"We increasingly see the evolving role of ‘precision medicine’ in urology, using genetic and genomic testing to guide [management] for a variety of diseases, particularly bladder and prostate cancer," says 1 urologist.
“One item is the significant interest in ablation technology, a less invasive way of [managing] prostate cancer by using energy rather than our current gold standards—surgery and radiation.
Interest in ablation recognizes the importance of preserving quality of life. There are actually studies suggesting men are willing to give up quantity of life to preserve quality of life through reducing treatment [adverse] effects.
We’re incrementally seeing more good outcomes, but the main drawback is that ablation is not quite as effective as traditional treatments. Ablation leaves surrounding tissues and nerves in place, so it doesn’t have as much impact on urinary function. The impact on sexual function largely depends on the location of the cancer, so we can potentially target the cancer location with less damage than with surgery.
There’s less impact on quality of life, but also a risk of leaving cancer cells behind to recur.
Our failure rate is about 20%, so men who have repeat biopsies, which should be almost all men who have an ablation procedure, should be included in a registry. We’re tracking outcomes, biopsies, and quality of life.
It allows us to treat where cancer is located without having to treat the entire prostate yet feel comfortable that we are [managing] 80% or more of the cancer.”
Preston C. Sprenkle, MD
New Haven, Connecticut
“We increasingly see the evolving role of ‘precision medicine’ in urology, using genetic and genomic testing to guide [management] for a variety of diseases, particularly bladder and prostate cancer. Unfortunately, in our training, historically anybody who trained more than 10 years ago had virtually no training in genetics, genomics, and precision medicine.
Fortunately, today we’re introducing this evolving concept of precision medicine, not only to medical students but to our residents and fellows too. The benefit is being able to pick the best treatment and medications for the patient. It matches which patients are going to do best with treatment ‘A,’ who have certain genetic or genomic characteristics.
This is major for us. No longer do we just throw spaghetti against the wall and see what sticks. We try to identify the best treatment for patients with certain conditions. Today, most of it is in the area of oncology, but coming on very strong in precision medicine are ‘SNPs,’ single nucleotide polymorphisms. Those genetic tests are exploding across other areas such as responses to erectile dysfunction medications, overactive bladder medications, etc.
It’s a better way of diagnosing and treating patients because you can be very specific for patients’ individual conditions, which are often revealed by genomic/ genetic testing, not just give generic treatment to everybody.
A lot of urologists trained before 10 years ago. That could become a big problem, but several professional organizations are offering courses for [clinicians] to learn about this. Urologists have to go to the AUA and other meetings to learn about this.”
Leonard Gomella, MD, FACS
“One updated localized prostate guideline marks an increased awareness of the role of germline testing in patients who are diagnosed with aggressive or high-risk prostate cancer.
Historically, we would look for a family history of prostate cancer. Now we know that the genes altered in men that can increase the risk of prostate cancer and aggressive prostate cancer, those germline mutations are also seen in colon, pancreatic, ovarian, and lung cancers. We need to ask about other cancers in the family history.
It will affect how urologists practice in a couple ways. For patients who [don’t succeed on] treatments [for] localized disease, there are therapies directed at those mutations in those situations.
But there’s also a cascade effect because patients need to be counseled and their families need to be counseled—there’s about a 50% chance their relatives can carry the same mutation and could pass it on.
Again, it’s not just screening for prostate cancer, it’s screening for all those other baskets of cancers. If their children are at an age where they are at risk for developing these cancers, they need to be informed so they can decide whether they want to be tested earlier rather than waiting for something to occur.
Another new item concerns molecular imaging to stage high-risk men for metastatic disease. Guideline No. 7 gives the clinician the ability to use evidence-based molecular staging in patients, especially those with negative conventional imaging.
New PET scans are much more able to identify small volume metastases that we were never able to see before, so it adds complexity to [the disease] management, and treatments can be individualized.”
Michael S. Cookson, MD, MMHC
Oklahoma City, Oklahoma