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The Road Ahead for Prostate Cancer Disparity

Matt Cooperberg | November 17, 2020

The year 2020 will be remembered for many reasons, few of them good. But among the fires, floods, locusts, and other natural disasters, two tsunamis have swept the country and the world, unequaled in a generation. The first, of course, is the COVID-19 pandemic; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), the other is a groundswell of support for racial justice unequaled in breadth and impact since the civil rights movement over a half-century ago. Both have been met with breathtaking indifference and incompetence by a federal government whose three branches have been rendered virtually powerless by the small-minded machinations of a reactionary minority.

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Matthew R. Cooperberg, MD, MPH

Matthew R. Cooperberg, MD, MPH graduated from Dartmouth College, where he finished summa cum laude with a major in English. He earned his MD and MPH degrees at Yale University and completed residency in Urology and fellowship in Urologic Oncology at UCSF. At the end of his training, Dr. Cooperberg joined the faculty at UCSF, where he maintains busy clinical practices at the UCSF Helen Diller Family Comprehensive Cancer Center and the San Francisco VA Medical Center. He also holds a secondary appointment in the Department of Epidemiology & Biostatistics. He is actively engaged in research approaching the challenges of prostate cancer from many interrelated angles, from molecular analyses to health system-wide research. He has written or contributed to over 350 research articles. Early in 2013 Dr. Cooperberg co-authored a proposal for a national urology registry which served as the basis for the AUA Quality (AQUA) Registry, a project for which he now serves as Senior Physician Advisor. In 2015 he won the AUA Gold Cystoscope Award, and in 2016 was awarded his first R01 grant as Principal Investigator from the National Cancer Institute, to develop and validate novel miRNA-based biomarker signatures for refined prostate cancer prognosis. He lives in San Francisco with his wife, Jacqueline Dolev (a derm-atologist and fellow Yale Medical School alum), where they work primarily to keep up with their children, Jake and Sarah.

