Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Following presentation of the PRINCE at ASCO 2016, should we be offering intermittent docetaxel to patients with metastatic castration-resistant prostate cancer?
The simple answer is no, as this study was dramatically underpowered to reach any conclusion. A couple of issues:1. This trial was designed after the TAX 327 data showed q3 week therapy to be the standard of care. This trial allowed weekly therapy anyway, likely because some of their docs wanted to ...
For castration-naive metastatic prostate cancer patients who you plan to treat with LHRH agonist monotherapy, how long do you treat with an anti-androgen therapy prior to and after initiating the LHRH-agonist?
I only use bicalutamide prior to starting LHRH agonist in patients with high risk of spinal cord compression or urinary obstruction. I will start bicalutamide for 7 days then start LHRH agonist therapy. In all other patients, I start LHRH agonist without combination with anti-androgen therapy.
Do you routinely offer AR-v7 testing to determine whether to treat with chemotherapy versus enzalutamide or abiraterone in metastatic castration resistant prostate cancer?
The short answer is no, not yet, and not outside of a research study. AR-V7 testing using a CLIA approved circulating tumor cell (CTC) assay, either Qiagen-Hopkins using the Adnatest RT-PCR platform or the EPIC-Genomic Health protein assay, appear very promising as negative predictors of the clinica...
Do you routinely include sipuleucel-T as one of your lines of systemic therapy for metastatic castration resistant prostate cancer?
In select patients, I will use Sipuleucel-T as first line therapy for patient with early castrate resistant disease that are asymptomatic. Those that I use Sipuleucel-T I will observe them post therapy unless I see a rapid increase in PSA or other symptoms, then I will start AR directed therapy. Inc...
Which PET imaging modality, if any, is preferred to work up possible nodal involvement or local recurrence in prostate cancer?
In my view, better, more sensitive imaging will transform our management of prostate cancer. Soon, I believe, maybe very soon, we'll be able to detect small volume nodal metastases and small volume metastatic disease. How to manage patients with, say, a solitary, <1 cm lymph node seen on PET will be...
For patients eligible for and considering active surveillance for low-risk prostate cancer, do you routinely use tests for molecular risk stratification?
I have not incorporated genetic testing into my active surveillance strategy. As yet, it is not clear how to use this information to modify the approach to AS. At this point, multi parametric MRI is far more useful, and I recommend this test to all of my patients considering AS to try to rule out th...
When should multiparametric MRI (mpMRI) be utilized in prostate cancer workup?
Early adopters of prostate mpMRI are unique and always a pleasure to meet. I've learned a great deal from many of them. They’ve moved beyond aiming at a CT density in the pelvis and learned how to use mpMRI sequences to better classify the risk of disease they’re treating. This is in comparison to o...
How do you decide when to refer a patient with metastatic renal cell carcinoma for cytoreductive nephrectomy?
Although dated, two large randomized trials showed a nearly 6 month OS advantage with debulking nephrectomy in the cytokine era, and thus my opinoin is that debulking nephrectomy is the standard of care in appropriately selected patients. The phase 3 data and modern retrospective analyses in the TKI...
Which, if any, aspects of your management of prostate cancer differ in your African-American patients versus those of other racial/ethnic backgrounds?
My short answer is that I do not treat patients diagnosed with prostate cancer differently based on race or ethnicity. There is data to support a higher risk of progression on active surveillance among African American men as compared with Caucasian American men with low risk prostate cancer, but th...
In patients with Stage I seminoma who elect surveillance, how long do you recommend that tumor markers be followed?
I agree with @Dr. First Last that the data is vague. I would add the following: in series where patients are regularly re-staged with CT scans, serum tumor markers add essentially nothing. So if one follows the Princess Margaret Hospital schedule and gets scans every four months for the first 2 to 3...