Choosing First-Line Treatment for Metastatic Castration-Resistant Prostate Cancer: APCCC Highlights

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 4

The choice of initial treatment for newly diagnosed metastatic castration-resistant prostate cancer (mCRPC) is far more complex than it was even a decade ago. Today, many patients with mCRPC have already received intensive upfront therapies during the hormone-sensitive stage— a “leftward” shift in treatment (based on the clinical states model we so frequently employ) which can spur a “rightward” shift in disease biology due to the earlier emergence of treatment-resistant clones.

Choosing First-Line Systemic Therapy for Newly Diagnosed Metastatic Hormone Sensitive Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 4

Metastatic hormone-sensitive prostate cancer (mHSPC) has become increasingly prevalent in the United States. Between 2009 and 2020, experts have projected a nearly 17% increase in the number of newly diagnosed mHSPC cases and a more than 18% increase in cases of mHSPC occurring after failure of local (curative-intent) treatment.1 This increase is likely multifactorial, reflecting changes in prostate-specific antigen (PSA) screening practices, the increased use of more sensitive imaging modalities, and other factors.2, 3

Controversies with PSMA-Based Imaging and Targeted Therapy

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 4

Prostate-specific membrane antigen (PSMA) is expressed 100 to 1,000 times more highly in prostatic adenocarcinoma than in benign prostate tissue, particularly in the setting of androgen deprivation.1 Around the world, we are seeing the rapid adoption of PSMA PET-CT/MRI, which is able to detect metastatic disease that is inapparent on conventional imaging (CT and bone scintigraphy). It remains unclear, however, if the earlier detection of asymptomatic metastatic disease improves clinical outcomes for patients. Various questions and controversies also surround the emerging field of PSMA-based targeted therapies.

A Review of Comprehensive Bone Health Management Strategies for Men with Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 4

Bone health is a critical area of unmet need among men with advanced prostate cancer. Age increases the risk for fragility fractures among both men and women, and older men with fragility fractures are at higher risk of subsequent death than are women.1-3 Systemic anti-androgen therapies for prostate cancer, while life-prolonging, accelerate bone loss by tipping the balance of bone homeostasis toward bone resorption, which further increases patients’ risk of fragility fractures.4

Monitoring and Managing Toxicities in Patients with Metastatic Hormone-Sensitive Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 4
A 65-year-old man presents with skeletal pain. His PSA is 101 ng per mL, computed tomography (CT) reveals pelvic lymphadenopathy, a 99mTc bone scan shows extensive bone metastases, and prostate biopsy cores are interpreted as Gleason score 9 with intraductal features. The patient starts long-term androgen-deprivation therapy (ADT) and completes five cycles of docetaxel. His pain resolves. His PSA declines but remains persistently elevated at 2.6 ng per mL, so the decision is made to add enzalutamide, a next-generation androgen receptor (AR)-targeted therapy, to ADT.

Genetic Evaluation of Hereditary Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 2
During much of the past 30 years, genetic tests for heritable disorders have assessed limited numbers of genes and have often employed serial testing algorithms in which the next test was determined by the results of the prior test.¹ The advent of next-generation (also known as massively parallel high-throughput) sequencing has transformed this picture by making it possible to sequence the entire human genome for less than $1,000.1,2

Darolutamide: Approved For Non-Metastatic Castration-Resistant Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 3

Androgen deprivation therapy (ADT) is the longstanding initial treatment for advanced hormone-sensitive prostate adenocarcinoma. Nonetheless, patients who are initiated on ADT will invariably progress by developing prostate cancer cellular clonal populations, which creates a phenotype of more castrationresistant disease with more aggressive biology.1

Preparing Your Practice for the New Era of Theranostics

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 3

Patients whose metastatic castration-resistant prostate cancer (mCRPC) has progressed on taxane chemotherapy and second-generation anti-androgen agents have few alternatives to palliative care. However, radiolabeled prostate-specific membrane antigen (PSMA) conjugates are now in latephase studies. In this article, I discuss theranostics, the phase 3 VISION trial, and the questions we will need to consider when PSMA-targeted radioligand therapies become available for use in our advanced prostate cancer clinics.

Optimizing Bone Health in Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 2
Summary

Protecting and improving bone health is critical when managing all stages of prostate cancer. Androgen deprivation therapy (ADT) accelerates bone resorption, which compromises bone mass and integrity starting early in treatment.1 Metastatic prostate cancer is associated with a marked increase in risk of skeletal events (fracture, spinal cord compression, and bone surgery or radiotherapy) associated with both bone metastases and treatment-induced bone loss.

