AUA 2018: Journal of Urology: Top Papers in Prostate and Testis

San Francisco, CA ( Laurence Klotz, MD, the editor responsible for prostate and testis related papers at the Journal of Urology, highlighted some key JU publications in the past 12 months. He noted that there were 231 papers on prostate cancer and 11 papers on testis cancer, hence he focused primarily on prostate cancer.  The papers from the prostate cancer realm encompassed the shifting epidemiology of prostate cancer, active surveillance (AS), imaging, biomarkers, and focal therapy. Below, I highlight the papers he discussed, and if possible, include references to those papers.

He first highlighted the new AUA/ASTRO/SUO Guidelines1 for the management of localized prostate cancer, just published last month. He didn’t delve into the details, but recommend reading it.

Vasavada et al. (JU May 2018)2 – he highlighted this paper that found that inflammation (acute or chronic) on prostate biopsies was associated with lower risk of prostate cancer diagnosis. While reassuring, it does not delve into the “why.” Regardless, as a meta-analysis, it touched on the role of inflammation and prostate cancer.

Pishgar F et al. (JU May 2018)3 – this very interesting epidemiologic paper highlighted the growing incidence of prostate cancer worldwide, and that it was not limited to western countries (where increased diagnostics may have accounted for increased PCa diagnoses). There seems to be a real worldwide rise in prostate cancer. 

Bernstein A et al (JU Dec 2017)4 – this study, amongst others, highlights the early impact of the USPSTF recommendations against PCa screening in 2012. While incidence of localized PCa diagnosis has gone down, there has been a steady rise in the diagnosis of cN+ disease. There has not yet been an increase in diagnosis of metastatic disease, but this may not have had time to declare itself.

Halpern JA et al (April 2018)5 – in this study, the authors utilized the PLCO data to look at the clinical impact of DRE in the diagnosis of clinically significant PCa. They found that it only had a significant impact at PSA > 3 ng/mL, and did not recommend DRE in patients with lower PSA. 

Perlis N et al. (May 2018)6 – as MRI is being increasingly utilized in the management of AS patients, the authors of this study evaluated the impact of an additional PCA3 test. In doing so, they found patients who were negative on MRI and PCA3 testing represented a small subset of patients that may safely forego biopsy – NPV was 100%. This represents the future as adjunct tests may help increase the utility of mpMRI.

Hassan O et al. (JU Nov 2017)7 – the recurrence question of whether Gleason 3+3=6 (GG1) disease should still be considered cancer. Epstein’s group found that 4% had focal EPE and 2.4% had nonfocal EPE. While there is no metastatic disease, local invasion means this should still be considered cancer.

Aghazadeh MA (JU May 2018)8 and Gearman DJ et al. (JU May 2018)9 – Yet another two papers in a series of studies that have continued to demonstrate the need for caution in patients with Gleason pattern 4 disease (GG2 or favorable intermediate risk disease) when considering AS. Worse adverse pathologic featues at the time of RP and faster time to biochemical recurrence noted.

Klein EA et al. (JU Jan 2017)10 – Decipher, a genomic test, was able to discriminate amongst patients with Gleason 3+3=6 disease on biopsy – 13% of these patients had intermediate Decipher score and 7% had a high Decipher score. This was correlated to adverse pathologic features at RP.

He lastly, very briefly, touched on the growing HIFU / focal therapy literature – citing the Ganzer et al.11 Phase II multicenter trial – but noted that short term follow-up still limits their discussion as equal alternatives to definitive therapy.

