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Clinical Focus

Oncology Decoded Live! Revolutionizing GU Cancer Care: Applying Cutting-Edge Evidence to Practice

, 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

“MPS2 could potentially improve the health of our patients by avoiding overdiagnosis and overtreatment and allowing us to focus on those who are most likely to have aggressive cancers," says Ganesh S. Palapattu, MD, FACS. 

MPS2 test validated for detection of high-grade prostate cancer in non-DRE urine

Overall, the open-label phase 1/2 study is assessing the safety and anti-tumor activity with INKmune across 3 dose levels. 

Trial of immune therapy in mCRPC expands enrollment to VA medical center

According to the authors, these findings highlight the need to more effectively include Black men in prostate cancer research. 

Black men cite lack of invitation, information as key barriers to prostate cancer trials

“The key here is I don’t believe that testosterone increases the risk of prostate cancer progression or biochemical recurrence," says Mohit Khera, MD, MBA, MPH.

Testosterone therapy and prostate cancer: Risk-benefit and individualized treatment

Overall, 39% of those who received a university-formatted report and 56% of those who received a VA-formatted report were able to identify that they had prostate cancer. 

Standard pathology reports may be difficult to understand for patients with prostate cancer 

Channing J. Paller, MD, discusses vitamin C’s role in prostate cancer management

Channing J. Paller, MD, on vitamin C and prostate cancer

discusses vitamin C’s role in prostate cancer management. She is the senior author of the recent 

paper, “Harnessing nature's therapeutic potential: A review of natural products in prostate cancer management.” Paller is an associate professor of oncology at the Johns Hopkins University School of Medicine, director of Prostate Cancer Clinical Research, and associate director of oncology, Johns Hopkins Clinical Research Network, Baltimore, Maryland.

What are the most promising natural products with the strongest preclinical evidence for their potential anticancer effects?

There are so many, it's hard to pick. This review looked at vitamin C, curcumin, lycopene, green tea, soy isoflavones. If I had to pick one, I'd pick vitamin C. That has a fun story. It was studied many, many years ago by Linus Pauling to figure out about scurvy, and he also studied it in cancer. What he figured out was, if he gave it intravenously, it prolonged the survival of cancer patients compared to not giving it. Later, it was studied orally by Mayo, and unfortunately, that study was negative. But what one scientist, Mark Levine [MD], figured out was that if you take it orally, it is an antioxidant. You can only absorb so much of it in your intestines, but if you take it intravenously at higher doses, you can get to super high levels that become an oxidant and have a different mechanism of action. So what we've seen pre clinically is that ascorbic acid has an ability to induce oxidative stress in cancer cells selectively and not in our normal cells, unless you have something called G6PD deficiency, which not that many people have. So this study that I just finished, in [patients with] metastatic castrate-resistant prostate cancer who were eligible for docetaxel chemotherapy, we gave them placebo with their chemotherapy, or ascorbic acid, and it was actually negative. And this is the second trial that was negative. The first trial was just once-a-week ascorbic acid, and it was also negative. And this was at high doses intravenously, a couple times a week with my trial. So what we noticed was there was not an improvement in overall survival, there was not an improvement in progression-free survival or any difference in PSA response. What we're wondering, though, is a few patients more in the vitamin C group did have more PSA responses, but it was not significant. The reason I point that out is before I write off all of vitamin C for prostate cancer, I want to point out there was another study just published around the same time in pancreas cancer that was positive. So adding ascorbic acid intravenously to chemotherapy improved their survival. It was so positive, the data safety monitoring board shut down their trial to close it because so many patients were benefiting. So what I'm telling you here is, I think we're learning slowly—I hope faster—how to use these agents as any other drug that a pharmaceutical company would study. So our first agents, like Taxol, came from natural products. And so we are figuring out, even though you can't patent these natural products, some of them have really incredible activity.

This transcript was AI generated and edited by human editors for clarity.

Videos

"I think we're learning slowly—I hope faster—how to use these agents as any other drug that a pharmaceutical company would study," says Channing J. Paller, MD.

Vanita Gaglani, RPT, gives an overview of her clinic and discusses the importance of seeing a pelvic floor physical therapist prior to undergoing radical prostatectomy

Physical therapist discusses her work in men undergoing prostatectomy

gives an overview of her clinic and discusses the importance of seeing a pelvic floor physical therapist prior to undergoing radical prostatectomy. Gaglani is a registered physical therapist and owner of Vanita’s Rehab in Melbourne, Florida. She was interviewed during the Desai Sethi Urology Institute Urology on the Beach meeting in Miami Beach, Florida.

