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The prostate cancer section is a comprehensive resource for urology news and expert insights. Read more at Urology Times.

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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

, discusses the need to increase diversity in clinical trials, specifically focusing on studies in prostate cancer. He also highlights the recent Northwestern-led course, “Enhancing Recruitment of Ethnic Minorities in Cancer Clinical Trials,” which took place on February 16, 2024. Murphy is a prostate cancer disparities researcher and a urologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

During the discussion, Murphy provides some advice for researchers looking to increase diversity in their trials. He also references a study in which 64% of Black patients indicated that they would be willing to discuss clinical trials in prostate cancer, compared with 82% of White patients.

 While there is a difference, Murphy notes that the percentage of more than half of Black patients being willing to discuss clinical trials is not insignificant, and the data supports the idea of clinicians continuing to make the ask to their patients in order to help increase diversity in prostate cancer trials.

Murphy ends the discussion by sharing some of his thoughts on future work building on the Northwestern-led course, such as a session focused on mock recruitments with patients who have previously enrolled in clinical trials.

Don’t forget to subscribe to Speaking of Urology® on 

, or anywhere that podcasts are available.

1. Senft N, Hamel LM, Manning MA, et al. Willingness to discuss clinical trials among Black vs White men with prostate cancer. 

. 2020;6(11):1773-1777. doi:10.1001/jamaoncol.2020.3697

In this podcast episode, Adam B. Murphy, MD, MBA, MSCI, discusses the need to increase diversity in clinical trials, specifically focusing on studies in prostate cancer.

Dr. Murphy on increasing diversity in cancer clinical trials 

On an episode of Cleveland Clinic’s Cancer Advances podcast, host Dale Shepard, MD, PhD, talked with Zeyad Schwen, MD, about the use of focal therapy to treat patients with localized prostate cancer.

Schwen, who is a urologic oncologist at Cleveland Clinic, covers these topics:

The difference between traditional treatments and focal therapies

Factors that make a patient a good candidate for focal therapy

Focal procedures, including Nanoknife, high-intensity focused ultrasound and cryotherapy

Clinical trials devoted to focal therapies

Zeyad Schwen, MD, a urologic oncologist at Cleveland Clinic, discusses how patient factors and cancer characteristics are key to deciding between focal therapies and whole gland treatment for prostate cancer. 

Dr. Schwen on focal therapies for prostate cancer

In this episode of Speaking of Urology®, 

, discuss precision medicine and the use of biomarker tests in prostate cancer screening and detection. Albala is the chief of urology at Crouse Hospital in Syracuse, New York, and Punnen is an associate professor of urologic oncology and an associate professor and vice chair of research at the Desai Sethi Urology Institute at the University of Miami in Florida.

This discussion originally took place during a live X (formerly Twitter) Spaces event held by Urology Times. In this exclusive interview, Albala and Punnen discussed the significance of advances such as liquid biopsies in prostate cancer, reviewed the current liquid biopsy tests available, and shared their own clinical experiences with the tests in their practice. They also highlighted data on the ExoDx prostate test from studies of clinical utility and validation studies.

Albala and Punnen ended their discussion by highlighting current education gaps surrounding the use of biomarker tests in practice and their predictions for the future of precision medicine.

In this episode, David M. Albala, MD, and Sanoj Punnen, MD, discuss precision medicine and the use of biomarker tests in prostate cancer screening and detection.

Speaking of Urology: Liquid biopsy in prostate cancer 

 (NCT04384770), which compared Magnetic Resonance Imaging-guided stereotactic body radiotherapy with Computed Tomography-guided stereotactic body radiotherapy in localized prostate cancer. Kishan is an associate professor of radiation oncology and urology and the chief of genitourinary oncology for radiation oncology at University of California, Los Angeles. 

Don’t forget to subscribe to Speaking of Urology

Amar Kishan, MD, highlights findings showing that MRI-guided SBRT is superior to CT-guided SBRT in localized prostate cancer.

Dr. Kishan highlights findings from the MIRAGE trial in prostate cancer

® spoke with Dr. Aaron Laviana, who discusses decisional regret in patients with prostate cancer. Laviana is an assistant professor of surgery and perioperative care and a courtesy faculty member of the department of oncology at The University of Texas at Austin Dell Medical School.

“Localized prostate cancer is a very complicated disease space,” says Aaron A. Laviana, MD, MBA.

