the recommendation is EBRT +/- BT with 4-6 months of ADT (GnRH agonist); and for high-risk (NCCN definition) patients, the recommendation is EBRT +/- BT with 24 months of ADT(GnRH agonist). Dr. Finkelstein then introduces Kevin D. Healey, a research intern and medical student level two, who delivers the second part of the presentation, focusing on the salvage setting. Mr. Healey presents research from the GETUG-AFU 16 trial, examining short-term ADT combined with RT as salvage treatment after radical prostatectomy for prostate cancer: a 112-month follow-up of a phase 3, randomized trial. He concludes that salvage RT combined with short-term ADT significantly reduced the risk of biochemical or clinical progression and death compared with salvage RT alone. Further, the results of the trial confirm the efficacy of ADT plus RT as salvage treatment in patients with increasing PSA concentration after radical prostatectomy for prostate cancer. Dr. Finkelstein then concludes the presentation with the current summary recommendations for the salvage setting, including adding a 6-month course of ADT (LHRHa) to salvage RT in men with no or minimal comorbidity, given the near halving of progression and the possible reduction in mortality due to prostate cancer.

Fear and Frustration Among Women with Recurrent UTIs

Posted by A. Lenore Ackerman, MD, PhD | Nov 2021

In conversation with A. Lenore Ackerman, MD, PhD, Assistant Professor of Urology and Director of Research in the Division of Female Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, Ja-Hong H. Kim, MD, Associate Professor in the Division of Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, and Victoria C. Scott, MD, Associate Program Director of the FPMRS Fellowship at Cedars-Sinai Medical Center, discuss a recent study of the experience of women with recurrent urinary tract infections (rUTIs). Dr. Scott explains that 29 women were recruited to participate in 1 of 6 focus group discussions to investigate the perspective of women suffering from rUTIs. She then lists some preliminary themes from the discussions with the women, including fear of development of antibiotic resistance, widespread knowledge of the collateral damage from antibiotics, concern about taking unnecessary antibiotics, anger at physicians for “throwing” antibiotics at them, a feeling that the medical profession underestimates the impact of rUTIs, a need for research on nonantibiotic options for prevention and treatment, and resentment towards the medical system for not dedicating more research efforts to providing more timely diagnosis. Dr. Scott synthesizes these themes into two emergent concepts: fear about the overuse of antibiotics and frustration at the medical system for not providing alternative treatments or taking rUTI symptoms seriously. Dr. Kim then notes that this initial study has produced two additional studies on the current management of rUTIs that take expert and personal care provider experiences into account. Dr. Ackerman highlights the importance of data capturing that patients are not seeking antibiotics necessarily in the way doctors assume they are, though Dr. Kim does add the caveat that the women in the study were a relatively homogeneous group of college-educated white women. Dr. Ackerman also muses that the attitudes expressed in this study suggest that this population may be interested in a vaccine for rUTIs. Drs. Ackerman, Scott, and Kim conclude by noting that the study made evident the importance to patients with rUTIs of focusing on their experience rather than merely the clearance of bacteria.

PCa Commentary | Volume 159 – November 2021

Posted by Edward Weber, MD | Nov 2021

This Commentary looks at the application of genomics to therapy selection for patients metastatic hormone-sensitive prostate cancer (mHSPC).

LUGPA Government Policy Panel: Overview

Posted by R. Jonathan Henderson, MD | Nov 2021

R. Jonathan Henderson, MD, a urologist with Regional Urology, LLC, in Shreveport, Louisiana, discusses the Large Urology Group Practice Association, or LUGPA, the only nonprofit urology trade association in the United States. Dr. Henderson, who is the current President of LUGPA, explains LUGPA’s mission to preserve and advance the independent practice of urology; its core values of quality, collaboration, innovation, and integrity; and its strategic priorities, including advocacy and health policy, value-based care, practice management and benchmarking, and leadership development. Dr. Henderson expounds upon LUGPA’s dyad leadership model, wherein a practice is run by both a physician leader and an administrator, and he asserts this results in stronger practices, both medically and businesswise. Dr. Henderson then promotes Practice Management for Urology Groups, LUGPA’s Guidebook as a “recipe book for what we do in urology” before summarizing LUGPA’s benchmarking and executive leadership programs. Turning to the future, Dr. Henderson says LUGPA is following innovation and breakthroughs in urologic care, cost containment pressures, evolving payment methods, and practice and hospital integration and consolidation. He highlights health care personnel (HCP) shortages, citing data to support his assertion that it is a “perfect storm,” with 277 urologists completing residency annually, 2,000-3,000 current US job openings, and an average urologist age of 58. Dr. Henderson concludes by discussing the LUGPA 2021 Annual Meeting as well as new virtual offerings spurred by the COVID-19 pandemic, emphasizing LUGPA’s value in facilitating powerful networks and its relevance to all urology practitioners, whether they be academic, hospital-based, independent, or employed.

Use of Polygenic Risk Scores for Prostate Cancer Screening

Posted by Peter R. Carroll, MD, MPH | Nov 2021

Peter R. Carroll, MD, MPH, Professor of Prostate Cancer and Urology at the University of California, San Francisco, introduces his talk on polygenic risk scores by asserting that serum prostate-specific antigen (PSA) testing has limitations as a stand-alone screening tool. He explains that hereditary factors have a strong influence on prostate cancer risk and outcomes and that prostate cancer has high heritability. Dr. Carroll argues that while high-penetrance genes are important, they only explain a fraction of prostate cancer risk. Further, numerous genome-wide association studies (GWAS) have identified over 250 single nucleotide polymorphisms (SNPs) associated with risk. Dr. Carroll lays out the potential relevance of polygenic risk scores, showing where the scores have the potential to impact clinical care by supporting risk prediction, diagnosis, treatment decision-making, and prognosis of disease course and outcome. He then reviews a trans-ancestry genome-wide association meta-analysis of prostate cancer that demonstrates that genomic risk score (GRS) was predictive across populations. The study concluded that 269 risk variants were estimated to capture 33.6 percent of familial relative risk (FRR) in men of East Asian ancestry, 38.5 percent in Hispanic men, 42.6 percent in men of European ancestry, and 43.2 percent in men of African ancestry, with higher GRS associated with younger age at diagnosis and family history, but not disease aggressiveness. Dr. Carroll concludes with a summary of the use of GRS in prostate cancer early detection: prostate cancer is related to many risk variants across populations; GRS improves on the use of age and family history in assessing risk, though early detection guidelines have not incorporated GRS use yet; and larger populations (particularly those of African ancestry) require further examination.