Please provide an overview of your clinic.

Basically, my whole practice is focused on the pelvic floor, the bowel, and the bladder, but 99% is men who have had a radical prostatectomy. My main focus in my practice is to get them dry and back to their normal life without using pads or Depends or going to the bathroom. I use a multi-pronged approach. I focus on behavior modification, nutrition, hydration, and exercise. Exercise is not just Kegels; there are about 24 other exercises that all are required to make a man dry.

Why is it important to see a pelvic floor physical therapist prior to prostate surgery?

It is important to go to a therapist before surgery for several reasons. One is to know what causes bladder [aggravation], so that when you go for surgery, you are already prepared [so] that your bladder does not go into spasms, and you leak more. Second is what to eat, what to drink, what precautions to follow. The reasons the precautions are important is because [there are 5] cuts on the belly, and a person feels perfectly all right, but the pelvic floor is not healed, and it is a challenge for men not to go out and do activities like canoeing or yard work or golf, and then also having them do exercises in a correct manner. Kegels are great, but they are really geared toward women. And if men do similar Kegels, instead of getting dry, they'll start [having] more leakage. The reason being, [some] women have had children, and the pelvic floor is stretched out, and it needs to be hypertrophied and brought back in position, because the elasticity of the pelvic floor is lost. Men did not have children, so the pelvic floor needs to learn how to work with the bladder. It's a totally different concept. It is like a tendon transplant. When you move 1 tendon to another body, you have to first learn how to work it before you start pushing it or doing strenuous activity with it. So Kegels, in the end, will be more challenging, but initially they have to be started on a slow pace, and then slowly the endurance of the pelvic floor has to be picked up.

"I use a multi-pronged approach. I focus on behavior modification, nutrition, hydration, and exercise," says Vanita Gaglani, RPT.

Channing J. Paller, MD, gives an overview of the recent Urologic Oncology paper, “Harnessing nature's therapeutic potential: A review of natural products in prostate cancer management.”

Investigators look at natural products for prostate cancer

Please provide an overview of this study and its notable findings.

This study provides a comprehensive review of the role of natural products as complementary treatments for prostate cancer. What we really focus on is their mechanisms and clinical efficacy. There's been a lot of preclinical research with encouraging results. However, the use of natural products in prostate cancer clinical trials has not come to have the same positive results, unfortunately. And so the use of natural products in prostate cancer treatment still remains controversial. This review stresses the need for high-quality, rigorous evidence of adequately powered trials to validate the therapeutic potential and safety of these natural products in cancer care, and proposes future directions for optimizing therapeutic potential.

"This study provides a comprehensive review of the role of natural products as complementary treatments for prostate cancer," says Channing J. Paller, MD.

Jaspreet S. Sandhu, MD, summarizes his talk from the Desai Sethi Urology Institute Urology on the Beach meeting titled “Updates in Management of Male SUI” 

Jaspreet S. Sandhu, MD, on post-prostatectomy incontinence

summarizes his talk from the Desai Sethi Urology Institute Urology on the Beach meeting titled “Updates in Management of Male SUI” and discusses the psychological impact of urinary incontinence in men who have undergone radical prostatectomy. Sandhu is an attending surgeon at Memorial Sloan Kettering Cancer Center in New York, New York.

Please share some highlights from your Desai Sethi Urology Institute Urology on the Beach talk "Updates in Management of Male SUI."

I was asked to give a talk on updates and management of male stress urinary incontinence, which I did, and luckily, the AUA helped me out, because they had an amendment to our recent guideline on incontinence after prostate treatment. So it was basically going over evaluation, management, primarily focusing on new things, and pretty straightforward actually, because all the guidelines are available at auanet.org So anybody who wants to find out what I did can go there and just pretty much download everything.

How do you address the psychological impact of post-prostatectomy incontinence on patients, such as anxiety, depression, and social isolation?

