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The age of tumor sequencing is here. Does it help? Earlier this year a paper in JAMA oncology permitted us to begin to ask that question aloud. Oncology has doubled down on the promise that cancer therapy decisions are going to be personalized. That promise has been made to the public, professorships have been established and whole

A meditation on the need and utility for Sip T in 2018. On a nearly weekly basis I am confronted by the question of whether I should be giving a patient Sipuleucel T. I still use it, but not in all my CRPC patients, and I like to think of this therapy as having a reasonable benefit for patients - who are at an early point in the CRPC spectrum. I will explain but first let’s review the data and its limitations.

My first book, The Virility Paradox,  came out in February. I have written about it before and an interview with me (by UCSD Urologist Kelly Parsons) has been posted elsewhere on UroToday. It has been a four-year project and, perhaps a bit melodramatically, I’ll use an overused word and call it a four-year ‘journey’. Here I want to focus on how that process changed me as a physician and affected my care of patients. Hopefully, there’s a lesson here for other clinicians and patients.
The ASCO Genitourinary Cancers Symposium for 2018 will feature the presentation of two-phase III studies of AR directed therapy in patients with non-metastatic CRPC. Before we get these results we can reflect on why these two studies were done in this patient population in the first place, and what exact clinical need is being addressed by the development of the studies in this space. 
If you treat mCRPC you need to know about mismatch repair. I don’t say this often, but it could be a matter of life or death. And that is not an exaggeration.

Ok, now that I have your attention, let’s talk about the science, the clinical care and the implications for the field.

But first, a brief case. Consider my patient Arnold (not his real name). He is a 68-year old man who underwent radical prostatectomy in 2011.
Late last November Bayer issued a press release notification of the premature halting of a study in which abiraterone and prednisone plus radium-223 was being compared to abiraterone and prednisone alone (ERA 223, NCT02043678). The announcement revealed that the study was being terminated early due to an imbalance in fractures and survival between the two arms – favoring the control arm
One of the biggest misconceptions in all of cancer care and oncology is the notion that a solid tumor ‘recurs’ after local therapy. If, as is often stated, ‘we got it all’ during surgery, then how can a cancer recur? The answer of course is that it was there all along. But that’s only the beginning of the story.
Cancer can limit one’s physical activity. Can physical activity limit one’s cancer? I’ve become a convert to thinking that it is possible that it can. I’m not convinced yet, but a few years ago I decided that it was worth my time and effort to study it. Compelling patient stories stick with us. I’ll never forget the story of a patient of mine who died several years ago. Let’s call him Dan.
Cell-free DNA analysis may improve the scalability of genomics for prostate cancer.  The management of CRPC has long been plagued by the inability of clinicians to get an accurate sense of the underlying biology of the tumor that they are treating. 
The flurry of media recently in reaction to Senator John McCain’s diagnosis of glioblastoma multiforme, a highly malignant brain tumor, touched right at the heart of where cancer fits in the American psyche:  That it is a battle to be won.
I write today not from the files of the Jimmy Buffet musical collection, nor from a Caribbean Margaritaville-esque cabana, as the reference might suggest (for the unfamiliar, I have been humming his song “Changes in Latitude, Changes in Attitude…for about 2 weeks now)  but rather as a dispatch on the latest development in clinical trials in prostate cancer.  The topic:  Data from the Latitude study that was presented at ASCO by Karim Fizazi and simultaneously published in the New England Journal of Medicine.
It is becoming increasingly well known that about 25% of CRPC tumors harbor some form of a mutation in BRCA1, 2, ATM or other such genes. Colin Pritchard and others have done some really excellent work on this topic by giving us genomic snapshots of the disease (you can see me interview him in St Gallen on this topic here on UroToday: link).1 The efficacy of Parp inhibitors in this setting is being tested in a number of trials at the moment. 
I have been struck in the past few weeks by the number of patients in my practice who have advanced metastatic CRPC who were diagnosed more than 15 years ago and had, on their original biopsy specimen, ONLY a Gleason 6 pattern prostate carcinoma.
Welcome to my blog on UroToday!  I am a genitourinary medical oncologist at the University of California – San Francisco and specialize in the management of advanced prostate cancer. I maintain a specific focus on androgen and androgen receptor (AR) interactions in the tumor as well as in the patient. The science of testosterone and prostate cancer have both exploded in the last decade, and one of my goals is to help navigate these findings through both a scientific and a patient oriented perspective. 
I have spent the better part of the last 20 years thinking about testosterone and the androgen receptor (AR) and its effect on prostate cancer. I started by applying synthetic testosterone to cancer cells in the laboratory at the University of Wisconsin, progressed to studying the effect of retained androgen receptor signaling in human prostate tumors at Memorial Sloan Kettering and finally studied the clinical effects of abiraterone, apalutamide, ketoconazole and other drugs as therapies for prostate cancer here at UCSF. One of the best pieces of career advice that I ever got was a very simple: Follow the AR.
In the last two weeks I’ve had one patient refuse ADT because of his history of depression, another who has been on ADT for 10 months asked me to refer him to a psychiatrist, and another, with CRPC who has been on ADT for 4 years, told me his depression is finally under control. This leaves a lot of issues to confront.

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