Articles

Post-Operative Radiotherapy in Prostate Cancer – The State of the Data

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 4

Published January 2021

Contemporary treatment options for patients with clinically localized prostate cancer include radical prostatectomy, radiotherapy, and active surveillance. Surgery can be curative for approximately two-thirds of patients choosing radical prostatectomy.¹ However, men with adverse pathologic findings at the time of radical prostatectomy, such as the presence of positive surgical margins, extraprostatic extension, or seminal vesicle invasion,^2,3 experience up to a 60% risk of recurrence at 10 years and may require subsequent radiation therapy.²

The Evolving Landscape of First-Line Therapy for Metastatic Clear Cell Renal Cell Carcinoma

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 4

Published January 2021

When examined at a national level in the United States, cancers of the kidney and renal pelvis (despite different histology) are considered in aggregate and represent the sixth most common newly diagnosed tumors in men and eighth most common in women in the United States in 2020,¹ representing an estimated 73,750 new diagnoses and 14,830 deaths. The vast majority of these cancers will be renal parenchymal tumors with renal cell carcinoma (RCC) comprising the preponderance of these lesions. As previous UroToday Center of Excellence articles have highlighted, clear cell renal cell carcinoma (ccRCC) is the most common histologic subtype of renal cell carcinoma (RCC). Likely due to its much higher prevalence, the vast majority of systemic therapies for RCC have been investigated among patients with ccRCC. However, there have been important recent advances in treatment for patients with non-clear cell renal cell carcinomas (nccRCC) as well in recent years.

Despite ongoing stage migration as a result of widespread use of axial abdominal imaging for non-specific abdominal complaints,² a large proportion (up to 35%) of patients present with advanced disease, including metastases.³ Historically, metastatic RCC has been early uniformly fatal, with 10-year survival rates less than 5%.⁴ However, there has been a transformational change in this disease space over the past fifteen years and, with newer immunotherapy-based approaches, the potential for long-term cure is something that may be considered. Certainly, a significantly longer natural history is feasible given available therapeutic options.

Update on Low-Grade Upper Tract Urothelial Carcinoma

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 3

Published Date: October 2020

Upper tract urothelial carcinomas (UTUCs) are a heterogeneous group of malignancies arising from the urothelium at the level of the renal pelvis or ureter. They comprise 5% to 10% of all urothelial carcinomas and are diagnosed in approximately two per 100,000 persons in the United States annually, the majority of whom are adults older than 70 years.^1-3 A significant percentage of UTUCs are low-grade; these primarily papillary tumors are substantially less aggressive than high-grade UTUCs and demonstrate a low rate of cancer-specific mortality, but hematuria and urinary obstruction are common and require management.^{^4-6}

Non-muscle Invasive Bladder Cancer: Overcoming Diagnostic and Therapeutic Challenges

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 3

Published Date: October 2020

In 2020, approximately 81,000 cases of urothelial carcinoma of the bladder will be diagnosed in the United States, with nearly 18,000 associated deaths.¹ Bladder cancer disproportionally affects men and is associated with well-defined environmental risk factors—tobacco use underlies approximately 50% of cases.² Nonmuscle-invasive bladder cancer (NMIBC) is primarily managed by transurethral resection, risk-stratified use of intravesical chemotherapeutic or immunotherapeutic agents, and close surveillance.

What is Changing in Advanced Prostate Cancer?

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 2

Introduction

Prostate cancer, while commonly diagnosed in early forms, remains the second leading cause of cancer mortality in the United States and Europe.¹ For patients who die of prostate cancer, some will be initially diagnosed and treated for metastatic castration-sensitive disease (mCSPC) while others will progress through non-metastatic castration-resistant disease (nmCPRC) following initial local therapy followed by androgen deprivation therapy (ADT) for biochemical recurrence. In either case, nearly all men who die of prostate cancer will have metastatic castration-resistant disease (mCRPC) prior to death.

ARAMIS: Favorable Overall Survival and Safety Findings for Darolutamide in Nonmetastatic Castration-Resistant Prostate Cancer

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 2

Patients with non-metastatic castration-resistant prostate cancer (nmCRPC, formerly known as M0 CRPC) have rising prostate-specific antigen (PSA) levels despite castrate levels of testosterone with approved androgen deprivation therapy (ADT) and no detectable metastases on conventional imaging with computed tomography (CT) and bone scans.^¹

The Advanced Bladder Clinic: Are You Ready?

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 1

Published Date: March 2020

In 2015, cisplatin-ineligible patients with metastatic urothelial carcinoma could not be offered a first-line treatment option capable of prolonging their survival. Also, a paucity of second-line treatments resulted in these same patients usually surviving for only 3 to 6 months after progressing on platinum-treatment.

Percutaneous Renal Biopsy in the Ambulatory Surgery Center: A Primer

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 1

Published Date: March 2020

The earliest renal biopsies were obtained by open surgical techniques performed by urologists or transplant surgeons, or by pathologists at the time of autopsy. In 1951, physicians in Copenhagen published the first clinical report of percutaneous renal biopsy.¹ They placed patients in a seated position and used intravenous pyelogram (IVP) as the imaging guide. Not surprisingly, both the yield and quality of biopsy tissue samples were low by contemporary standards, with only about half to two-thirds of specimens permitting histologic examination.

UTI – Is Traditional Culture Testing Obsolete?

Published in Everyday Urology - Oncology Insights: Volume 5, Issue 1

Published Date: March 2020

Urinary tract infections are the most common type of bacterial infection,¹ accounting for at least 11 million physician office visits, 2 to 3 million emergency department visits, 400,000 hospitalizations, and approximately $2.3 billion in healthcare costs annually in the United States.^2,3,4,5

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

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

Published Date: December 2019

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

Published Date: December 2019

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

Published Date: December 2019

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).

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

Published Date: December 2019

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

Published Date: June 2019

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

Published Date: September 2019

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 castration-resistant 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

Published Date: September 2019

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

Published Date: June 2019

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

Published Date: March 2019

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

Published Date: March 2019

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.

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