Presented by: Laurence Klotz, MD, FRCSC, CM University of Toronto

1. Sanda M et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part II: Recommended Approaches and Details of Specific Care Options. J Urol. 2018 Apr;199(4):990-997. doi: 10.1016/j.juro.2018.01.002. Epub 2018 Jan 10.
2. Vasavada SR et al. Inflammation on Prostate Needle Biopsy is Associated with Lower Prostate Cancer Risk: A Meta-Analysis. J Urol. 2018 May;199(5):1174-1181. doi: 10.1016/j.juro.2017.11.120. Epub 2017 Dec 12.
3. Pishgar F et al. Global, Regional and National Burden of Prostate Cancer, 1990 to 2015: Results from the Global Burden of Disease Study 2015. J Urol. 2018 May;199(5):1224-1232. doi: 10.1016/j.juro.2017.10.044. Epub 2017 Nov 9
4. Bernstein AN, Shoag JE, Golan R, Halpern JA, Schaeffer EM, Hsu WC, Nguyen PL, Sedrakyan A, Chen RC, Eggener SE, Hu JC. Contemporary Incidence and Outcomes of Prostate Cancer Lymph Node Metastases. J Urol. 2017 Dec 26. pii: S0022-5347(17)78181-5. doi: 10.1016/j.juro.2017.12.048. [Epub ahead of print]
5. Halpern JA, Oromendia C, Shoag JE, Mittal S, Cosiano MF, Ballman KV, Vickers AJ, Hu JC. Use of Digital Rectal Examination as an Adjunct to Prostate Specific Antigen in the Detection of Clinically Significant Prostate Cancer. J Urol. 2018 Apr;199(4):947-953. doi: 10.1016/j.juro.2017.10.021. Epub 2017 Oct 20.
6. Perlis N, Al-Kasab T, Ahmad A, Goldberg E, Fadak K, Sayid R, Finelli A, Kulkarni G, Hamilton R, Zlotta A, Ghai S, Fleshner N. Defining a Cohort that May Not Require Repeat Prostate Biopsy Based on PCA3 Score and Magnetic Resonance Imaging: The Dual Negative Effect. J Urol. 2018 May;199(5):1182-1187. doi: 10.1016/j.juro.2017.11.074. Epub 2017 Nov 23.
7. Hassan O, Han M, Zhou A, Paulk A, Sun Y, Al-Harbi A, Alrajjal A, Baptista Dos Santos F, Epstein JI. Incidence of Extraprostatic Extension at Radical Prostatectomy with Pure Gleason Score 3 + 3 = 6 (Grade Group 1) Cancer: Implications for Whether Gleason Score 6 Prostate Cancer Should be Renamed "Not Cancer" and for Selection Criteria for Active Surveillance. J Urol. 2017 Nov 15. pii: S0022-5347(17)77915-3. doi: 10.1016/j.juro.2017.11.067. [Epub ahead of print] 
8. Aghazadeh MA, Frankel J, Belanger M, McLaughlin T, Tortora J, Staff I, Wagner JR. National Comprehensive Cancer Network® Favorable Intermediate Risk Prostate Cancer-Is Active Surveillance Appropriate? J Urol. 2018 May;199(5):1196-1201. doi: 10.1016/j.juro.2017.12.049. Epub 2017 Dec 26.
9. Gearman DJ1 et al. Comparison of Pathological and Oncologic Outcomes of Favorable Risk Gleason Score 3 + 4 and Low Risk Gleason Score 6 Prostate Cancer: Considerations for Active Surveillance. J Urol. 2018 May;199(5):1188-1195. doi: 10.1016/j.juro.2017.11.116. Epub 2017 Dec 7.
10. Klein EA, Santiago-Jiménez M, Yousefi K, Robbins BA, Schaeffer EM, Trock BJ, Tosoian J, Haddad Z, Ra S, Karnes RJ, Jenkins RB, Cheville JC, Den RB, Dicker AP, Davicioni E, Freedland SJ, Ross AE. Molecular Analysis of Low Grade Prostate Cancer Using a Genomic Classifier of Metastatic Potential. J Urol. 2017 Jan;197(1):122-128. doi: 10.1016/j.juro.2016.08.091. Epub 2016 Aug 26.
11. Ganzer R et al. Prospective Multicenter Phase II Study on Focal Therapy (Hemiablation) of the Prostate with High Intensity Focused Ultrasound. J Urol. 2018 Apr;199(4):983-989. doi: 10.1016/j.juro.2017.10.033. Epub 2017 Oct 26.

Written by:  Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, | twitter: @tchandra_uromd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA