Urology Times' 50th anniversary is this year, and we are celebrating by highlighting 50 pivotal innovations from the past 50 years. This week, we spotlight β3 agonists for overactive bladder with expert insight from  Ekene A. Enemchukwu, MD, MPH.

50th Anniversary Innovation Celebration: β3 agonists for overactive bladder

I don’t know that we want to go into a lot of discussion on it, but we alluded to this earlier, the importance of PSMA [prostate-specific membrane antigen] PET [positron emission tomography] vis-à-vis the enhancement of diagnostic imaging. Then there is the second component of bringing in the PSMA antibody conjugates with a radiopharmaceutical in the form of a beta particle. This is the VISION trial, utilizing lutetium and PSMA for patients who were PSMA positive, and 87% of the patients at baseline had a positive PSMA scan. This was in a group of patients who were heavily pretreated with prior taxane, 1 or 2 novel hormonal agents [NHAs], and then were randomized to Lu-PSMA-617 vs best standard of care, but a taxane, cabazitaxel, was not part of this. But even with this caveat, this was probably the most important data that came out of the ASCO 2021 [American Society of Clinical Oncology annual meeting] and essentially demonstrated that the primary analysis, the rPFS [radiographic progression-free survival], and I will show in a second the OS [overall survival], hit their end points with a statistically significant hazard ratio. Here on the rPFS, it is 0.4, in a heavily pretreated and high tumor burden population. Here is the OS primary end point, also demonstrating its significance.

What’s interesting and important now is what we talked about, theragnostics. Most of us are expecting this will lead to FDA approval for patients with mCRPC [metastatic castration-resistant prostate cancer] post-chemotherapy, post-NHA. We expect this approval to certainly happen in the very near term, and this will open the flood gates for other important trials looking at both other beta particles and alpha particles in the form of, most classically used globally would be actinium. There are others even combining beta and alpha particles, and even small molecules as well. This is an exciting area that our colleagues need to stay tuned for. Much like PSMA PET, it’s not about if, it’s only when you will be utilizing this novel mechanism of action strategy. Like in VISION and so many other advanced prostate cancer therapeutics, it will start to be interrogated prechemotherapy and even within metastatic castration-sensitive disease.

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Neal Shore, MD, FACS, reviews the VISION clinical trial in prostate cancer imaging.

Prostate Cancer Imaging: the VISION Trial

Great discussion. Let’s go to our last case, and it’s interesting because it’s into this area of the nmCRPC [nonmetastatic castration-resistant prostate cancer], or what we used to call index case 1 AUA [American Urological Association] M0. Larry, would you like to review this?

A 62-year-old man presents with reduced urinary flow and hematuria. Past medical history is significant for hypertension controlled with medication. Family history, father had lung cancer in his early 70s. Clinical work-up, PSA [prostate-specific antigen] is 7.9 ng/mL. Prostate biopsy shows Gleason score of 7 (4+3). Treatment and follow-up, the patient undergoes robotic-assisted laparoscopic prostatectomy and pelvic node dissection. Results show pT3b, focal extracapsular extension and seminal vesicle invasion, margins negative, N1, M0. Postoperative PSA is 0.53 ng/mL. The patient undergoes adjuvant radiation therapy and is started on leuprolide. PSA is undetectable. Follow-up, 2 years later the patient presents with rising PSA of 0.5 ng/mL, 4 months later PSA is 0.8 ng/mL.

This is a classic patient with nonmetastatic castration-resistant prostate cancer. The next question, if we are going to a tumor board now compared to just a few years ago when we were doing the phase 3 trials, the SPARTAN, PROSPER, and ARAMIS that led to the approval of those 3 androgen receptor [AR] drugs, respectively apalutamide, enzalutamide, and darolutamide. Those were all done on conventional imaging using CT scan and technetium bone scan, and they had to be negative, had to have a doubling of less than 10 months to get into those trials comparing the AR inhibitor vs placebo. Now, I guess the question is what’s the role for PSMA [prostate-specific membrane antigen] PET [positron emission tomography] in nmCRPC? This is summarizing the points I was making. Perhaps Larry you want to comment on this nice work that was done by [Wolfgang] Fendler, [MD,] and colleagues and looked at the use of PSMA PET in these patients who would have qualified for SPARTAN, PROSPER, or ARAMIS. What are your thoughts about the results of the PSMA PET in these patients?

It’s an interesting retrospective study. Probably to do it justice, I am going to respectively defer to my clinical colleagues.

I’ll go on with it because I know this well. Of 200 patients who would have been in enrolled in SPARTAN, PROSPER, and ARAMIS, 98% had positive findings. About 55% had findings within the pelvis and 45% above the pelvis based upon PSMA PET. But it gets back to our prior conversation, how would that change what you would do? Today, those 3 trials have led to the level 1 evidence in virtually all of our international guidelines, including NCCN [National Comprehensive Cancer Network], that says if the doubling time is less than 10 months, go with an AR inhibitor, apalutamide, enzalutamide, or darolutamide. It’s interesting, the label for those drugs doesn’t talk about the doubling time. But it is still fascinating in this paper that 198 of the 200 patients who would have had no findings, were found to have clear findings, and half had disease findings above the pelvis. What are your thoughts about that? Maybe I will ask Mike first and then Steven.

Because many of these drugs are approved in every line of therapy now, whether it’s newly diagnosed metastatic prostate cancer, nonmetastatic castration-resistant, or metastatic castration-resistant, in some ways it’s neither here nor there because they are going to see all these different lines of therapy anyway. But imagine a scenario where the patient has seen androgen deprivation, they have received an androgen receptor blocker, and they haven’t received docetaxel yet. And docetaxel wouldn't be indicated in nonmetastatic castration-resistant, but we know it would be in metastatic castration-resistant. Here, almost half of the patients have metastatic disease, can we start pulling the trigger and moving docetaxel into an earlier line of therapy for these patients who did not see it in their first or second course of treatment? There are no data to support doing that of course, but it really begs the question of whether these patients could potentially be candidates for that in the future.

I think we are going to find a situation where the imaging gets so good that we are going to be able to find sites of disease in every patient we look at, where the PSA is rising. However, what we are defining is its own unique subset. It’s not that we couldn’t find it anymore, it’s just low volume disease. It’s disease where you need next-generation imaging to be able to find it, and we know those drugs worked when we couldn’t point to where the individual spots were. We know these drugs will work when we say it’s low volume disease, it’s only detectable by fancy next-generation imaging. I don’t want us as specialists to throw the baby out with the bath water. We should embrace the history of what we have done. The imaging is going to drive, “Oh my goodness, there is a whole bunch of disease we see on this picture, or hey, there is only a little bit of disease on this picture.” We are going to be able to temper our enthusiasm for pulling the right treatment at the right time in the right patient.

Now, a lot of this is undiscovered country. We have to do those trials to use the imaging with some of the agents that we have classically used to find out if there are better agents to potentially use in certain scenarios. But like Mike alluded to, a lot of drugs that we use are indicated across the spectrum of the prostate cancer continuum. I think we are going to find that a lot of these drugs are just going to be moved up as we are able to find the disease and point to it sooner.

A look at the patient profile of a 62-year-old man presenting with reduced urinary flow and hematuria.

Patient Profile 7: Gleason 7 Prostate Cancer

As part of the Urology Times' 50th Anniversary Innovation Celebration, 

, discusses how high-intensity focused ultrasound (HIFU) revolutionized the way urologists treat localized prostate cancer. This techology, she emphasizes, creates another safe and effective minimally-invasive therapy for this population of patients. Linehan is an associate professor of urology and urologic oncology at the John Wayne Cancer Institute in Santa Monica, California.

"In trying to localize and focalize the treatment on just the lesion of prostate cancer, HIFU was incredibly powerful in the sense that it really allowed you to do that with great precision," said Jennifer Linehan, MD.

