Genomics and other tools enhance precision of active surveillance in prostate cancer

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"All of our tools, including genomics and MRI, enable us to do a better job of risk stratifying [patients] to have a more appropriate shared decision-making discussion [about active surveillance]," explains David Morris, MD.

A panel discussion at the 2023 LUGPA Annual Meeting highlighted how genomics and other tools are allowing physicians to implement a more personalized approach with active surveillance for patients with low-risk prostate cancer. In an interview during the meeting, panel member David Morris, MD, FACS, a practicing urologist of the Advanced Therapeutics Center at Urology Associates of Nashville in Tennessee, discussed the key takeaway points from the exchange.

At the 2023 LUGPA Annual Meeting, you participated in a panel on best practices for active surveillance. What were some of the key points that came from that discussion?

"For more than intermediate-risk men, where their disease profile could fall either into the lower- or higher-risk categories, genomics can sometimes help nudge that risk one way or the other, and testing can make people feel more confident in the decision or can shift the direction of the discussion from surveillance to active treatment or vice versa," said David Morris, MD.

"For more than intermediate-risk men, where their disease profile could fall either into the lower- or higher-risk categories, genomics can sometimes help nudge that risk one way or the other, and testing can make people feel more confident in the decision or can shift the direction of the discussion from surveillance to active treatment or vice versa," said David Morris, MD.

The takeaway from the active surveillance [session] was that we have increased the utilization of active surveillance for low-risk men [when] appropriate. [Active surveillance] for intermediate-risk men is more of a shared decision making model about delaying therapy vs aggressive up-front treatment. All of our tools, including genomics and MRI, enable us to do a better job of risk stratifying [patients] to have a more appropriate shared decision-making discussion.

Looking at genomics, could you expand on how testing may help drive decisions regarding accuracy?

Most of the panel members felt that genomics [can] help. In the lowest-risk men, [genomics serve as] more of a confirmation to help with the comfort level of a patient and physician in accepting that their risk is low. [Genomic testing] puts this in a concrete manner. For more than intermediate-risk men, where their disease profile could fall either into the lower- or higher-risk categories, genomics can sometimes help nudge that risk one way or the other, and testing can make people feel more confident in the decision or can shift the direction of the discussion from surveillance to active treatment or vice versa.

What factors do you look for in patients undergoing active surveillance that may point to the need for further treatment?

Most of us use prostate-specific antigen [PSA] kinetics and PSA changes as a first-step metric to decide on some sort of confirmatory test, whether that be an MRI or a fresh MRI with a biopsy. It's rare for most of us to move directly to active treatment just based on PSA levels because the PSA can be driven by other factors, such as prostate size.

We did briefly touch on androgen receptor inhibitors being utilized for men with prostate cancer on active surveillance to try to minimize some of the noise of PSA changes. However, generally, most of us would use biopsy changes in grade or a significant change in MRI [to inform the decision] to move to active treatment.

You will also participated in a session on utilizing social media effectively in health care. What were some points discussed?

Although I am not a social media expert myself, as you can ask my two daughters in middle school and high school, I have enough social media experience to know that it can be dangerous, but it can also be very enriching in terms of education. I tend to use social media for professional education in terms of conferences that I can't attend and tracking what is presented at some of those global locations. It can be great for the professional educational side and sharing some of those best practices and new publications.

From a patient outreach and education [perspective], it's really about caution. Whatever you put out into social media is your face to the public, and you need to take some precautions that we're not oversharing patient information and that we're being very respectful.

It can be very dangerous if you move too far in one direction or another, whether it be politics or religion. They are things that become very nonprofessional, and you need to take caution [when drawing the line between] a professional or personal account. Patients can find us often on social media, whether we're intending [those accounts] to be patient facing or not.

You mentioned that you use social media to follow conference coverage. Could you expand on the benefits of this approach?

Things like Twitter have [allowed for clinicians to follow] conferences, and it has enabled us to form networks that are connected across large geographic areas. I have many people who are friends in the virtual world and are professionals in prostate cancer and bladder cancer that I don't physically interact with very often, but we can interact and share ideas through the internet.

I can virtually attend conferences that I'm not physically able to be at, just largely by following the streams of people who are in attendance. That's really changed the way that I'm able to absorb the scientific advancements. [Now, I’m] not waiting for journals to read the published articles; rather, I’m catching them 6 months before that when they're presented live, which enables you to be one step ahead of waiting for it to be published.

Are there any big stories in urology that you don't see covered or talked about on social media as much as they should be?

A lot of [stories] covered through social media are the ones that have the most financial support. Oncology may drive a lot of the attention because there's a lot of marketing dollars that are spent to drive eyeballs toward cancer therapies and testing. Often, some of the things that [more prevelant] in our practices, such benign prostatic hyperplasia, voiding dysfunctions, and urinary tract infections [UTIs], are not the sexy things that are on social media; however, honestly, [these are what affect] the majority of our patients.

Although I don't see a lot of social media directed toward recurrent UTIs, that's probably the biggest thing that most urologists deal with on an ongoing basis if they're not a cancer specialist. We need to ensure that we're paying attention to what is proportionately coming into our office, not just what has the most attention from the industry, which can sometimes drive some of the algorithms to get it in front of us. Therefore, sometimes you have to dive a little deeper to find stuff that's appropriate for the larger proportion of patients you're seeing.

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