Dr. Laviana on decisional regret after prostate cancer treatment

®Assistant Editor Janelle Hart spoke with 

. She discusses the findings of a recent 

 study, “Representation in Online Prostate Cancer Content Lacks Racial and Ethnic Diversity: Implications for Black and Latinx Men.” More specifically, she explains how these findings emphasize the need for content creators to focus more on equity, diversity, and inclusion when it comes to online medical literature. Loeb is a professor in the departments of urology and population health at the NYU Grossman School of Medicine in New York City, New York.

“The current landscape of online materials about prostate cancer is generally pretty bleak,” says Stacy Loeb, MD, PhD, MSc.

Study finds lack of Black and Latinx representation in online prostate cancer literature

® Assistant Editor Janelle Hart spoke with 

 She discusses the role that high-intensity focused ultrasound (HIFU) has played among other minimally invasive and robotic technologies to mitigate the side effects and complications of treatment for prostate cancer, compared toe other treatment options. Linehan is an associate professor of urology and urologic oncology at the John Wayne Cancer Institute in Santa Monica, California.

“It's really become the epicenter of all the surgeries that we do in urology,” says Jennifer Linehan, MD.

Emerging HIFU technology shows promise in men with prostate cancer

 He discusses how even though there are stigmas surrounding active surveillance, a lot of research actually suggests that this form of care is preferred in patients with prostate cancer. Therefore, he emphasizes that this treatment method should be counseled accordingly by clinicians. Ehdaie is a urologic surgeon at the Memorial Sloan Kettering Cancer Center, New York City, New York.

“It doesn't need to be surgery or radiation. Setting that stage, really focusing on those conversations, using the appropriate tools that we've grasped from behavioral psychologists that are being used by negotiation specialists, are critical in medicine,” says Behfar Ehdaie, MD, MPH.

Destigmatizing Urology: Dr. Ehdaie discusses active surveillance

. She discusses the benefits of plant-based diets given the promising findings of the prospective study, “Association of plant-based diet index with prostate cancer risk,” published recently in the 

. Loeb is a professor in the departments of urology and population health at the NYU Grossman School of Medicine, New York City, New York.

“We find that consuming more healthy, plant-based foods is associated with a lower risk of aggressive and lethal prostate cancer, and has many other health benefits, too,” says Stacy Loeb, MD, PhD, MSc.

Dr. Loeb on the association between plant-based diets and prostate cancer risk

 He discusses how his new technology, The PrecisionPoint Transperineal Access System, is used for detecting prostate cancer in patients. Matthew J. Allaway, MD, is the founder and president of Perinealogic and a urologist and managing partner at Urology Associates, Cumberland, Maryland.

“We need to do a better job sampling the prostate,” says Matthew J. Allaway, MD.

Dr. Allaway on the increased efficiency of transperineal biopsies

New data from ESMO 2024 support an initial dose of Radium223 prior to chemotherapy among patients with mCRPC.

Radium223, chemotherapy improves mCRPC quality of life in phase 2 RAPSON

New findings from the open-label SPLASH trial show patients with mCRPC achieved improved progression-free survival as well as response rates and antigen-specific reductions.

SPLASH: 177Lu-PNT2002 achieves phase 3 outcomes for mCRPC

"The urgency to increase awareness about prostate cancer is underscored by our most recent data and analysis," says William L. Dahut, MD.

ACS launches National Prostate Cancer Roundtable to address increasing incidence

“Our study reveals potential differences in tolerance and effectiveness of AR inhibitors in practice, which can help clinicians and patients with treatment decisions," says Daniel J. George, MD. 

Darolutamide associated with more favorable tolerability vs other ARIs in nmCRPC

Olaparib plus abiraterone and prednisone or prednisolone was granted FDA approval in May 2023 for the treatment of adult patients with deleterious or suspected deleterious BRCA-mutated mCRPC.

FDA approves companion diagnostic for olaparib/abiraterone in BRCA+ mCRPC

Gerhardt Attard, MD, PhD, FRCP, highlights the background and key findings from the study, “Decipher mRNA score for prediction of survival benefit from docetaxel at start of androgen deprivation therapy (ADT) for advanced prostate cancer (PC): An ancillary study of the STAMPEDE docetaxel trials,” 

Gerhardt Attard, MD, on the interaction between Decipher score and docetaxel benefit

, highlights the background and key findings from the study, “Decipher mRNA score for prediction of survival benefit from docetaxel at start of androgen deprivation therapy (ADT) for advanced prostate cancer (PC): An ancillary study of the STAMPEDE docetaxel trials,” (NCT00268476) which was presented at the 

2024 European Society for Medical Oncology Annual Congress

 in Barcelona, Spain. Attard is a medical oncologist at University College London in the UK.