Urology Times 50 Innovations Series: Dr. Jennifer Linehan on HIFU for prostate cancer

, discusses the background and results of the study, “Decreased opioid use & equivalent pain score outcomes after urologic robotic surgery using a simplified opioid minimization protocol: a prospective, non-inferiority study,” which he presented at the 2022 AUA Annual Meeting (abstract MP31-02)

Laviana Assistant is a professor of Surgery and Perioperative Care at the University of Texas at Austin Dell Medical School.

"We wanted to implement an opioid minimization pathway that was easy to follow and successful,” says Aaron Laviana, MD.

Dr. Laviana on novel opioid minimization protocol after urologic robotic surgery

Initial findings from the phase 2 TRUCE-02 study shared during the 2022 AUA Annual Meeting showed promising activity with the combination of tislelizumab and nab-paclitaxel (Abraxane) in patients with high-risk non–muscle invasive bladder cancer (HR-NMIBC), regardless of PD-L1 expression.

In the study, an open-label, single-arm, phase 2 study (NCT04730232), there was a complete response (CR) rate of 62.5%, which met the primary end point of the trial. Additionally, the high-grade adverse events (AEs) rate was lower than 5% across the study participants.

Previously, the PEANUT trial (NCT03464734) investigating pembrolizumab (Keytruda) plus nab-paclitaxel showed a significant CR rate and low AE rate in the second-line treatment of patients with bladder cancer. The phase 2 KEYNOTE-057 trial (NCT02625961) also demonstrated efficacy and safety with pembrolizumab monotherapy as antitumor treatment in Bacille Calmette-Guérin–unresponsive patients with HR-NMIBC. Previously, tislelizumab showed efficacy in locally advanced or metastatic urothelial carcinoma, and TRUCE-02 investigators are seeking to confirm the benefit of tislelizumab plus nab-paclitaxel.

In this trial, patients with HR-NMIBC that cannot be completely resected received 3 or 4 cycles of tislelizumab on day 1 and nab-paclitaxel on day 2, both at 200 mg intravenously every 3 weeks followed by a multipoint resection biopsy. The primary end point is the patients’ CR rate, and secondary end points included cystectomy-free survival, duration of response, and the number and severity of AEs. The biospecimens of patients’ tumors were sent for analysis by AcornMed panel, which targets 808 cancer-related hotspot genes, before starting treatment. Immunohistochemistry staining was used to measure PD-L1 expression and whole-genome sequencing was used to evaluate urine sediments.

So far, 51 patients have been enrolled in the TRUCE-02 study; 32 patients have completed treatment of 3 or 4 cycles and met the primary end point. There were 20 patients of the 32 total who achieved CR, with a CR rate of 62.5%. Furthermore, 4 patients (12%) experienced a partial response (PR), and 5 (16%) had stable disease. Progressive disease was observed in 3 patients (9%). Currently, 4 patients (12.5%) have proceeded to cystectomy after treatment.

Positive PD-L1 expression was found in 12 (50%) out of the 24 patients who had response of either CR or PR. Three patients out of 8 (38%) who were unresponsive to treatment had positive PD-L1 expression. However, homologous recombination repair mutations may predict favorable prognosis, according to the investigators. The whole-genome sequencing results of patients’ tumor tissue and urine were considered uniform.

In patients receiving the tislelizumab combined with nab-paclitaxel, the most common low-grade treatment-related AEs included alopecia in 81% and fatigue in 34%. All other AEs were seen in 7% of patients or fewer. Immune-related severe AEs included cytokine release syndrome in 1 patient (3%) and 1 patient (3%) with popular and pustular rash.

The median age on the trial was 67 years (range, 44-85), and there were 25 male patients recruited. Patients had to have an ECOG performance status of 0 to 2. If patients had previously received PD-1, PD-L1, or CTLA-4 antibodies, or other immunotherapies previously, they could not be enrolled on the trial.