Videos
Clinical Conversations by Experts
The Impact of Decipher Biopsy Testing on Clinical Outcomes in Localized Prostate Cancer – Randy A. Vince Jr.
NCCN Guidelines 2022 - Prostate Cancer on Comparison of Treatment Options for Localized Disease + Local Therapies + Disease Monitoring - Zachary Klaassen and Chris Wallis
Treatment-Related Regret Among Men With Localized Prostate Cancer Journal Club - Christopher Wallis & Zachary Klaassen
High Risk Prostate Cancer and Genomics - Paul Nguyen & Alan Pollack
NCCN Prostate Cancer Clinical Practice Guidelines on Risk Stratification for Clinically Localized Prostate Cancer – Christopher Wallis & Zachary Klaassen
Improving the Quality of Care for Men in Michigan With Prostate Cancer, the MUSIC Collaborative, a Focus on the G-MINOR and G-MAJOR Trials – Todd Morgan
Personalized Hormone Therapy with Post-Operative Radiation Therapy and Validation of the Decipher Genomic Classifier in SAKK 09/10 Trial - Dan Spratt and Alan Dal Pra
When to Add ADT to Early or Late Salvage Radiation - Dan Spratt
Clinical Case Discussions - "Rising PSA 18 Months Post RP and Timing of Radiotherapy" - Ashley Ross, Alan Dal Pra, and Dan Spratt
Prostate Cancer Screening and Shared Decision Making in the Veterans Health Administration - Stacy Loeb
Validating the Genomic Classifier to Identify Patients With a High Risk of Metastasis Among African American Men With Early Localized Prostate Cancer, VANDAAM Study – Kosj Yamoah
PCORI-Funded Initiative Evidence Gaps To Guide Future Research on the Use of Active Surveillance for Prostate Cancer – M. Minhaj Siddiqu
Prognostic Utility of Decipher® Prostate Genomic Classifier in the SAKK 09/10 Phase III Trial - Alan Dal Pra
Prostate Cancer Modeling: The CISNET Prostate Group - Ruth Etzioni
The Decipher® Genomic Classifier for Recurrent Prostate Cancer in the NRG/RTOG 9601 Randomized Clinical Trial, Journal Club - Christopher Wallis & Zachary Klaassen
Genomics Guide Treatment Decisions in Post Prostatectomy Patients - Ashley Ross
A Systematic Review of the Decipher® Genomic Classifier in Prostate Cancer - Ashley Ross & Daniel Spratt
Timing of Radiotherapy After Radical Prostatectomy (RADICALS-RT) Journal Club - Zachary Klaassen and Christopher Wallis
The Accidental Journey of Shepherding PSMA PET Imaging in Prostate Cancer to the Clinic in the United States - Thomas Hope
Clinical Implications of the Study Findings from the Radiotherapy Adjuvant Versus Early Salvage ((TROG 08.03/ANZUP RAVES) Trial - Andrew Kneebone and Declan Murphy
(TROG 08.03/ANZUP RAVES) Phase 3 Trial on Adjuvant Radiotherapy Versus Early Salvage Radiotherapy Following Radical Prostatectomy Journal Club - Christopher Wallis & Zachary Klaassen
Prostate Active Surveillance Study (PASS) - Daniel Lin
How Can We Accelerate Clinical Trial Accrual in Localized Prostate Cancer? - Brian F. Chapin
An Expert Discussion on Gleason 6 (Grade Group 1) Prostate Cancer - Scott Eggener 
MRI Versus Ultrasound for Prostate Cancer - Samir Taneja
Active Surveillance for Low-Risk Prostate Cancer - Laurence Klotz and Peter Carroll
Data from the RTOG 9601 Study: Treating Prostate Cancer Patients with Low-Volume Disease - Daniel Spratt
Study of Baseline PSA Screening of Men (45 years old) - Peter Albers
Epidemiologic Outcomes of Prostate Cancer Patients Undergoing Active Surveillance - Sigrid Carlsson
Increasing Rates of Active Surveillance as the Standard of Care in Men with Low Risk Prostate Cancer- Matthew Cooperberg
Practice Patterns of Active Surveillance in Prostate Cancer - Matt Cooperberg
Active Surveillance: Recent Findings and Case Studies - Laurence Klotz
Long-Term Outcomes of Active Surveillance for Prostate Cancer - Interview with Sigrid Carlsson
The Men’s Eating and Living (MEAL) Study, Diet Intervention in Men on Active Surveillance for Prostate Cancer - Interview with J. Kellogg Parsons
Active Surveillance: Who is the Right Patient? - Matt Cooperberg
Physician-Scientist Commentaries
State of the Evidence Review Articles
Written by Udit Singhal, MD, and Randy A. Vince Jr., MD, MS
Genomic classifiers are used for prognostication and risk stratification in prostate cancer. Despite the emerging data, a commonly cited limitation is the retrospective datasets used for analysis. While there has been a litany of data using retrospective datasets to extrapolate the value of commercially available platforms in the pretreatment setting, the evaluation of these assays using prospectively collected data is still needed.
Written by Bishoy M. Faltas, MD
Englander Institute for Precision Medicine, Weill Cornell Medicine
Germline DNA damage repair (gDDR) alterations are common in men with prostate cancer (PCa). Men with PCa and gDDR alterations showed poor clinical outcomes. It is unclear if men with high-risk PCa and gDDR alterations would respond differently to neoadjuvant androgen
Physician-Scientist Review Articles
State of the Evidence Review Articles
Written by Christopher J.D. Wallis, MD, PhD, University of Toronto, Toronto, Ontario, Canada & Zachary Klaassen, MD, MSc, Medical College of Georgia, Augusta, Georgia, USA
December 8, 2021

Active Surveillance Background


Prostate cancer represents a public health dilemma: while prostate cancer is the second leading cause of death among men in the US1 and third in Canada,2 it is widely over-diagnosed and over-treated, leading to significant patient anxiety and morbidity.3 Much of the over-diagnosis of prostate cancer relates to the use of serum prostate-specific antigen (PSA) testing for prostate cancer screening, beginning in 1987.4
Written by David Crawford, MD
December 8, 2021

Over the nearly two years of navigating the COVID pandemic, urology practices were forced to increase their efficiency by focusing on streamlining patient visits without sacrificing care quality. However, postponed checkups were unavoidable as the public was encouraged to stay home. According to the Centers for Disease Control and Prevention (CDC), 40% of Americans in 2020 delayed or avoided medical care due to pandemic-related concerns. Although necessary, we are now facing the severe consequences of delayed diagnosis and prostate cancer seems to be leading the way.

