2021 Archives

Real World Utilization of Guideline Based Therapy in mCSPC: Update From the 2021 ASCO Annual Meeting

Posted by Neeraj Agarwal, MD | Nov 2021

Neeraj Agarwal, MD, Professor of Medicine and Presidential Endowed Chair of Cancer Research at the Huntsman Cancer Institute at the University of Utah in Salt Lake City, examines the underutilization of effective intensified androgen deprivation therapy (ADT) for patients with metastatic castration-sensitive prostate cancer (mCSPC). He begins by emphasizing the unprecedented efficacy of intensified ADT in improving survival for patients with mCSPC. Dr. Agarwal then asserts that, despite those findings, less than a third of patients are being offered intensified ADT therapies as first-line (1L) treatment for mCSPC, even four to five years after data has become available. Dr. Agarwal supports this argument by citing three studies from the 2021 ASCO Annual Meeting: real-world utilization of advanced therapies and racial disparity among patients with mCSPC, a Medicare database analysis of over 35,000 patients (2009-2018); real-world 1L treatment patterns in patients with mCSPC in a U.S. health insurance database (2014-2019); and real-world treatment patterns among patients diagnosed with mCSPC in community oncology settings (2014-2019). Dr. Agarwal summarized the most salient finding: less than one-third of men received intensified treatment (ADT combined with docetaxel or with a novel hormonal therapy) as their first-line treatment for mCSPC. Additionally, most men received ADT alone or ADT combined with a nonsteroidal antiandrogen as their 1L treatment, even as recently as 2019, with Black and Hispanic men even less likely than White men to receive an intensified treatment. Further, most men whose cancer had spread to soft organs (e.g., liver, lungs) had received ADT alone. Dr. Agarwal concludes by reemphasizing that the vast majority of patients are not receiving intensification therapy which is backed by level-one evidence. Dr. Agarwal points to the importance of education, awareness, and access as critical to developing better science around implementation and leading to more patients being able to receive these transformative treatments.

The Medicinal Value of Humor

Posted by Neil H. Baum, MD | Nov 2021

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the health benefits of humor and gives suggestions on how urologists can incorporate it into their practices. He begins with a brief history of humor and medicine, noting that sources from as far back as the Old Testament link humor to good health. Dr. Baum then considers the scientific relationship between laughter and illness, noting that laughter increases heart rate, releases endorphins, stimulates the immune system, and decreases cortisol. He explains that research indicates these physiological effects can decrease stress, increase pain tolerance, and perhaps even help with depression. Dr. Baum highlights the particular importance of humor in the high-stress COVID era, especially since laughter may increase immunity for upper respiratory illnesses. He then provides some examples of how to bring humor into a urologic practice, such as hanging humorous images on the walls, keeping comedy magazines in the lobby, and putting jokes on fax sheets. Dr. Baum concludes that humor is great medicine, and that urologists should not only use it with their patients, but should also prescribe it to themselves.

TITAN Phase 3 Trial with Apalutamide in Metastatic Castration Sensitive Prostate Cancer

Posted by Neeraj Agarwal, MD | Nov 2021

Neeraj Agarwal, MD, Professor of Medicine and Presidential Endowed Chair of Cancer Research at the Huntsman Cancer Institute at the University of Utah in Salt Lake City, summarizes results from the phase 3 TITAN trial of apalutamide in metastatic castration-sensitive prostate cancer (mCSPC), focusing on patient-reported quality of life outcomes. He briefly discusses the design of the study, explaining that it featured a 1:1 randomization of over 1000 patients to apalutamide plus ADT or placebo plus ADT and had dual endpoints of overall survival (OS) and radiographic progression-free survival (rPFS). Dr. Agarwal notes that both primary and final analysis found significant improvements in both OS and rPFS. Surprisingly, adjusting for the approximately 40% crossover from the placebo arm to the apalutamide arm actually led to an even greater reduction in risk of death (48% compared to 35%). Dr. Agarwal notes that this is an unprecedented improvement in survival with mCSPC, and also that rapid and deep PSA decline with apalutamide and ADT was associated with improved OS. He also considers quality of life (QoL) measurements, describing the assessment tools for evaluating pain, fatigue, and health-related QoL, and then highlighting that neither primary nor final analysis saw declines in any of these with apalutamide as compared to placebo. In fact, patients on apalutamide reported experiencing less pain. Dr. Agarwal concludes that in men with mCSPC treatment with apalutamide significantly improved survival outcomes without adversely affecting quality of life and fatigue.

International Prostate Cancer Update 2021 Session Review: Next Generation Imaging – Focus on PSMA

Posted by Phillip J. Koo, MD | Nov 2021

Phillip J. Koo, MD, summarizes talks from a session he moderated on next generation imaging, with a focus on PSMA, during IPCU 31.

The OPTIMUM Trial: 29 MHz Micro-Ultrasound vs. MRI in Diagnosis of Prostate Cancer

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

Gerald L. Andriole, Jr., MD, 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, introduces the OPTIMUM trial comparing high-resolution 29 MHz micro-ultrasound to MRI in the diagnosis of prostate cancer. After an introduction by E. David Crawford, MD, Professor of Urology at the University of California, San Diego, and Editor-in-Chief of Grand Rounds in Urology, Dr. Andriole explains that micro-ultrasound is a novel ultrasound-based system operating at 29 MHz that results in a 300 percent improvement in resolution compared to conventional ultrasound. He explains that micro-ultrasound can be used for transrectal or transperineal biopsy, with or without MRI. Dr. Andriole also notes that, like MRI with PI-RADS, micro-ultrasound has its own prostate risk identification using micro-ultrasound (PRI-MUS) classification system and works with all the skills urologists already have. He observes that several small studies have found superior or comparable sensitivity and/or clinically-significant prostate cancer detection with micro-ultrasound as compared to MRI, but that level 1 evidence is lacking. Dr. Andriole explains that the OPTIMUM trial, a 3-arm randomized controlled trial, is intended to fill in that gap and provide better evidence regarding micro-ultrasound’s efficacy. He describes the design of the trial, noting that 1200 biopsy-naïve subjects will be randomized to micro-ultrasound-only biopsy, MRI/micro-ultrasound “FusionVu” biopsy, and MRI/ultrasound biopsy with conventional fusion system, and that the trial is set to begin in winter 2021 and finish by spring 2023. The discussion concludes with a question and answer session in which Drs. Crawford and Andriole discuss which fusion platforms will be used, the price of micro-ultrasound, other potential applications for micro-ultrasound, and more.