That's a very good question. We actually don't have formal mental health folks that help us, unlike sexual medicine, where they do have formal psychiatrists and psychologists that work with them. But men, it has been shown over and over again that urinary incontinence is associated with depression, not exercising—patients actually have weight gain. They're isolated. That's actually very well documented. When I have patients come in, they've gained 10 to 20 pounds because they haven't been to gym recently. Part of the reason they haven't been the gym recently is because they leak a lot. You can help them and tell them, "If we can get your leakage or urinary incontinence better, there's a pretty good chance you'll get your life back." And in fact, once we do procedures—and by procedures I mean generally minor surgical procedures: slings, sphincters, balloons are the 3 that we talked about this morning—when they have those procedures, most of the patients afterwards think their life has changed. In fact, I have letters from patients saying, "you actually renewed my faith in the medical system because you helped me out so much." So if you can do this surgery well, patients actually go back to living a normal life, and they're immensely, immensely happy.

"If you can do this surgery well, patients actually go back to living a normal life, and they're immensely, immensely happy," says Jaspreet S. Sandhu, MD.

Jindan Yu, MD, PhD, discusses ongoing prostate cancer research projects at Emory University.

Jindan Yu, MD, highlights ongoing prostate cancer research projects 

, discusses ongoing research projects at Emory University. Yu is the Fray F. Marshall Chair in biomedical urologic research, professor, and vice chair for research in the department of urology at Emory University School of Medicine in Atlanta, GA.

In addition to my laboratory research, I'm also the contact PI for the SPORE program, which is an NIH funded, over $10 million center grant. The goal of this program is to accelerate the translation of laboratory discoveries into the clinic. We have 4 projects led by over 30 investigators. The 4 projects, one is led by Dr. Martin Sanda and collaborators on the biomarker discovery of distinguishing aggressive prostate cancer vs indolent prostate cancer in the active surveillance space. We have another project is in case immunology, led by Hayden Kissick, PhD, who is also in our department. We have a project, led by myself, which is looking at epigenetic determinants of later stage, castration-resistant prostate cancer, specifically neuroendocrine prostate cancer. We are trying to develop epigenetic biomarkers that can predict patients that are starting to progress to neuroendocrine prostate cancer. We [also] have a clinical trial looking at a new drug that can potentially block the transformation or progression of the disease, or inhibit neuroendocrine prostate cancer that has already progressed.

This SPORE program also involves a lot of investigators from all the Atlanta institutions, including the minority institute school, Morehouse. We have multiple PIs, me as a contact PI, but we have Dr. Martin Sanda, my previous chair, as a PI, and also Dr. Rick Kittles, who's [the senior] president for research at Morehouse, another PI on the on the grant. We have [another] major project. I said 3 projects, there is a fourth project that’s from Clark Atlanta University, led by Dr. Daqing Wu, to test a new treatment for chemo-resistant prostate cancer. It's really a joint effort from multiple institutions at Atlanta to combat prostate cancer together. By incorporating these 2 minority institutions, another major focus of our SPORE program, or [something that] distinguish[es] our program from some existing SPORE programs, is that we have a major focus on health disparities, trying to adjust health disparities. [We have an] advantage at Atlanta [in] our institutions, because 30% of our patients are African American. We want to take advantage of this environment to address this very important question.

"We are trying to develop epigenetic biomarkers that can predict patients that are starting to progress to neuroendocrine prostate cancer," says Jindan Yu, MD, PhD.

Tobias Nordström, MD, PhD, discusses the integration of new screening and diagnostic tools for prostate cancer into real-world practice.

Tobias Nordström, MD, on the evolving landscape of prostate cancer screening 

, discusses the integration of new screening and diagnostic tools for prostate cancer into real-world practice. Nordström is a clinical urologist and prostate cancer researcher at Karolinska Institutet in Sweden.

I think the field will move simultaneously in several directions. First, we now have implementation pilots. This is really a field of implementation, how to make this work in the real-world setting, which in the northern part of Europe is really on the population-based scale, but also taking into consideration the requirements for the individual patient and how to provide value for that individual man seeking testing for prostate cancer.

Another aspect is how to make this more and more complex diagnostic chain for prostate cancer work in practice, because we now have so many more tools than we had a decade ago. We started off with traditional, systematic biopsies and a PSA. That's 2 variables that can shift. We now have several risk calculators. We have tests such as the STHLM3 test or the 4Kscore. We have different versions of MRI and how to use that in order to target biopsies. So, we have so much more complexity in the chain. I think we will see more and more focus on how to secure that these complex tools work together to provide value for the individual man seeking testing.

“Another aspect is how to make this more and more complex diagnostic chain for prostate cancer work in practice, because we now have so [many] more tools than we had a decade ago,” says Tobias Nordström, MD, PhD. 

Vikram M. Narayan, MD, discusses the background and key findings of the study, “Tailoring language for genitourinary function in patients with newly diagnosed prostate cancer to facilitate discussions in diverse populations and overcome health literacy barriers."