November 8, 2021
In prostate pre- and post-biopsy decision making, more precision is urgently needed. Whereas expert imaging and biomarker-based risk scores already enable the clinician in this respect, the dilemma remains for those patients that are diagnosed with apparent indolent cancer. Additional diagnostic tools that (de)select patients for active surveillance (AS) would provide a great benefit for the patient.
Written by Neal D. Shore, MD, FACS, and Michael S. Cookson, MD, MMHC
October 12, 2020
The COVID-19 pandemic has resulted in numerous physical and psychological adjustments for clinicians, patients, and their families—wearing personal protective equipment, adopting telemedicine, adjusting clinic workflow, etc. The ensuing uncertainty and attendant anxiety from the fluidity of information and healthcare policy debate has augmented the need for enhanced communication
Written by Neal D. Shore, MD, FACS, and Michael S. Cookson, MD, MMHC
June 24, 2020
Despite the recent disruptions in health care delivery due to the COVID-19 pandemic, patients at risk for developing prostate cancer as well as those diagnosed with prostate cancer still deserve timely and optimal decision making.
Written by Zachary Klaassen, MD, MSc and Christopher J.D. Wallis, MD, PhD
April 20, 2020
Currently, there is a global pandemic surrounding the spread of betacoronavirus SARS-CoV-2 leading to Coronavirus Disease 2019 (COVID-19). The rapid spread to all corners of the globe has had tremendous health and economic implications, including the appropriate allocation of healthcare resources.
Written by Christopher J.D. Wallis, MD, PhD and Zachary Klaassen, MD, MSc
April 17, 2020
The rapid spread of Coronavirus Disease 2019 (COVID-19) throughout the world, caused by the betacoronavirus SARS-CoV-2, has had dramatic effects on health care systems with impacts far beyond the patients actually infected with COVID-19. Patients who manifest severe forms of COVID-19 requiring respiratory support typically require this for prolonged durations, with a mean of 13 days of respiratory support reported by the China Medical Treatment Expert Group for Covid-19.1
Written by Zachary Klaassen, MD, MSc and Christopher J.D. Wallis, MD, PhD
March 19, 2020
Radiographic imaging has played a key role in the diagnosis and staging of patients with prostate cancer for decades. Today, transrectal ultrasound and multiparametric magnetic resonance imaging are important in diagnosis and local staging of the primary tumor while axial imaging and molecularly targeted positron emission tomography
Conference Coverage
Conference Highlights Written by Physician-Scientist
Presented by Alan Dal Pra, MD

The 2021 ASTRO Meeting included a session on biomarkers and salvage radiotherapy and discussion by Dr. Alan Dal Pra regarding the performance of a genomic classifier within a phase 3 randomized trial of dose escalated salvage radiotherapy after radical prostatectomy.

Presented by Paul Nguyen, MD

The 2021 ASTRO Meeting included a session on biomarkers and salvage radiotherapy and discussion by Dr. Paul Nguyen regarding the validation of a 22-gene genomic classifier in the NRG Oncology/RTOG 9202, 9413, and 9902 phase III randomized trials.

Presented by Brian Baumann, MD

The 2021 ASTRO Meeting’s included a session on biomarkers and salvage radiotherapy and a discussant presentation of five presentations in this session by Dr. Brian Baumann. With regards to organizing these five presentations into clinical context, Dr. Baumann highlighted the SAKK 09/10 trial, a phase I trial of neoadjuvant stereotactic body radiotherapy, biomarker studies in high-risk intact disease include the genomic classifier analysis from three high-risk RTOG trials, and a PSMA PET-derived risk stratification tool.

