Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How does a low Decipher score impact your management of patients with unfavorable intermediate-risk prostate cancer?
In the NRG-GU010 trial, those patients were randomized to RT alone vs. RT + ADT, reflecting a hypothesis that these patients may not need ADT, although we will have to wait for the trial to read out to be sure. However, what we do know is that with widespread use of MRI-guided biopsies and PSMA PET ...
What are your recommendations in managing pudendal neuralgia/red scrotum syndrome?
Red scrotum syndrome is very challenging to treat. The list of reported treatments is long, but I have not found one to be consistently effective. Treatment selection depends significantly on patient characteristics and preferences. In my opinion, every patient with red scrotum syndrome should under...
Is long term ADT now the standard of care with salvage prostate bed RT?
The dreaded hormone question...After 40 years of embarking on extremely well designed randomized trials, we still are confused about the who, what, when of ADT. Will RTOG 9601 create a new care standard? As @Dr. First Last said, I think we will see increased utilization. I have been using bicalutami...
Is there any data on the use of PARP inhibitors in patients with metastatic urothelial carcinoma with deleterious DDR mutations?
Urothelial cancers harbor high rate of deleterious DDR alterations. Based on clinical data from other tumor types, especially TOPARP-A in metastatic castration-resistant prostate cancer where responses to olaparib monotherapy were observed especially among men with defective DDR genes, the use of PA...
Is there a role for DDR gene mutation or tumor mutation burden/load in predicting response to immunotherapy in urothelial cancer?
Our recent work showed that urothelial cancers harbor high rate of alterations in DDR (DNA damage repair and response) genes, with 25 – 29% rate of deleterious alterations and up to 25% with variants of unknown significance – considering the genomic complexity of urothelial cancers, it is not un...
Do you consider MSI testing for mCRPC?
I agree that data for response to immunotherapy in MMR-deficient (dMMR) prostate cancer is limited, and we estimate the rate of dMMR in prostate cancer to be low, in the 2-3% range. Nonetheless, based on responses in other dMMR tumors, pembrolizumab is now FDA approved for all dMMR/MSI-high unresect...
What is the role of liquid biopsy in patients with metastatic castration resistant prostate cancer to asses BRCA1/2 or other mutations and consider PARP inhibitors?
There are no FDA cleared tests that have been shown to accurately predict response or benefit from PARP inhibitors in men with prostate cancer. The risk of both false positives and false negatives remains high with these assays due and no studies in prostate cancer have shown concordance with a high...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...
How are you using the Decipher score in the definitive setting for prostate cancer?
This is an excellent question.Before I can answer the question directly, you must ask yourself: how do you currently decide who to give ADT to with RT?The easy answer is that you use RCTs to choose who to give short-term and long-term ADT to. However, I wish it was that easy.Lets take RTOG 9408- It ...
Do you get DEXA scans routinely before starting ADT for prostate cancer or endocrine therapy for breast cancer?
When initiating long-term ADT, I order a DEXA scan, check vitamin D level, ensure adequate dietary calcium intake, and discuss weight-bearing exercise/refer to PT when appropriate. I also continue check DEXAs every 2 years unless they otherwise meet criteria for a bone-modifying agent (mCRPC with bo...