Scott Eggener, MD, on a pragmatic approach to prostate cancer innovations

Scott Eggener, MD

Urologists should be open to innovative technologies and methodologies without getting swept up in the hype of new things, Scott Eggener, MD, told attendees at the 2024 LUGPA Annual Meeting in Chicago, Illinois.

“You have to be balanced in what to embrace vs what not. It is easy to be wowed by new things. I think it's part of our operating system, and it's also…easy to be hijacked by things that may not be so important for patients. And I think it's important to temper some of the enthusiasm sometimes,” said Eggener, the Bruce and Beth White Family Professor of Surgery at the University of Chicago in Illinois.

Eggener gave a talk at the LUGPA annual meeting titled “Leveraging cutting-edge technologies to enhance prostate cancer treatments.” He began by discussing screening.

“There are a lot of tests out there that absolutely, positively outperform traditional PSA [prostate-specific antigen]. The good news is some of them are easily accessible and cheap,” Eggener said. The tests, he explained, do well at identifying men with grade group 2 or higher. Eggener did say, however, that he doesn’t order these tests frequently.

“I tend to use PSA free, PSA, PSA density, things like that. There are absolutely times I order these, but it's certainly not a reflexive test. But there is absolute value in these tests. I do think it's also important for us as a reminder to remember all the cheap, free things that are at our disposal to make smart decisions with screening,” Eggener said.

Eggener made the point that not every patient needs PSA screening

“We've got a bit of an epidemic of sick old men getting PSAs,” he commented. He urged attendees to be familiar with current screening guidelines.

Eggener also stressed the importance of repeating an elevated PSA.

“I'm not sure of any situation with screening treatment or post treatment where you change the plan based on one new change in PSA. Always repeat it,” he said.

Obtaining a baseline PSA for a man, Eggener said, is “gold. PSA velocity, on the other hand, is “not very helpful.”

“I think free PSA, if we could monetize it, commercialize it, sell it, it is better than total PSA, if you look at the at the at the raw data. If someone asked me, ‘Would I rather know my total PSA or my free PSA?’ I'd rather know my free PSA, so I every single person I screen, I get a free PSA on,” Eggener said.

Eggener then shifted his talk to imaging, where he spoke highly of MRI.

“MRI has taken over. MRI is a win. I order a ton of MRIs. There is value, but they're good, sometimes great, and rarely perfect,” Eggener said. He also touched on technology such as artificial intelligence that can enhance MRI, as well as prostate-specific membrane antigen (PSMA)-PET imaging. PSMA-PET, he said, is a “clear winner” vs MRI.

“Now, it would be wonderful if PSMA-PET was cheaper, easier, quicker. I'd love to order it on all my patients, from surveillance on up. I don't, because at least at our place, I'm told it's a $7000 test, and I try to be at least at times cost conscious with it. I hope there's a time where we order it more regularly,” Eggener said.

In terms of prognosis and staging, Eggener commented, “We've got a lot of genomic tests out there. I don't have any ties to any of them. I would tell you that I think the single best one, based on extensive validation [and] really good science, is Decipher. I do think it has value in certain clinical situations [like if] a guy is really struggling between surveillance and treatment and you're looking for something to tip the needle a little bit. But it's not the end-all-be-all.”

Eggener added, however, that he feels the test is over-ordered. “There are urologists around the Chicago area that every single patient diagnosed with prostate cancer gets a Decipher score. I see a ton of patients where I say to myself, ‘why did they get this? No matter what the Decipher shows, you're not going to change a darn thing in your counseling or your management for that patient,’ ” he said.

Eggener also discussed advancements in prostate cancer treatment, particularly the potential of theranostic approaches. “This is an exploding space with new isotopes for theranostics,” he noted, referencing isotopes such as actinium and scandium that offer more targeted treatment options with potentially fewer adverse events.

Regarding focal therapy, “There are a lot of visceral opinions on focal therapy, and a lot of blowback. I would just remind us that sometimes, history reminds us that we can be wrong in certain things. And as someone who's taken an interest in focal therapy for many years, I've done a lot of reading about breast cancer focal therapy, and it's fascinating. I can make a very compelling argument to you that we're almost exactly 50 years behind the breast cancer community…I have absolute confidence there's going to be a subset of patients where focal therapy is a very reasonable option,” Eggener said.

Eggener also touched on radiation therapy, including proton therapy and hypofractionation. “Proton therapy is exactly the same as regular radiation therapy, IMRT for prostate cancer. It's not any better, it's not any safer, there's not less side effects,” Eggener said. Regarding hypofractionation, he reminded the audience of its place in the clinical guidelines as a viable option. “If…your patients are getting six to eight weeks of radiation therapy, there’s only one benefit of that six to eight weeks…and it’s not to the patient,” Eggener said.

He concluded his talk by urging attendees to “seek newer and better ways” and regarding innovations, “Try to be sensible about things, and don't be a sucker.”