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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

, discusses the need to increase diversity in clinical trials, specifically focusing on studies in prostate cancer. He also highlights the recent Northwestern-led course, “Enhancing Recruitment of Ethnic Minorities in Cancer Clinical Trials,” which took place on February 16, 2024. Murphy is a prostate cancer disparities researcher and a urologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

During the discussion, Murphy provides some advice for researchers looking to increase diversity in their trials. He also references a study in which 64% of Black patients indicated that they would be willing to discuss clinical trials in prostate cancer, compared with 82% of White patients.

 While there is a difference, Murphy notes that the percentage of more than half of Black patients being willing to discuss clinical trials is not insignificant, and the data supports the idea of clinicians continuing to make the ask to their patients in order to help increase diversity in prostate cancer trials.

Murphy ends the discussion by sharing some of his thoughts on future work building on the Northwestern-led course, such as a session focused on mock recruitments with patients who have previously enrolled in clinical trials.

Don’t forget to subscribe to Speaking of Urology® on 

, or anywhere that podcasts are available.

1. Senft N, Hamel LM, Manning MA, et al. Willingness to discuss clinical trials among Black vs White men with prostate cancer. 

. 2020;6(11):1773-1777. doi:10.1001/jamaoncol.2020.3697

In this podcast episode, Adam B. Murphy, MD, MBA, MSCI, discusses the need to increase diversity in clinical trials, specifically focusing on studies in prostate cancer.

Dr. Murphy on increasing diversity in cancer clinical trials 

On an episode of Cleveland Clinic’s Cancer Advances podcast, host Dale Shepard, MD, PhD, talked with Zeyad Schwen, MD, about the use of focal therapy to treat patients with localized prostate cancer.

Schwen, who is a urologic oncologist at Cleveland Clinic, covers these topics:

The difference between traditional treatments and focal therapies

Factors that make a patient a good candidate for focal therapy

Focal procedures, including Nanoknife, high-intensity focused ultrasound and cryotherapy

Clinical trials devoted to focal therapies

Zeyad Schwen, MD, a urologic oncologist at Cleveland Clinic, discusses how patient factors and cancer characteristics are key to deciding between focal therapies and whole gland treatment for prostate cancer. 

Dr. Schwen on focal therapies for prostate cancer

In this episode of Speaking of Urology®, 

, discuss precision medicine and the use of biomarker tests in prostate cancer screening and detection. Albala is the chief of urology at Crouse Hospital in Syracuse, New York, and Punnen is an associate professor of urologic oncology and an associate professor and vice chair of research at the Desai Sethi Urology Institute at the University of Miami in Florida.

This discussion originally took place during a live X (formerly Twitter) Spaces event held by Urology Times. In this exclusive interview, Albala and Punnen discussed the significance of advances such as liquid biopsies in prostate cancer, reviewed the current liquid biopsy tests available, and shared their own clinical experiences with the tests in their practice. They also highlighted data on the ExoDx prostate test from studies of clinical utility and validation studies.

Albala and Punnen ended their discussion by highlighting current education gaps surrounding the use of biomarker tests in practice and their predictions for the future of precision medicine.

In this episode, David M. Albala, MD, and Sanoj Punnen, MD, discuss precision medicine and the use of biomarker tests in prostate cancer screening and detection.

Speaking of Urology: Liquid biopsy in prostate cancer 

 (NCT04384770), which compared Magnetic Resonance Imaging-guided stereotactic body radiotherapy with Computed Tomography-guided stereotactic body radiotherapy in localized prostate cancer. Kishan is an associate professor of radiation oncology and urology and the chief of genitourinary oncology for radiation oncology at University of California, Los Angeles. 

Don’t forget to subscribe to Speaking of Urology

Amar Kishan, MD, highlights findings showing that MRI-guided SBRT is superior to CT-guided SBRT in localized prostate cancer.

Dr. Kishan highlights findings from the MIRAGE trial in prostate cancer

® spoke with Dr. Aaron Laviana, who discusses decisional regret in patients with prostate cancer. Laviana is an assistant professor of surgery and perioperative care and a courtesy faculty member of the department of oncology at The University of Texas at Austin Dell Medical School.

“Localized prostate cancer is a very complicated disease space,” says Aaron A. Laviana, MD, MBA.

Dr. Laviana on decisional regret after prostate cancer treatment

®Assistant Editor Janelle Hart spoke with 

. She discusses the findings of a recent 

 study, “Representation in Online Prostate Cancer Content Lacks Racial and Ethnic Diversity: Implications for Black and Latinx Men.” More specifically, she explains how these findings emphasize the need for content creators to focus more on equity, diversity, and inclusion when it comes to online medical literature. Loeb is a professor in the departments of urology and population health at the NYU Grossman School of Medicine in New York City, New York.