Patients with metastatic prostate cancer are now treated with intensified hormone treatment. So, they receive injections every 3 to 6 months, and then androgen receptor pathway inhibitors, and there are 4 or 5 that are used routinely. The outcomes for some are very good, and for some patients are not good. In fact, the natural history and prognosis is highly variable. As a community, we're looking at better ways to improve outcomes, and one way to achieve that, potentially, is docetaxel chemotherapy. We've never tested the question of randomizing patients receiving ADT and what we call an ARPI, androgen receptor pathway inhibitor, with docetaxel or no docetaxel, but many in the community believe docetaxel will improve patients' life expectancy. However, we also know with certainty that docetaxel impacts quality of life significantly within 16 months. But we've also shown in an analysis in STAMPEDE that after 18 months, that quality of life remains reduced. We have worked for about 7 or 8 years now to identify a predictive biomarker that identifies docetaxel-sensitive cancers. That could allow physicians to choose which patients would have intensified docetaxel chemotherapy and tilt the balance of benefits, or the balance in favor of potential benefits, outweighing the risks.

To do this, we have analyzed diagnostic tumor samples from just over 1500 patients who are randomized in 2 trials in the STAMPEDE platform protocol. Half of the patients were randomized ADT, ADT/abiraterone, and half were randomized––the hormone suppression is ADT––hormone suppression with or without docetaxel. Together with our partners at Veracyte, we generated expression values for all genes in the transcriptome. We then extracted a signature. In fact, we've extracted a number of signatures, and focused on 59. Before looking at the data we prespecified Decipher as a signature of interest for prediction of docetaxel effect. This is based on pilot data we generated in a training set in another trial called CHAARTED.

Today, we're presenting the results of this analysis, and we show that patients who have a high Decipher score derive significant benefit from docetaxel. The hazard ratio in that group is about 0.6. For patients in the low Decipher group, there's no evidence of benefit from docetaxel treatment; that hazard ratio is close to 1. We, probably for the first time, in the context of docetaxel chemotherapy, have a statistically significant interaction P value. What this means is that there is statistical certainty that the benefit of docetaxel differs by the Decipher test.

We currently are using metastatic volume, number of metastases on conventional scans, to make the decision on whether to treat someone with docetaxel or not. We show in an exploratory way that this greater effect with high Decipher is consistent regardless of metastatic volume. So, both in the high-volume patients and in the low-volume patients. The debate will now center on whether they should be implemented into clinical practice [over the] next week. Views will differ. Do we need to prospectively re-validate this in a large, randomized trial over the next 5 to 10 years, or can we use this data in isolation, potentially with other retrospective studies––and I've mentioned CHAARTED––to change our clinical practice? I think that's what we'll debate further over the next few weeks. My view is that this data is so strong we should be starting to act on it. But of course, there are nuances, and there are differences in access globally. There's a number of considerations to be made in that regard.

This transcription has been edited for clarity.

Videos

“Today, we're presenting the results of this analysis, and we show that patients who have a high Decipher score derive significant benefit from docetaxel,” says Gerhardt Attard, MD, PhD, FRCP.

Gerhardt Attard, MD, on the interaction between Decipher score and docetaxel benefit 

Dosing and Administration Considerations for Abiraterone Formulations   Access Challenges Regarding the Use of Abiraterone in Patients With mCRPC

How do you navigate these challenges to ensure patients receive optimal care?

How might the barriers differ between various health care settings (eg, rural vs urban, private vs public)?

Panelists discuss how to address the challenges in providing optimal care for mCRPC patients and how barriers may vary between different healthcare settings, such as rural vs. urban and private vs. public.

Video Series

Access Challenges Regarding the Use of Abiraterone in Patients With mCRPC

Dosing and Administration Considerations for Abiraterone Formulations

In your experience, what are the main differences in dosing and administration between the various formulations of abiraterone?

How do food-related effects influence the administration and efficacy of abiraterone treatments?

What strategies can be employed to manage these food-related effects to optimize patient outcomes?

Panelists discuss how the dosing and administration of different abiraterone formulations vary, how food-related effects impact treatment efficacy, and strategies to manage these effects for optimal patient outcomes.

Shyam Natarajan, PhD, discusses the practical implementation of AI-generated cancer maps in clinical settings. 

Dr. Shyam Natarajan on Unfold AI and prostate cancer

 discusses the practical implementation of AI-generated cancer maps in clinical settings. He is an author of the recent 

study, “Extracapsular extension risk assessment using an artificial intelligence prostate cancer mapping algorithm.” Natarajan is the founder and CEO of Avenda Health.

How do you envision the practical implementation of AI-generated cancer maps in clinical settings? What are the potential challenges and barriers to widespread adoption?

