Dr. Hafron on LUGPA 2021 and the rapidly evolving prostate and bladder cancer treatment landscapes

Jason M. Hafron, MD

There was a palpable excitement about the return of in-person conferences among attendees of the 2021 LUGPA annual meeting. In this interview, Jason M. Hafron, MD, discusses the “buzz” surrounding the meeting and touches on clinical topics including germline and somatic testing, PARP inhibitors, and mitomycin-containing reverse thermal gel (Jelmyto). Hafron is a partner at the Michigan Institute of Urology, PC; an associate professor of urology at the William Beaumont School of Medicine, Oakland University; and the director of robotic surgery at Beaumont Hospital Royal Oak in Michigan.

What are some considerations urologists should be aware of regarding germline and somatic testing?

I think, first of all, it's very important that urologists get involved with germline and somatic testing. As you look at where we're headed and 2 recent approvals last year of the PARP inhibitors, we are moving to true precision medicine. In order to allow our patients to have these therapies, you have to have germline and somatic testing in place. At Michigan Institute of Urology, we've adopted this hybrid model where we will do the testing, [and] the urologist will do the informed consent, explain the value, the good and bad of genetic testing, and the issues associated with it. I think that's what's really critical. And then, obviously, if they're positive, if they have a germline or somatic mutation, or they have a VUS, [then] we will automatically refer to our genetic counselors. I think if you don't have a model like that, where the urologist is not testing, it's going to be very hard to get these patients appropriately evaluated and do that critical genomic profile, which as you see in the therapies that are being introduced, is going to be so important in the future.

What’s been your experience with PARP inhibitors in prostate cancer?

We've incorporated PARPs into our pathways. We use them when appropriate, when they have the appropriate mutations. There is a learning curve associated with PARPs but [in] working with our oncologists and working with various entities, we've become comfortable with PARP inhibitors. Unfortunately, PARP inhibitors are a later line of therapy and typically these patients are very sick. But I think as our understanding of mutations [and] our understanding the PARP inhibitors [grows], if the data pans out, we'll be using these earlier and earlier in patients, which I think we'll [will allow us to] see probably more benefit.

What are your thoughts on prostate-specific membrane antigen (PSMA)-targeting agents in prostate cancer?

The PSMA was FDA approved [at] the end of May this year. Our hospital system is just coming online. We've been ordering these one-offs. Patients have either been paying out of pocket or we send them to various locations, but I think that will evolve and PSMA, starting January 1, will be approved by Medicare. Once that approval goes through, which it will, I think PSMA technology is going to change the field of advanced prostate cancer significantly and all prostate cancer. This is very disruptive technology. It will put us in places or give us challenges that [don't] really correlate with the data. A lot of our trials are based on conventional imaging, and now we have a study that can see things that we never could see before. It will be a critical part of my practice. I can't wait to use it. It’s going to be a game-changer. PSMA PET imaging will disrupt advanced prostate cancer and even high-risk localized prostate cancer—how we manage this disease. [Out] of everything going on, this is probably 1 of the most exciting areas in prostate cancer. Now we have such an incredible imaging modality, something we've never really seen before.

What's been your experience with mitomycin-containing reverse thermal gel (Jelmyto) in treating patients with low-grade upper tract urothelial cancer?

Jelmyto is a paradigm shift in how we treat upper tract disease. Historically, it was treated with radical surgery removal—the kidney nephroureterectomy. But based on the trials and the response rate, it's shifted our thinking process with upper tract disease in that [the] 30% of the patient population [who] truly [have] low-grade upper tract disease [are] the candidates for Jelmyto. And what's great about it is you can avoid a pretty morbid operation in a typically unhealthy older population, and treat them with localized therapy, keep the kidney intact. We found it very effective. We've been using it in our practice. I think the only thing that we've done differently, and I know centers around the country are doing it, is we brought it into the office and we will do percutaneous antegrade Jelmyto. If you look at that data closely, there is a high ureterostenosis rate. What we feel and we'll see over time is that if we can give this percutaneously through a nephrostomy tube, potentially we may avoid those adverse events associated with repetitive retrograde insertion of catheter. It's worked out really well. We do it in our office and it's been effective. Again, the goal here is to avoid unnecessary or radical surgery when patients don't really need it.

What has been the "buzz" surrounding the 2021 LUGPA annual meeting?

I think the buzz around the hall is [that] people are very happy to be in person. I think what the challenges are, and the theme of the meeting, is reimagining urology. As we get through COVID-19, as we have new challenges that we never even dreamed of, [it's] how can we take these challenges and make them successes or make them positives? We've seen it with telehealth and virtual meetings with our patients, but even beyond that. As these challenges have come to us, how can we be better physicians [and] do better than urological care? So, I think the buzz is higher than ever. It's partially that we're all back together and talking again, but also what the future is. The future in bladder cancer [and] prostate cancer is really exploding. The therapeutics are coming faster than we ever thought. The imaging, genomic profiling, we're seeing a significant explosion of technology and it's just great to be a part of it, great to be a part of it as a physician to utilize these great therapies, but also great for our patients. One of the trials that came out this year was [the] PEACE-1 trial for high-risk and metastatic CSBC. [It] was a phenomenal trial using triplet therapy, or very tumor-intense therapy, but for the first time we saw that the median survival of advanced prostate cancer went to 5 years. That is something that we've never seen in a clinical trial to date. So again, along those lines, as these therapies come online, as we know how to use them better, patients are living longer and that's what's exciting.