“The current landscape of online materials about prostate cancer is generally pretty bleak,” says Stacy Loeb, MD, PhD, MSc.

Study finds lack of Black and Latinx representation in online prostate cancer literature

® Assistant Editor Janelle Hart spoke with 

 She discusses the role that high-intensity focused ultrasound (HIFU) has played among other minimally invasive and robotic technologies to mitigate the side effects and complications of treatment for prostate cancer, compared toe other treatment options. Linehan is an associate professor of urology and urologic oncology at the John Wayne Cancer Institute in Santa Monica, California.

“It's really become the epicenter of all the surgeries that we do in urology,” says Jennifer Linehan, MD.

Emerging HIFU technology shows promise in men with prostate cancer

 He discusses how even though there are stigmas surrounding active surveillance, a lot of research actually suggests that this form of care is preferred in patients with prostate cancer. Therefore, he emphasizes that this treatment method should be counseled accordingly by clinicians. Ehdaie is a urologic surgeon at the Memorial Sloan Kettering Cancer Center, New York City, New York.

“It doesn't need to be surgery or radiation. Setting that stage, really focusing on those conversations, using the appropriate tools that we've grasped from behavioral psychologists that are being used by negotiation specialists, are critical in medicine,” says Behfar Ehdaie, MD, MPH.

Destigmatizing Urology: Dr. Ehdaie discusses active surveillance

. She discusses the benefits of plant-based diets given the promising findings of the prospective study, “Association of plant-based diet index with prostate cancer risk,” published recently in the 

. Loeb is a professor in the departments of urology and population health at the NYU Grossman School of Medicine, New York City, New York.

“We find that consuming more healthy, plant-based foods is associated with a lower risk of aggressive and lethal prostate cancer, and has many other health benefits, too,” says Stacy Loeb, MD, PhD, MSc.

Dr. Loeb on the association between plant-based diets and prostate cancer risk

 He discusses how his new technology, The PrecisionPoint Transperineal Access System, is used for detecting prostate cancer in patients. Matthew J. Allaway, MD, is the founder and president of Perinealogic and a urologist and managing partner at Urology Associates, Cumberland, Maryland.

“We need to do a better job sampling the prostate,” says Matthew J. Allaway, MD.

Dr. Allaway on the increased efficiency of transperineal biopsies

At the 24-month time point, patients who received apalutamide had a 23% reduction in the risk of death compared with patients who initiated enzalutamide. 

Apalutamide associated with improved 2-year survival vs enzalutamide in mCSPC

Demogeot discusses his team's GETUG 14 findings regarding early administration of ADT plus high-dose radiotherapy for intermediate to high risk prostate cancer.

Nicolas Demogeot, MD: Impact of GETUG 14 on early-stage prostate cancer care

Findings from GETUG 14 show short-term ADT with high-dose radiotherapy provided 5-year improved efficacy without increased risk of toxicity.

Short-term ADT plus radiotherapy improves disease-free survival in higher-risk prostate cancer

Data from the PARTIQoL trial show no significant difference in progression-free survival, bowel function, and other patient quality-of-life measures between PBT and IMRT.

PBT, IMRT provide similar patient-reported outcomes for prostate cancer at 5 years

A late-breaking abstract at ASTRO 2024 shows local therapy history does not significantly affect the risk of death in patients with mCRPC receiving an ARPI.

Prior local therapy does not impact mCRPC survival with ARPI treatment

Pastuszak discusses the evolving nature of understanding how testosterone therapy post-radiation for prostate cancer may beneficial or harmful to patients, and how to navigate the decision.

Alexander Pastuszak, MD, PhD: Is hormone therapy safe after prostate cancer radiotherapy?

American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting 

in Washington, DC, this week, Alexander Pastuszak, MD, PhD, assistant professor of surgery and urology in the department of surgery at The University of Utah School of Medicine, discussed the evolving understanding and clinical implications of testosterone therapy in patients with 

Though testosterone therapy has been historically marked for its increased risk of androgen-dependent tumors in patients, emerging data has shown its benefit in measures including bone density, cardiovascular health and overall patient quality of life.

“We know that it's optimized for insulin responses, for body habitus, for libido, and to some extent, energy levels, and then other aspects...such as better sleep and mental clarity—some of these symptoms that may not be fully and well defined, since the symptoms of hypogonadism are fairly nonspecific, but nevertheless, that you see improvements in men with when you give them testosterone,” Pastuszak said.

At the same time, patients face risks including erythrocytosis, increased estrogen levels, risk of infertility, liver damage, sleep apnea, and even prostate cancer.