Vikram Narayan, MD, on the importance of tailoring patient communication

, discusses the background and key findings of the study, “Tailoring language for genitourinary function in patients with newly diagnosed prostate cancer to facilitate discussions in diverse populations and overcome health literacy barriers.” Narayan is an assistant professor of urology at Emory University and the director of urological oncology at Grady Memorial Hospital in Atlanta, Georgia.

I work at Grady Memorial Hospital, which is one of our safety net hospitals here in Atlanta. A challenge that we face at any hospital is being able to deliver information to a patient at the language at which they can understand and comprehend. One of the things that I think a lot of physicians don't realize is that even when we try and break things down into what we perceive to be simpler terms, there are still words and sayings that we say that a patient doesn't understand. Common things that we describe in urology include things like urethra [and] prostate—words that you and I may understand, but it turns out a lot of our patients don't understand.

This is a study that was done by Dr. Kerry Kilbridge in Boston through a collaboration with her. It was her project, and Dr. Viraj Master’s, one of my partners here. We essentially conducted a series of interviews with patients being treated for prostate cancer. All of the patients were underserved minorities. We did structured interviews with those patients to understand where they are in terms of comprehension from basic prostate cancer care discussions and how they would have liked that information to be delivered.

The key take home message of that study was that having assumptions about basic medical terminology that we think are simple may actually leave patients confused. You really do have to ask patients what they comprehend and use some of those basic teach back techniques that we're taught in medical school, like having patients present information back to you to make sure they've understood what it is that that was presented to them. This is a really important area of research, and we're really glad to see that published and for folks to be able to look at.

“The key take home message of that study was that having assumptions about basic medical terminology that we think are simple may actually leave patients confused,” says Vikram M. Narayan, MD. 

Scott T. Tagawa, MD, MS, FACP, FASCO, speculates on the mechanism of action for 177Lu-TLX591 (177Lu-DOTA-rosopatamab), which is being assessed in the phase 3 ProstACT GLOBAL trial.

Scott Tagawa, MD, on the mechanism of action for 177Lu-TLX591 in mCRPC

, speculates on the mechanism of action for 177Lu-TLX591 (

Lu-DOTA-rosopatamab), which is being assessed in the phase 3 ProstACT GLOBAL trial (NCT06520345) in patients with metastatic castration-resistant prostate cancer (mCRPC). Tagawa is a professor of medicine and urology at Weill Cornell Medicine and an attending physician at NewYork-Presbyterian – Weill Cornell Medical Center in New York, New York.

It's radiation. We know that whether it's an antibody or small molecule, it will circulate, land, and bind to PSMA. I mentioned before the places that the antibody typically doesn't bind, like the salivary glands, but it binds to PSMA and then is internalized. That's one thing that is different in terms of antibody for small molecules, internalized and retained. Small molecules are internalized and externalized, but they can go in a neighboring cell, and whatever's attached to it is brought into the cell. In this case, the beta emitter lutetium 177. We think the mechanism of action is radiation leading to DNA damage. If there's enough radiation, then the cells can't repair themselves and die because of the radiation. The mechanism, I think, is radiation. There could be some other mechanisms, immune and other things, but I think the primary mechanism is radiation that is delivered to all of the PSMA-positive cells. Generally speaking, it's going to be most tumors in the advanced disease state will be PSMA-positive. Those small fractions that are negative are not included in the study. There is a screening PSMA-PET that is done that will eliminate those that have low or no PSMA expressions visible on the scans.

“If there's enough radiation, then the cells can't repair themselves and die because of the radiation,” says Scott T. Tagawa, MD, MS, FACP, FASCO. 

team conducted dozens of video interviews in 2024, comprising a variety of topics, ranging from erectile dysfunction to urinary tract infection. Here are the top-performing 

Dr. Dubin on trends in erectile dysfunction medication usage

, shares key findings from the study, “Beyond the prescription: trends and challenges in erectile dysfunction medications among young adult men,” for which he served as the senior author. Watch the video 

Olivia Paulsen on the association between BPH and erectile dysfunction

 gives an overview of the study “Benign Prostatic Enlargement Is Associated With Erectile Dysfunction in United States,” which she presented at the 25th Fall Scientific Meeting of the Sexual Medicine Society of North in Scottsdale, Arizona. Watch the video 

As the year comes to a close, we revisit some of this year’s top video content from Urology Times.

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