1. Hu H, Niu Y, Wang H, et al. Update of TRUCE-02: an open label, single-arm, phase 2 study of tilelizumab combined with nab-paclitaxel for high-risk non-muscle-invasive urothelial bladder carcinoma (HR-NMIBC) which is not completely resectable. Presented at: 2022 American Urological Association Annual Meeting; May 13-16, 2022; New Orleans, LA. Abstract MP59-19.

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Patients in the study had tumors that were not completely resectable.

Tislelizumab plus nab-paclitaxel shows promise in high-risk NMIBC

Findings from the phase 3 FinnBladder 9 trial published in 

 suggest that public knowledge of the increased risk of bladder cancer due to smoking is low, highlighting the need to raise awareness through more publicity and education.

In a baseline survey, 44% of patients were unsure if smoking was a risk factor for bladder cancer. At the 12-month follow-up, awareness that smoking cessation decreased bladder cancer risk increased from 82% to 92% with the fact that smoking cessation can cause bladder cancer recurrence (

 = .038). Additionally, older patients had significantly less knowledge of the association between smoking and bladder cancer recurrence, progression, and mortality.

“Bladder cancer survivors’ awareness of smoking-related risk factors should serve as a basis for prevention initiatives. In this prospective study, we demonstrated that patients’ awareness of smoking as a risk factor for bladder cancer is lower than for other smoking-related medical conditions such as lung cancer and coronary heart disease. Our study relied on the undetermined fact that smoking cessation reduces the risk of disease recurrence and progression and cancer-specific mortality,” the investigators of the study wrote.

A total of 411 patients were enrolled on the study (NCT01675219), 41 of whom did not complete the baseline questionnaire. Three hundred and seventy patients were included in the analysis. A total of 71% of patients completed questionnaires on smoking-related bladder cancer risk, 73% on bladder cancer recurrence, 72% on bladder cancer progression, and 72% on bladder cancer death.

The majority of patients were men (83%), with a mean age of 70 years. Investigators reported that 62% of patients had primary tumors and 51% had low-grade tumors. Eighty one percent of patients also had non-muscle invasive tumors and 13% had no cancer even with clinical suspicion at the time of randomization.

At baseline, 59% of patients were former smokers, 19% were current smokers, and at the 12-month follow-up, 16% were still smoking (

 = .54). The median smoking duration for ever-smokers was 20 years. Among smokers, 65% were interested in smoking cessation with a median of 4 prior cessation attempts. During the 12-month follow-up there was no significant interest or changes in smoking cessation.

Additional findings indicated that at baseline, 56% of patients stated that smoking was a definitive risk factor for bladder cancer vs 58% at 12 months. Responding proportions for lung cancer, coronary artery disease, stroke, and asthma were 93%, 80%, 73%, and 69%, respectively. There were no significant changes after 12 months of follow-up.

The recurrence of bladder cancer (OR, 0.33; 95% CI, 0.15-0.71; 

 = .005), and older age (OR, 0.45; 95% CI, 0.21-0.96; 

 = .039) were associated with less knowledge of bladder cancer and recurrence. Age (OR, 0.36; 95% CI, 0.15-0.81; 

 = .013) and previous bladder cancer recurrence (OR, 0.27; 95% CI, 0.11-0.61; 

 = .002) impacted knowledge of bladder cancer-specific mortality.

1. Sell V, Ettala O, Perez IM, et al. Awareness of Smoking as a risk factor in bladder cancer: results from the prospective FinnBladder 9 trial. 

. Published Online January 27, 2022. doi:10.1016/j.euf.2022.01.012

Almost half of individuals surveyed were unaware of the link between smoking and bladder cancer.

Study shows low public awareness of smoking as a risk factor for bladder cancer

Novel machine learning algorithms can make predictions about treatment outcomes in patients with overactive bladder (OAB) that are similar to — or even more precise — than those of a specialist. This was the chief finding from a recent Cleveland Clinic-led 

, that tested trained algorithms on the largest OAB datasets available and compared them to predictions from human experts. The study investigators also recently presented these data at the American Urological Association annual meeting in New Orleans.