“A big part of the reason that patients come and see doctors like me after or even before... surgery or radiation therapy for prostate cancer, is really to help them mitigate the negative outcomes, right?” Pastuszak said. “And it's a process of shared decision making. A lot of men are told what the negative side effects of their therapy are going to be before they undergo therapy, but if you query those men after therapy, a lot of them will not remember, right? And they'll come back and say, 'Wow, this is not what I expected,' or 'This is worse than I expected.'”

A proactive approach to planning testosterone therapy post-prostate cancer radiotherapy could include Pastuszak and colleagues helping to design a penile rehabilitation program for either before or right after treatment. Specialists can also help assure what effect the treatment should have on domains including sexual function and physical rehabilitation. Additionally, they can provide perspective on the evolution of understanding around radiotherapy that may address misconceptions borne from data now nearly a century old.

“A lot of the concerns that were raised with this initial study in 1941 by Huggins and Hodges have been, to a large extent, put to bed,” Pastuszak said. “The urological community has successfully treated men with low, intermediate and even high risk prostate cancer...with hormone therapy without necessarily seeing an increase in either prostate cancer incidence, recurrence or progression. And while that doesn't satisfy the question of, is hormone therapy safe in the context of these treated and/or untreated men, it does allay a lot of concerns.”

Pastuszak A. Testosterone Replacement Therapy (TRT) Following Radiation Treatment for Prostate Cancer: Are We Doing a Disservice or Providing a Benefit? Session presented at: American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting. Washington, DC. September 29 – October 2, 2024.

HUGGINS C, STEVENS RE, HODGES CV. STUDIES ON PROSTATIC CANCER: II. THE EFFECTS OF CASTRATION ON ADVANCED CARCINOMA OF THE PROSTATE GLAND. Arch Surg. 1941;43(2):209–223. doi:10.1001/archsurg.1941.01210140043004

Videos

News

Soumyajit Roy, MS, MBBS, explains how findings showing 5-year biochemical recurrence status may predict prostate cancer cure should alter the clinician-patient interaction.

Refining prostate cancer therapy strategy to address RAPTOR findings

The implication of patient natural history on 

r recurrence, distant metastasis and cancer-specific mortality is a highly influential, yet still lesser interpreted association. Follow-up post-treatment stages may be limited in the means by which a clinician can definitely state whether a patient has achieved cancer cure, or is at risk of recurrence.

But new data from a meta-analysis presented at the 

in Washington, DC, this week help provide better insights into prostate cancer patients’ risk of recurrence or odds of cured disease based on natural history. The findings from Soumyijat Roy, MS, MBBS, of the Rush University Medical Center, and colleagues showed that only 3% and 1% of patients who avoided biochemical recurrence within 5 years of prostate cancer radiotherapy experienced distant metastasis and cancer-specific mortality at 10 years, respectively. Additionally, patients who did experience 5-year biochemical recurrence were far more likely to experience 10-year distant metastasis (40%) and cancer-specific mortality (30%).

In the second segment of an interview with 

, Roy discussed further details of the meta-analysis, including an interpretation as to whether even patient treatment history for prostate cancer may influence this association—and therefore, patient likelihood of cured or recurred status.

“And we found this risk of distant metastasis after biochemical recurrence by 5 years or this risk of cancer specific mortality after biochemical recurrence by 5 years was not different among patients who were treated with various durations of (antigen deprivation therapy [ADT]), or even without ADT,” Roy said. “So, what I meant to say, in a little more clinical term, that we did not find any statistically significant evidence of heterogeneity in this association between biochemical recurrence by 5 years with relative incidence of subsequent cancer-specific events among patients treated with various doses of definitive radiation and/or various durations of ADT.”

Roy additionally discussed the prospect of using these findings to inform the prostate cancer treatment decision-making conversation with patients. While patients will frequently raise the question of opportunity to achieve cure versus recurrence with their therapy, Roy stressed these data show the “evolving” nature of those likelhoods.

“So, that is why having that landmark time point of 5 years, and telling patients that if you do not recur by 5 years biochemically or your PSA doesn't rise up, you will probably be declared cured—whereas, if your PSA rises by that time and you reach the threshold of biochemical failure by 5 years, there is a high risk that there will be subsequent events like distant metastasis or cancer-specific mortality,” Roy said. “So, we need to follow you more frequently, or maybe we need to monitor your PSA more frequently.”

Roy S, Romero T, Roach M, Michalski JM, et al. Natural History after Likely Cure vs. Recurrence vs. after ProsTate RadiOtheRapy (RAPTOR): A Pooled Analysis of More than 13000 Patients from 21 Randomized Controlled Trials. Poster presented at: American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting. Washington, DC. September 29 – October 2, 2024.