Presented by Chris H. Bangma, MD, PhD
In this presentation, Dr. Chris Bagma, Professor of Urology at Erasmus MC, focused on anxiety and quality-of-life for men on active surveillance for prostate cancer. First, he started by reviewing active surveillance. Active surveillance (AS) is a treatment option for low-risk prostate cancer per the EAU and AUA guidelines. 
Presented by David Monty Berman, MD
In plenary abstract presentation at the 2021 ASCO GU, Dr. Berman and colleagues present their work which sought to create objective molecular biomarkers that would be resistant to sampling error and should be useful when applied to biopsy tissue, on the basis of radical prostatectomy grade.
In a plenary abstract presentation in the Poster Highlights Session: Prostate Cancer - Localized Disease session at the 2021 ASCO GU meeting, Dr. Fairmichael and colleagues presented results of the Stereotactic Prostate Radiotherapy (SPORT) trial, examining the feasibility of performing a randomized trial of SABR ± PNI.
Presented by Jim Hu, MD, MPH
(UroToday.com) The Society of Urologic Oncology (SUO) held a virtual meeting on Saturday, July 18, 2020, in place of the usual meeting held at the American Urological Association (AUA) annual meeting. This virtual meeting was divided into sessions on bladder cancer, kidney cancer, and prostate cancer. In the session on prostate cancer, Jim Hu, MD, MPH, discussed the Study of Prostate Ablation Related Energy Devices (SPARED) Collaboration.
Presented by Ivo Schoots, MD, PhD
San Francisco, CA  (UroToday.com)  Dr. Ivo Schoots from the Netherlands discussed the optimal use of multiparametric MRI in the management of localized prostate cancer.
Presented by Laurence H. Klotz, MD, FRCSC
Washington, DC (UroToday.com) The recipient of this year’s Huggins Medal is Dr. Laurence Klotz from the University of Toronto and Sunnybrook Medical Centre. Dr. Klotz has 470
Presented by Matthew R Cooperberg, MD, MPH, FACS
Washington, DC (UroToday.com) In the first prostate cancer session at the 2019 Society for Urologic Oncology meeting in Washington, DC, Dr. Matthew Cooperberg highlighted the similarities
Presented by Ganesh S. Palpattu, MD, FACS
Athens, Greece (Urotoday.com) In today’s medical environment of the growing number of patients, increasing complexity of patient problems, an ever-growing body of literature
Presented by Derya Tilki, MD
Athens, Greece (Urotoday.com) In this talk, Dr. Tilki reviewed several prognostic biomarkers in the setting of localized prostate cancer management. 
Presented by Andre Abreu, MD
Athens, Greece (UroToday.com) Cryoablation involves freezing of the targeted prostate tissue in two cycles, reaching minus 40 degrees Celsius, with the following histological changes:
Presented by Professor Christopher Parker
Barcelona, Spain (UroToday.com) Men who undergo surgery as definitive therapy for their localized prostate cancer generally only receive subsequent radiation therapy
Presented by Claire Vale, PhD
Barcelona, Spain (UroToday.com) There are three randomized trials, RADICALS,1 GETUG-AFU 17 and RAVES; recently presented at ASTRO 2019, that have compared adjuvant radiotherapy with a policy of salvage radiotherapy
Presented by Zachary Kornberg, Staff Research Associate
Chicago, IL (UroToday.com) Dr. Kornberg presented his talk on- A 17-gene Genomic Prostate Score as a Predictor of Adverse Pathology for Men on Active Surveillance. The Oncotype DX® Genomic Prostate Score (GPS) test is an RNA expression assay that can be performed on needle-core biopsies from men with prostate cancer (PCa).
Presented by Zachary Klaassen, MD, MSc
Barcelona, Spain (UroToday.com) At the Active Surveillance vs Focal Therapy in Prostate Cancer session at EAU 2019, Dr. Francesco Giganti and colleagues from the United Kingdom presented results of their use of the PRECISE recommendations and outcome of men on active surveillance for prostate cancer. 
Presented by Roderick van den Bergh, MD
Barcelona, Spain (UroToday.com) Dr. van den Bergh presented on the current and future role of active surveillance in prostate cancer. Approximately 350 studies on active surveillance have been published per year in the last 5 years. This therapeutic strategy has been incorporated into all major urological guidelines
Presented by Guan Hee Tan, Clinical Fellow
Barcelona, Spain (UroToday.com) Active Surveillance (AS) for prostate cancer (PCa) is the standard of care of men with low-risk PCa. However, approximately 30-40% of men on AS will eventually progress to treatment – either due to choice or due to progression. Progression can either be due to grade or volume progression
Presented by Monique J. Roobol, PhD., MSc
Prague, Czech Republic (UroToday.com) As part of the ESOU 2019 prostate cancer session there was a discussion regarding the appropriate treatment of Gleason 3+4 disease. Dr. Monique Roobol discussed the possible utilization of active surveillance for these patients.
Presented by Nicolas Mottet, MD, Ph.D
Prague, Czech Republic (UroToday.com) It is good news for both patients and physicians that there has been wider adoption of appropriate utilization of active surveillance (AS) among patients with prostate cancer. Dr. Nicolas Mottet presented risk stratification for active surveillance.
Presented by Laurence Klotz, MD, FRCSC
Toronto, Ontario (UroToday.com) Dr. Laurence Klotz presented on the current status of active surveillance for prostate cancer. Through the years there has been greater recognition of the overtreatment problem of prostate cancer patients, and the concept of active surveillance has been more accepted.
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