OAB is a common urologic diagnosis that affects about 1 in 6 patients. Patients with severe refractory symptoms may be candidates for onabotulinumtoxinA (OBTX-A) and sacral neuromodulation (SNM), similarly effective interventions.

But a certain subgroup of patients does not respond to these treatments, and predicting those who will not respond is an “open question in the field,” says Glenn Werneburg, MD, PhD, lead author of the study and a resident in Cleveland Clinic’s Department of Urology.

Dr. Werneburg and coauthors developed neural networks using a series of novel approaches. They then applied them to the prediction problem in OAB using datasets from the ROSETTA (Refractory Overactive Bladder: Sacral NEuromodulation v. BoTulinum Toxin Assessment) study, a trial that randomized patients to either OBTX-A or SNM interventions. Alongside this, blinded expert urologists also predicted outcomes.

Remarkably, the algorithms demonstrated outstanding accuracy in predicting treatment response (OBTX‐A: AUC 0.95; SNM: 0.88), the authors report.

“Our algorithms were extremely accurate in predicting treatment response to both modalities. In fact, they could correctly predict which patient was a responder and which patient was a non-responder about 90% of the time in patients they had never seen before,” says Dr. Werneburg.

Additionally, he explains, the algorithms generally outperformed human experts in prediction.

“At first glance, this was somewhat surprising, but we have to be careful with how we interpret this finding. The design of the study, which was the most optimal way to test the algorithms at this early stage, favored algorithms over humans. Essentially, we gave the algorithms the ‘home-field advantage’ here by asking the humans to predict based on spreadsheets of data,” he explains.

“And certainly that’s not how prediction is done in the clinical sense. So while both the algorithms and the humans have the same data to start with, the next step is to validate these results in the more natural clinical setting.”

Data from the ROSETTA study, a National Institute of Child Health and Development-sponsored trial and one of the most complete datasets in the field, was important for this type of analysis. The multicenter, open-label randomized trial included 381 women with refractory urgency incontinence across nine different U.S. centers to compare the two interventions. These findings were published in 

Sandip Vasavada, MD, an investigator on the ROSETTA trial and senior author of the study conducted with Dr. Werneburg, says the datasets generated by this work are valuable for a study like this.

“There isn’t anything at this scale that exists for this type of analysis, so we were pleased to be able to utilize this robust data for identification of these types of parameters in the context of machine learning,” he says.

The clinician-patient relationship is nuanced

Will this technology supplant patient counseling? Put simply, no, the physicians say.

“Many aspects of the physician-patient interaction are not computable. For example, a patient may have a particular treatment preference in mind; in other cases, a complex socioeconomic situation might preclude repeat office visits or certain other comorbidities that lead to shared decision between the patient and the urologist regarding an optimal treatment,” says Dr. Werneburg.

Ultimately, the physicians are hopeful that these algorithmic approaches will complement clinical expertise and judgment.

“At the end of the day, the patient decides their course of treatment with their physician. But in select patients, a machine learning approach might help guide patient decision-making, helping them make a more educated and informed decision about their care,” Dr. Vasavada concludes.

“Our algorithms were extremely accurate in predicting treatment response to both modalities. In fact, they could correctly predict which patient was a responder and which patient was a non-responder about 90% of the time in patients they had never seen before,” said Glenn Werneburg, MD, PhD. 

Study shows machine learning is predicting outcomes in overactive bladder

® is celebrating its 50th anniversary in 2022. To mark the occasion, we are high-lighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, 

 discusses high-intensity focused ultrasound (HIFU) for the treatment of prostate cancer. Linehan is an associate professor of urology and urologic oncology at the Saint John’s Cancer Institute in Santa Monica, California.

Please provide an overview of the development of high-intensity focused ultrasound (HIFU) for treatment of prostate cancer.