Optimizing TURBT and Optical Diagnostics in Bladder Cancer

Published in Everyday Urology - Oncology Insights: Volume 4, Issue 1
The detection of recurrent tumor is a benchmark by which the success of intravesical agents is determined. Because the U.S. Food and Drug Administration (FDA) will now consider data from single-arm trials for patients with Bacillus Calmette-Guérin (BCG)-unresponsive bladder cancer, the complete response (CR) rates (i.e. absence of disease on biopsy) is a key factor that impacts the success of many registration studies.

Immuno-Oncology: The Urologist's Role

Published in Everyday Urology - Oncology Insights: Volume 4 Issue 1
This is an extraordinary time in urology. After decades of relative stagnation, patients with urothelial carcinoma are receiving approved immuno-oncologic drugs that significantly extend survival and are safer and more tolerable than chemotherapy.  The success of these treatments in metastatic bladder cancer has generated strong interest and promising early results for their use in localized disease.

Update on ADT in Advanced Prostate Cancer

Prostate cancer is the leading incident cancer among men, and population growth and aging have fueled a 40% rise in global case burden since 2006.1,2 Despite recent improvements in treatment, patients with locally advanced and advanced prostate cancer experience significant emotional distress, diminished quality of life, and increased risk of cancer-specific mortality.1,2,3

Practice-Changing Applications of Radiology and Nuclear Medicine in Genitourinary Malignancies

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 4
Experts at Harvard Business School first coined the term disruptive innovation to describe how small, poorly resourced companies could successfully challenge larger ones.1 More than two decades later, this concept is central in medicine, where innovations in everything from proteomics and wearables to electronic health records and health economics are upending our status quo.2,41

Nephrectomy in the Era of Targeted Therapy: Takeaways from the CARMENA Trial

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 3

A 62-year-old man presents with a one-week history of hematuria. Ultrasound and computed tomography identify a 7-cm exophytic anterior left renal tumor, adenopathy, and two
small lung nodules. No bone or central nervous system lesions are detected. His Eastern Cooperative Oncology Group (ECOG) performance-status (PS) and Memorial Sloan-Kettering Cancer Center (MSKCC) scores are 1. The patient asks whether to undergo cytoreductive nephrectomy. What do you tell him? 

Spacers and Prostate Radiation Therapy: What Urologists Should Know

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 4
Radiation has been used to treat prostate cancer since the early 1900s.¹ In recent decades, advances in radiation delivery systems and the advent of computed tomography and magnetic resonance imaging have spurred the development of targeted, high-dose radiotherapy techniques such as intensity-modulated radiotherapy (IMRT), image-guided radiation therapy (IGRT), stereotactic radiation therapies, proton beam

Blue Light Cystoscopy: Insights on Recurrence, Progression, and Clinical Management

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 3

More than 81,000 individuals are diagnosed with bladder cancer in the United States every year, of whom 75% have non-muscle invasive disease.1,2 Unfortunately, half these cases recur despite transurethral resection of bladder tumor (TURBT), and from 5% to 25% of repeated recurrences progress to muscle-invasive disease.3,4,5

Immuno-oncology for Bladder Cancer

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 2
Initial Considerations
From BCG to interferon gene therapy, physicians have treated bladder cancer with immunotherapy for decades. Treatment particulars generally depend on whether bladder cancer is non-muscle invasive, muscle-invasive, or metastatic. About 75% of patients have non-muscle invasive bladder cancer (NMIBC),1 which is considered high-risk if it consists of non-invasive papillary carcinoma (TaHG),

Imaging Controversies for Localized and Advanced Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 2
Imaging in prostate cancer (PC) remains a controversial topic that can be challenging to navigate. In this article, I focus on some of the best tools in our current armamentarium: multiparametric prostate magnetic resonance imaging (mpMRI) for local prostate cancer (PC) and positron emission tomography-computed tomography (PET/CT) for advanced disease. In research settings, these modalities often overlap, but here I take a more practical approach by focusing on the use of PET/CT for the detection of metastatic disease.

An Unmet Need is Met: (The PROSPER Study): Evaluating the Safety and Efficacy Study of Enzalutamide in Patients with Nonmetastatic Castration- Resistant Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 3, Issue 1
For men with non-metastatic, castration-resistant prostate cancer (nmCRPC), who are invariably at risk of metastasis, the PROSPER trial clearly demonstrated that combining enzalutamide to androgen-deprivation therapy (ADT) resulted in prolonging metastasis-free survival by a median of 22 months compared with ADT plus placebo

How I Manage First-Line Therapy for Advanced Kidney Cancer

Published in Everyday Urology - Oncology Insights: Volume 1, Issue 2
Urologists are primed to acquire the knowledge to use targeted agents and immuno-oncologic (IO) therapies for the treatment of advanced and metastatic renal cell carcinoma (RCC). Toxicities are manageable given appropriate patient/caregiver education, on-call and nursing support, and multi-disciplinary care with consulting specialists. 
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