2022 Archives

How to Utilize MRI for Focal Therapy Planning

Posted by Samir S. Taneja, MD | May 2022

Samir S. Taneja, MD, the James M. Neissa and Janet Riha Neissa Professor of Urologic Oncology, Co-Director of the Smilow Comprehensive Prostate Cancer Center, and Vice Chair of the Department of Urology at NYU Grossman School of Medicine, discusses how to use MRI in planning and doing follow-up on focal therapy for prostate cancer. He begins by introducing the critical decisions in focal therapy implementation, including candidate selection, method of disease mapping/identification, choice of energy, and manner of follow-up/verification of efficacy. Dr. Taneja then lists imaging-related factors influencing oncologic efficacy including tumor size/extent, tumor location, focality, energy source, and gland size. He considers biopsy vs. MRI in treatment planning, explaining that systematic biopsy is inadequate for mapping disease, transperineal template biopsy is the gold standard, and MRI/MRI-targeted biopsy is not perfect, but very good. Dr. Taneja notes that MRI misses some clinically significant cancer, but observes that a 9 to 10 millimeter MRI/MRI-targeted biopsy guided focal ablation seems to identify all the index tumors. He also goes over imaging factors such as disease location and volume affect the choice of energy selection for focal therapy. Dr. Taneja then considers the benefits of imaging post partial gland ablation, explaining that very early imaging evaluates the anatomy of ablation but not its efficacy, intermediate interval imaging guides biopsy and identifies need for retreatment, delayed imaging identifies recurrence. He also briefly discusses the use of PET in cases where MRI does not detect recurrence. Dr. Taneja concludes that MRI has the ability to localize the index tumor, that margin considerations should take into account the known limitations of MRI in disease mapping, and that MRI remains the essential mainstay for monitoring following focal ablation.

Lessons from LEGO Blocks

Posted by Neil H. Baum, MD | May 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, considers five lessons medical practices can learn from the successes of the LEGO toy company. He begins with a brief history of the LEGO company, explaining that it started declining in 1992, but was able to reverse this decline in 2014 and is now the largest toy company in the world. Dr. Baum then goes through lessons for medical practices modeled on the success of LEGO, beginning with the idea of connectivity. He observes that each LEGO piece connects to every other piece, with no piece dominating, and he argues that practices must similarly connect with patients, hospitals, other providers, insurance companies, and the community. Dr. Baum’s second lesson is to build the right team, just as LEGO did a decade ago when it looked like the company was on its way to bankruptcy. He suggests that those running a medical practice ask themselves whether they would rehire each employee in their practice, and whether their doctors and staff are practicing at the top of their licenses. Dr. Baum’s third lesson is to create a clear path, much as LEGO did when they reconnected with their signature block and pivoted away from other products like video games. Medical practices, Dr. Baum argues, should be similarly focused on ensuring every patient has a positive experience. The fourth lesson is to create value based on the customer. Just as LEGO works to maintain customer satisfaction by replacing missing pieces from kits for free and using focus groups to develop new products, Dr. Baum suggests medical practitioners should observe how their patients interact with their practice and ensure they are not making assumptions based on outdated or inaccurate information by conducting regular patient surveys. Finally, Dr. Baum recommends that medical practices follow LEGO’s lead in developing strategic partnerships. He explains that LEGO’s partnerships with Star Wars, Harry Potter, and Disney lead to increased visibility, sales, and profits, and argues that medical practices can do much the same by nurturing partnerships with hospitals, payers, and the community.

Focal Prostate Cryotherapy

Posted by Thomas J. Polascik, MD, FACS | May 2022

Thomas J. Polascik, MD, FACS, Professor of Surgery at Duke University and Director of Surgical Technology at the Duke Prostate and Urological Cancer Center, discusses focal prostate cryotherapy and recent data on the treatment’s outcomes. He begins by describing the ideal patient for focal cryotherapy as someone with a greater than ten-year life expectancy and single or multiple mpMRI-visible, biopsy-proven Gleason Grade 2 prostate cancer (PCa) in locations amenable to ablation. Dr. Polascik outlines the procedure and states that the goals of the treatment are eradication of PCa, avoiding urinary and sexual dysfunction, and being a fast and simple outpatient procedure. He then begins discussing data on focal cryotherapy that shows that vitamin D3 functions as a sensitizer to cryoablation and that it is reasonable to re-treat about 20% of PCa patients with focal therapy. Dr. Polascik reviews the latest cryotherapy outcomes that all show focal cryotherapy to be approaching 100% rates of metastasis-free survival, cancer-specific survival, and urinary continence. He summarizes several studies that also show continence to be at about 95-100%, while potency was shown to be between 40-80%. Dr. Polascik then considers a study of long-term outcomes of focal therapy for low-intermediate risk cancer that found focal cryotherapy capable of increasing the time until radical or systemic therapy. He summarizes another study on anterior gland focal cryoablation showing that it can be effective based on erectile function and International Prostate Symptom Score (IPSS) not changing post-treatment. Dr. Polascik discusses expert consensus on how to surveil focal cryotherapy patients post-op, focusing on how in-field failure is a sign of poor treatment while out-of-field failure signals poor patient selection. He concludes by giving an overview of the Focal Therapy Society and by considering the future of focal cryotherapy.

PSMA Targeted Therapies and the Role of the Urologist

Posted by Phillip J. Koo, MD | May 2022

Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses PSMA targeted therapies for prostate cancer and the urologist’s role in using radiotherapy. He begins by looking at the results of the VISION trial of lutetium-177 PSMA-617 for metastatic castration-resistant prostate cancer (mCRPC), explaining that radioligand therapy significantly increased overall survival and radiographic progression-free survival. Dr. Koo then considers the TheraP trial of lutetium-177 PSMA-617 versus cabazitaxel which saw far better PSA response in PSMA arm than in the cabazitaxel one. He notes that the amount of imaging used in patient selection for TheraP would be impractical in a real-world setting. Dr. Koo also looks at the slate of upcoming clinical trials of PSMA, highlighting the number of combination therapy trials in the CRPC setting, as well as the number of trials looking at PSMA’s potential role in earlier phases of the disease. Finally, Dr. Koo discusses the role of the urologist in the new PSMA era, arguing that urologists need to understand and be comfortable with PSMA since it is an increasingly important tool for treating advanced prostate cancer. He recommends that urologists create advanced prostate cancer clinics featuring targeted radiotherapy clinics.

Comparative Outcomes: Prostate Brachytherapy vs. EBRT vs. SBRT for Low/Intermediate Risk Disease

Posted by Michael J. Zelefsky, MD | Apr 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Michael J. Zelefsky, MD, Vice Chair of Clinical Research in the Department of Radiation Oncology and Chief of the Brachytherapy Service at Memorial Sloan Kettering in New York City, compares outcomes for prostate brachytherapy vs. external-beam radiation therapy (EBRT) vs. stereotactic body radiotherapy (SBRT) for patients with low- and intermediate-risk disease. Dr. Zelefsky explains that when comparing outcomes, the focus is on toxicity after therapy and the efficacy of therapy. He also notes several limitations in comparing different radiotherapeutic modalities as well as dramatic technological innovation over the last 10 years that have greatly improved radiotherapy delivery. While this has been revolutionary in the treatment of disease, it creates what he calls “a moving target” when comparing outcomes because of the difficulty in comparing studies completed at various points in this technological revolution. Dr. Zelefsky cites a comparative study of patient-reported quality-of-life (QOL) outcomes after SBRT, low-dose-rate (LDR) brachytherapy, and high-dose-rate (HDR) brachytherapy for prostate cancer. Another study compared patient-reported QOL following SBRT and conventionally fractionated EBRT compared with active surveillance in those with localized prostate cancer. He reviews highlights from five-year outcomes of the HYPO-RT-PC randomized, non-inferiority, phase 3 trial that examined ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer, including that the estimated failure-free survival at five years was 84 percent in both treatment groups. Dr. Zelefsky notes that genitourinary and gastrointestinal toxicity were similar in both groups as well. He presents a chart illustrating urinary symptoms post-therapy which shows that while LDR has a higher rate of acute grade two urinary symptoms, late urinary toxicity and late urinary incontinence are similar across LDR, EBRT, and SBRT. Dr. Zelefsky outlines the benefits of prostate brachytherapy for favorable and intermediate-risk disease, pointing out that it has the most ablative potential, prostate-specific antigen nadirs are generally significantly lower than with EBRT, and post-treatment biopsy outcomes are positive in just seven percent of patients. He compares this with data showing that EBRT results in post-treatment positive biopsy outcomes of approximately 25-30 percent and data showing that SBRT with a dose of 40 Gy results in post-treatment positive biopsy outcomes of 11 percent. Dr. Zelefsky suggests then that SBRT has more ablative potential than EBRT but that brachytherapy has even more ablative potential than either of these. Finally, Dr. Zelefsky summarizes by explaining how these findings help inform patient decisions and treatment selection, pointing out that prostate brachytherapy may be preferable for the younger patient with few urinary symptoms, while patients with significant urinary symptoms may prefer SBRT. Patients with a larger prostate who may otherwise require downsizing with ADT may opt for SBRT over brachytherapy.