We know that prostate cancer breaks into 4 main groups: very low grade, low grade, intermediate ,and high grade. We found that many low-grade prostate cancers did not need to be treated and patients could go on active surveillance and didn't affect overall survival or affect quality of life. We started to look for ways to treat the cancer that were less invasive, but at the same time allow the patient to maintain as much of their quality of life as possible, as well as their continence and erectile function.

Focal therapies became the middle ground between active surveillance and more radical therapy like surgery or radiation. HIFU is able to ablate and treat the cancer without damaging the surrounding structures, and you can also do this through the rectum in a very effective manner without making any incisions on patients. You can do this in 1 treatment and retreat if needed. It also does not burn bridges if the patient needs radiation or surgery later. Multiple studies have shown its effectiveness over the past 10 years.

It became more and more of a clear option to use the technology to further the treatment of prostate cancer and provide options to patients who didn't want or could not have surgery or radiation.

Were there other focal therapies available at the time that you looked at HIFU?

Yes. Technically, there are 8 different energy sources you can use for focal therapy: HIFU, irreversible electroporation , cryotherapy, photodynamic therapy , focal laser ablation or laser interstitial thermotherapy, radiofrequency ablation, and focal brachytherapy.

Focal therapy with HIFU was attractive because, no. 1, there were fewer side effects for patients and the technology to use the energy modality was the most advanced and “surgeon friendly.” That's why it is such an attractive option for surgeons and for patients.

What are some of the other innovative treatments that have become popular in recent years?

There are other focal options that we’ve have explored for prostate cancer, like cryotherapy or brachytherapy, but a lot of the targeting is done through cognitive fusion, which can be difficult at times. You can treat the tumor inside the MRI, using MRI to target the lesion and delivering radiofrequency ablation or cryotherapy was another method but it often required the patient to actually be inside the MRI machine, which could take up to 4 hours.

The Tulsa procedure, like HIFU, uses ultrasound energy. The probe goes into the urethra and requires a cooling method for the urethra. We know that most cancers are in the peripheral prostate, so for me, it always made sense to treat transrectal. Focal One and HIFU have made it really easy to target and treat the lesion. I think for some patients, rectal access to the prostate cancer causes fewer symptoms like burning and dysuria.

What new innovations are on the horizon for treatment of prostate cancer?

The true innovation is finding better ways to do focal therapy that decreases the side effects for the patients and still treats the lesion effectively. I think that although active surveillance has been a great option for many patients, it does fail in some patients and many patients have anxiety with it. Some men don’t like the idea of just waiting and not doing anything about the cancer. So that's where focal therapy comes in.

With the Focal One, we have that ability to do the fusion of the MRI images and the ultrasound for guidance to the lesion. You know you're treating the specific area and the patient's going to get better results when you target in real time. To be very frank, I think the energy source is less important than the technology you use to deliver the energy source. That is the real innovation.

What would you say is HIFU’s legacy in the history of prostate cancer treatment and management?

HIFU’s legacy is that you're able to treat prostate cancer with minimal side effects to the patient in a way where you're able to distinctly target the lesion and not treat any other tissue that you don't want to treat or nerves or arteries or anything that's in the vicinity of the prostate that's going to affect the patient's overall urinary function or their erectile function. Urologists and doctors always worry about any transrectal therapies, and the small risk of creating fistula tracks or other issues in the rectal wall. The biggest benefit of HIFU is that the technology allows you to actually see where the rectal wall is and you can divert the energy so that it's not going to affect the rectal wall or surrounding tissues. HIFU has always been special in that it treats where you want and not where you don’t. I always recall talking to my surgical oncology friend, who uses it for liver cancer because you can literally treat tissue that is next to the vena cava or portal vein without injury.

"The true innovation is finding better ways to do focal therapy that decreases the side effects for the patients and still treats the lesion effectively," says Jennifer A. Linehan, MD.

