Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
For patients with muscle-invasive bladder cancer and borderline renal function, would you consider use of a split-dose cisplatin/gemcitabine regimen for neoadjuvant treatment?
Yes, in patients with borderline creatinine clearance, e.g. 50-59cc/min, we tend to split cisplatin dose, e.g. 35 mg/m2 on days 1 and 8, if gemcitabine/cisplatin is used, or on days 1 and 2, if dd-MVAC is used. Also, we consider 24-hour urine testing to assess more accurately creatinine clearance in...
How does a prominent component of intraductal spread affect your management in a patient with otherwise intermediate-risk prostate cancer?
There are no outcome studies that I am aware of that indicates that an intraductal prostate cancer alters prognosis in men receiving radiation therapy. However, there are numerous reports that this is an "adverse feature" when looking at initial staging (men with this finding seem to be more likely ...
Is there a substitution for etoposide you would recommend for testicular cancer patients who need multiple cycles of BEP?
If it is good risk disease can use our old regimen of cisplatin + vinblastine + bleomycin (PVB) as it was equivalent to BEP therapeutically in the good risk patient population. For intermediate or advanced disease, VeIP or TIP.
If a man has been on a 5-alpha reductase inhibitor for urinary symptoms prior to prostate radiation therapy, is there value in continuing it after radiation therapy?
5-alpha reductase inhibitors, e.g. dutasteride, are indicated for the treatment of symptoms related to BPH and an enlarged prostate and have some efficacy for this indication, especially when combined with alpha blockers. 5-alpha reductase reduces a double bond in testosterone to create a more poten...
For what patient groups (if any) do you routinely recommend screening colonoscopy prior to radiation for prostate cancer?
As a cancer care provider treating both GI and GU malignancies, I see this as a commonly. In many healthy men, an elevated PSA may be what allows them to "plug in" to the American health care system, often the first time in many years. Considering most prostate cancer is detected by an elevated PSA,...
How do you approach treatment for high-risk prostate cancer in patients who need clearance for organ transplant listing?
Our initial approach for these patients is to engage their transplant physician to understand the barrier for organ transplant listing. For some patients, the presence of a detectable PSA is the rate limiting factor, while for others having untreated disease is the main issue. The difference between...
Would you use apalutamide in high risk non-metastatic castrate resistant prostate cancer?
I would consider using apalutamide for the appropriate patient, which I would define as meeting the entry criteria for the study i.e. PSA DT 10 months or less. The label for the drug is broad i.e. any castration resistant PSA only patient, which I beleive is too far to inclusive, many of these folks...
Given the biochemical failure definition of PSA nadir+2 ng/mL, how do you approach a PSA bounce of magnitude 2 ng/mL or higher?
If a PSA bounces >2 points then PSA decreases subsequently without any treatment, I do *not* consider these patients to have failed. This does occur in the clinic occasionally. Thankfully, when patients have rising PSAs after RT, there usually is not an urgency to start salvage treatment. When a pat...
How would you treat a patient with high-volume metastatic prostate cancer who has asymptomatic biochemical relapse after having a good response to upfront docetaxel?
If the patient is asymptomatic or minimally symptomatic and now castrate-resistant, I would start with sipuleucel-T. Based on the PSA quartile data (Schellhammer et al 2013) and in line with current NCCN guidelines and supportive clinical and preclinical data, immunotherapy should be used as early a...
Would you de-escalate therapy for a prostate cancer that is barely high risk and has only 1 of 12 cores positive?
First let’s discuss high risk for cancer at the low-end of that category (example a T1c PSA6 1-2 core GS 8). Current standard of care for radiation management is to provide at least 18mo of ADT based on PCS-IV. This is somewhat of a dose de-escalation of hormonal therapy compared to EORTC regimen. ...