We see use of AI-generated cancer maps in the decision-making process of understanding who is the right patient for what therapy, as well as planning out the specific therapy, whether it's a whole-gland or a targeted therapy. The findings from the study that was just published could be indicative that Unfold AI may improve or help sort of that sub stratification of who could potentially get a nerve-sparing surgery vs a non-nerve-sparing surgery, or who is a better candidate for targeted therapy here. One of the key challenges or barriers that we're overcoming is that in order to run or develop this AI-generated map, the patient must receive a targeted prostate biopsy with an image-guided prostate fusion system. And while this technology is widespread, it's not universal. So we see this, especially with the issuance of new categories of codes for biopsy and fusion biopsy that are going to occur in the next couple of years, we're on the path to patients universally receiving the best-in-class diagnosis, and then we see AI adding on top of that to give patients a personalized decision-making platform and support paradigm.

"We see use of AI-generated cancer maps in the decision-making process of understanding who is the right patient for what therapy, as well as planning out the specific therapy," says Shyam Natarajan, PhD.

Biomarker Use in Patients on Active Surveillance

Video content above is prompted by the following question:

For patients on active surveillance, how do you use biomarkers?

The panel explores the role of biomarkers in monitoring disease progression for prostate cancer patients on active surveillance, discussing how these tests aid in detecting changes that may warrant intervention.

Viewpoints

Efficacy of Biomarker Test Results

How do you address the challenge of using biomarkers test results effectively?

The panel examines the challenges associated with effectively interpreting and applying biomarker test results in prostate cancer management and treatment decision-making.

Clinical Attributes of Patients Who Would Benefit From Micronized Abiraterone

In your opinion, what criteria should be considered when selecting the appropriate form of abiraterone for patients with mCRPC?

What are the potential benefits or drawbacks when using micronized abiraterone in specific patient populations (eg, those with comorbidities or differing levels of disease progression)?

Panelists discuss how criteria such as patient comorbidities, disease progression levels, and treatment goals should be considered when selecting the appropriate form of abiraterone for patients with mCRPC, and also explore the potential benefits and drawbacks of using micronized abiraterone in specific patient populations.

The Importance of Serum Testosterone Levels With the Use of Androgen Receptor-Targeting Therapies

To what extent do average serum testosterone levels guide selection between abiraterone formulations? 

STAAR study: Average serum testosterone levels≤0.1 ng/dL occurred in 25% of patients treated with micronized formulation vs 17% of patients receiving the originator formulation.

Panelists discuss how the STAAR study (Stein, 2018) indicates that the micronized abiraterone formulation results in lower average serum testosterone levels in 25% of patients compared to 17% with the originator formulation, potentially influencing treatment selection.

Dr Stencel discusses , “Stereotactic Body Radiation Adoption Impacts Prostate Cancer Treatment Patterns.”

Data point to disparities in receipt of SBRT for prostate cancer

 paper, “Stereotactic Body Radiation Adoption Impacts Prostate Cancer Treatment Patterns.” Stencel is a urologist with Charleston Area Medical Center in Charleston, West Virginia.

The study identified differences in treatment mix between SBRT and non-SBRT networks. How do you explain these differences, and what are the implications for patient outcomes?

The patients who received SBRT were more likely to be Caucasian. We observed that far fewer Black men were treated with SBRT in our cohort. And when we looked at the logarithmic regression model, the Black men were 43% less likely to receive SBRT, which I think goes in line with a little bit of what we know about prostate cancer treatment disparities, that mortality is worse for Black men in addition to stage at presentation. And so I think when we look at access to care and when we look specifically at access to SBRT, it looks like this group is at a particular disadvantage.

"The patients who received SBRT were more likely to be Caucasian. We observed that far fewer Black men were treated with SBRT in our cohort," says Michael Stencel, DO.

Influences and Challenges of Biomarkers on Treatment Selection

Please discuss different treatment approaches (e.g. surgery, radiation, hormone therapy) and how biomarkers may have influenced your choice.

What criteria do you use to decide between treatment options based on biomarker testing results?

What challenges and/or barriers have you encountered when selecting a biomarker?

Is there one that you use for a specific patient population?

The key opinion leaders explore various treatment approaches for prostate cancer, including surgery, radiation, and hormone therapy, explaining how biomarker results influence their treatment choices. They also detail the specific criteria they use to select between treatment options based on biomarker testing outcomes.

Experts on prostate cancer discuss current unmet needs in the therapeutic landscape and outline treatment considerations for patients receiving androgen deprivation therapy.

Prostate Cancer

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