An expert’s view on HIFU as an innovation in urology

In her new book, “Boundaries for Women Physicians: Love Your Life and Career in Medicine,” physician and author Tammie Chang, MD, writes about the challenges faced by female physicians and offers advice on how to overcome these obstacles. In a recent interview, Change discussed some of the key insights from her book.

What are some challenges female physicians face?

There are lots of challenges. I think one of the biggest ones is just the lack of support for women. For female physicians, there are very few accommodations. Typically, when women physicians are just coming out of training, they’re coming out during the peak childbearing years, when they’re trying to start a family. They’re trying to juggle a lot of things: the home, the families, the workplace. The jobs themselves have very demanding work schedules and call schedules, and there just really isn’t a supportive culture. There are also few women making it to leadership. The leadership funnel narrows very early in the career. Only about 50% of leaders within health care are women even though women actually make up more than 80% of health care workforce when you look at all different fields, not just women physicians. So they’re not becoming decision makers, they’re not getting a seat at that table to really make change that’s conducive and supportive of women in the workforce. I think there’s still a lot of gender bias that women struggle with. It’s becoming more and more open and talked about now, thankfully, in health care and in this industry, but it impacts the daily lives of women physicians, because they are viewed as leaders, even though they don’t realize that they are. There is a double standard when it comes to how women are viewed in the workforce compared to their male physician colleagues. There’s a much tougher standard.

What are some of the challenges you were facing when you decided to write your book?

I was severely burned out. I had taken on all the responsibility because that’s all I knew how to do. I was suicidal and had to take a leave of absence and almost quit practicing medicine. More than 70% of physicians are now experiencing moderate to severe levels of burnout at this stage in the pandemic. That rate is even higher in women physicians. But we don’t talk about it much, so that’s why I’ve written this book. I’ve essentially written everything that I wish someone had told me.

Do you have any favorite moments or conversations you’ve had with fellow female physicians?

I’m running a five-day mini book club right now. We were talking about how hard it is to set some basic boundaries and we watch our male colleagues at work, and they don’t seem to struggle at all. It doesn’t seem to faze them. And so then it brought up questions about why. Is it biology? Is it how we’ve been raised or nurtured or socialized? Is it how we were raised with kids? Or another way to think about it is maybe it is actually bothering them, but they’re not showing it. We don’t really know what they’re experiencing on the inside, and so maybe not just assume that it’s easy for them, maybe it’s hard, too.

Why is it so important that we support women physicians?

We’re finally at a place where 51% of med school students are women. However, 40% of women physicians are either quitting or going part time within six years of finishing training. That’s a problem. We’re not keeping them in the workforce. There is also data showing better patient outcomes (with women physicians) that include higher patient satisfaction scores and decreased morbidity and mortality. It’s so important for us to continue to push forward and make things more equitable because we want to make things better for the next generation.

One of the biggest issues today is the conversation surrounding the pay gap between male and female physicians. What do you think society can do to bridge that gap?

I think it’s huge that it’s hit big headlines recently. There are still a lot of people, even in medicine, who don’t believe it. I think awareness is the first piece, and then also getting people to recognize that it’s actually happening in their own system. There’s a 

 article that I shared and I got so much negative feedback from it. I had a few health care CEOs reach out to me say, “Oh, we don’t have that in our system.” And I’m like, “Yeah, I bet you do —you just haven’t looked.” It’s about being honest and having the humility to go, “Oh, maybe this is happening within my organization that I’m in charge of and who is responsible for these things?” Maybe it’s not happening, and that would be amazing, right? Then share that data widely. Make it one of your metrics that you’re trying to follow each year. It shouldn’t matter what the role is; it should be the same, regardless of gender. Doing that on a local level at home, in our own organizations and institutions — that’s huge.

What are some ways female physicians can support each other?

There’s an unspoken understanding and bond when we’re a group that’s struggled together. It’s finding each other wherever we’re working. I call it a “raft of otters.” Female otters band together in stormy seas and create a raft with their paws. That’s what I strive to do in my daily work as the medical director of provider wellness for my health care system to which is trying to create little pockets of rafts for every single person working for our system. I tell people to reach out and connect with just one person, because the reality is that the other person probably needs a friend, too.