Kunzmann K. Soumyajit Roy, MS, MBBS: The effect of prostate cancer patient history in RAPTOR. 

. Published October 1, 2024. https://www.urologytimes.com/view/soumyajit-roy-ms-mbbs-the-effect-of-prostate-cancer-patient-history-in-raptor

Findings from RAPTOR suggest 5-year biochemical recurrence may be a good indication of prostate cancer cure status.

Soumyajit Roy, MS, MBBS: The effect of prostate cancer patient history in RAPTOR

Biochemical recurrence within 5 years of treating 

 with radiotherapy may be a key indicator for risk of distant metastasis and cancer-specific mortality, according to new findings from a pooled analysis.

A meta-analysis of 13,000-plus patients from 21 randomized, controlled trials presented at the 

American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting 

in Washington, DC, this week, showed that only 3% and 1% of patients who avoided biochemical recurrence within 5 years of prostate cancer radiotherapy experienced distant metastasis and cancer-specific mortality at 10 years, respectively—suggesting a curative progression with this trend.

However, the data also showed patients who did experience 5-year biochemical recurrence were far more likely to experience 10-year distant metastasis (40%) and cancer-specific mortality (30%)—trends consistent with aggressive prostate cancer. The findings may help to interpret the role of natural history of disease beyond the 5-year mark after radiotherapy for prostate cancer.

 during ASTRO 2024, study author Soumyijat Roy, MS, MBBS, of the Rush University Medical Center, discussed the impact of the findings—particularly at a time when clinicians may use 5-year prostate-specific antigen (PSA) blood tests as a barometer for prostate cancer cure status.

“Often at that time, the frequency of follow-up goes down,” Roy said. “Patients sometimes get lost to follow-up. So, what happens in those patients who are "cured" at 5 years, we don't know. And similarly...did something else happened to them? Did they grow the disease somewhere else other than prostate, or did they die from their prostate cancer? These are things which are very unclear.”

These new data could use 5-year biochemical recurrence status as a true barometer for that cured status, Roy said. However, there may need to be more extensive follow-up on these outcomes.

“We could categorically say that...our clinical presumption that if the patient doesn't recur by 5 years biochemically that patient is cured, is probably true,” Roy said. “Although, I would still say that 12 years might not be even the optimum follow-up. We need even longer follow-up, but hopefully future data will have more clarity. But so far, this is the best evidence talking about natural history of prostate cancer after likely cure versus recurrence.”

Clarke H. BCR within 5 years is prognostic for metastasis, prostate cancer-specific mortality. 

. Published October 1, 2024. https://www.urologytimes.com/view/bcr-within-5-years-is-prognostic-for-metastasis-prostate-cancer-specific-mortality

Patient-Centered Approach to Use of Chemotherapy in Metastatic Prostate Cancer

Video Content above is prompted by the following:

What are some challenges of therapeutic combinations that include chemotherapy?

Discuss the additional resources needed to use chemotherapy (eg, need for collaboration with a medical oncologist, access to an infusion center) and potential inconveniences for the patient (eg, additional clinic visits and laboratory monitoring).

The panelist discusses how incorporating chemotherapy into combination treatments for metastatic prostate cancer presents challenges such as increased resource requirements, the need for interdisciplinary collaboration, and potential inconveniences for patients, including more frequent clinic visits and laboratory monitoring.

Investigator Perspectives

Video Series

Therapeutic Combination Therapies for Metastatic Prostate Cancer

The above content is prompted by the following:

Discuss some therapeutic combinations for metastatic prostate cancer.

What is the general rationale for using combination therapy (eg, androgen receptor–targeted agent and/or an androgen deprivation therapy with docetaxel)?

How do disease volume and level of disease risk affect selection of therapy?

Fred Saad, CQ, MD, FRCS, FCAHS, discusses how combining therapies like androgen receptor–targeted agents, androgen deprivation therapy, and docetaxel can potentially improve outcomes for metastatic prostate cancer patients, with treatment selection influenced by factors such as disease volume and risk level.

Van As makes the case for clinical evidence supporting the priority of SBRT, describing its convenience and cost-effectiveness without compromising outcomes.

Nicholas van AS, MD, MBBCH: The case for SBRT as a standard of care for localized prostate cancer

Stereotactic body radiotherapy (SBRT) has become a highly prominent method of treating early-stage cancer through 1 – 5 sessions of application. 

 has shown it may even be optimized in combination with radiotherapy and antigen deprivation therapy (ADT) to improve progression-free survival while maintaining low risk of toxicity and function impact on men with 

As one prominent radiation oncologist recently attested, SBRT should possibly be considered the standard of care for localized prostate cancer.

Prostate Cancer

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