This interview originally appeared on the site MedicalEconomics.com

“We’re finally at a place where 51% of med school students are women. However, 40% of women physicians are either quitting or going part time within 6 years of finishing training. That’s a problem,” says Chang. 

Dr. Tammie Chang discusses barriers and strategies for making medicine better for women

Let me take this opportunity to go around the horn for some closing and final thoughts. Larry, let’s start with you, and then we can go to Steven and then Michael, please.

First, thanks for including me in this exciting, stimulating discussion. But as a nuclear radiologist, I feel that PSMA [prostate-specific membrane antigen]-targeted imaging, and now we are talking about therapy, is a game changer, and that’s how I refer to it. It’s the most impactful breakthrough in the diagnostic imaging that I have seen in my career. We’re just beginning to realize the benefits on an imaging level, and then as a therapeutic agent. And theragnostics, we could spend another few tumor boards talking about theragnostics, but the implications are tremendous, and it’s just the tip of the iceberg. So thanks again, it’s a great time.

Let me echo that by saying it’s an absolute pleasure to be on this wonderful panel today, moderated by Neal. For me, it’s an incredibly exciting time to be a radiation oncologist who is interested in prostate cancer. When we look at the data that we talked about today from an imaging standpoint, it’s clear that next-generation imaging is going to continue to change the way we practice. As Neal alluded to, the VISION trial is a model system for showing how radiation drugs, radiotherapeutics, theragnostics, these words that we are talking about, drugs that can be given that have a radiation flavor that are tied to next-generation imaging, are going to be very important in the years to come. There are a lot of people watching this who are interested in this, but there are a lot of people I know out there who are not quite sure about where this is all going. All of the fancy imaging that we’re talking about is going to directly impact the way we take care of patients, all of us as urologists and radiation oncologists, and medical oncologists. I would encourage those who are watching today to get yourself educated because there is a lot of exciting work that is going to be coming down the pike.

Thank you Steven, and final thoughts, Mike.

Thank you. I want to echo the other panelists in thanking Dr Shore and 

® for organizing this evening’s tumor board. It has been fantastic participating with the other panelists. I would echo the comments of the earlier speakers about my excitement pertaining to PSMA-targeted imaging. I feel it has clearly made a substantial difference in our ability to risk stratify patients, determine the most appropriate therapies, and so forth, in particular in the initial staging evaluation in the biochemical recurrent space.

Clearly, some questions remain as we move into more advanced disease settings, and that evolves around, are we putting patients in the correct categories with respect to where different therapies have been approved? There are also questions surrounding the appropriateness of using metastasis-directed therapy with PSMA imaging and its role with following response to therapy. That’s really the 2.0 of PSMA-targeted imaging research, to figure out the answers to all those questions. It’s just the tip of the iceberg, especially with PSMA theragnostics now coming down the pipeline. We are going to see even more PSMA-targeted agents in the way of things like CAR [chimeric antigen receptor] T-cell therapy targeting PSMA, and so forth. It’s just the beginning of the story here and there is so much to learn, and it’s an amazing and exciting time to be a urologist.

Gentleman, thank you so much. Dr Steven Finkelstein, Dr Larry Saperstein, and Dr Michael Gorin, you guys are awesome. Thank you for all the preparation you did for this. Thank you for sharing your cases. Thank you for all the clinical trials, research, and education that you have done and continue to do.

To our viewing audience, it was a pleasure to have your attention and be part of 

® today. On behalf of all the faculty, we hope you found this to be valuable, especially the case presentations as well as the review of the data. I hope you can take a lot of this information from a practical standpoint back to the clinic. Like all of us, we are looking forward to additional studies. We have unmet needs and answers that we have to come up with, and that’s the exciting part for all of us being physician scientists.

Once again, gentlemen, thank you so much, and thank you everybody for listening.

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