Ariel Schulman

The Contemporary Role of Multiparametric Magnetic Resonance Imaging in Active Surveillance for Prostate Cancer

Purpose of ReviewGrowing research supports the use of multiparametric magnetic resonance imaging (mpMRI) for the evaluation of localized prostate cancer (PCa). We highlight contemporary evidence supporting its use in active surveillance (AS).Recent FindingsThe emerging approach to localized PCa favors risk-adapted screening, image-guided biopsies, and selective therapeutic interventions. mpMRI is increasingly critical to achieve each of these aims. Early evidence suggests a value of mpMRI before initial biopsy to guide fusion targeting and to rule out non-organ confined disease as well as in the initiation and serial monitoring of men on AS. There remain concerns regarding understaging cancer with mpMRI and the standardization of expertise beyond the most experienced centers.SummarympMRI is emerging as a critical decision point for staging localized PCa and guiding AS strategies. While there is increasing enthusiasm, the optimal clinical scenario and sequencing remains to be defined.

Validation of the 2015 prostate cancer grade groups for predicting long-term oncologic outcomes in a shared equal-access health system

A 5‐tier prognostic grade group (GG) system was enacted to simplify the risk stratification of patients with prostate cancer in which Gleason scores of ≤6, 3 + 4, 4 + 3, 8, and 9 or 10 are considered GG 1 through 5, respectively. The authors investigated the utility of biopsy GG for predicting long‐term oncologic outcomes after radical prostatectomy in an equal‐access health system.

New advances in focal therapy for early stage prostate cancer

ABSTRACT Introduction: Prostate focal therapy offers men the opportunity to achieve oncological control while preserving sexual and urinary function. The prerequisites for successful focal therapy are to accurately identify, localize and completely ablate the clinically significant cancer(s) within the prostate. We aim to evaluate the evidence for current and upcoming technologies that could shape the future of prostate cancer focal therapy in the next five years. Areas covered: Current literature on advances in patient selection using imaging, biopsy and biomarkers, ablation techniques and adjuvant treatments for focal therapy are summarized. A literature search of major databases was performed using the search terms ‘focal therapy’, ‘focal ablation’, ‘partial ablation’, ‘targeted ablation’, ‘image guided therapy’ and ‘prostate cancer’. Expert commentary: Advanced radiological tools such as multiparametric magnetic resonance imaging (mpMRI), multiparametric ultrasound (mpUS), prostate-specific-membrane-antigen positron emission tomography (PSMA-PET) represent a revolution in the ability to understand cancer function and biology. Advances in ablative technologies now provide a menu of modalities that can be rationalized based on lesion location, size and perhaps in the near future, pre-determined resistance to therapy. However, these need to be carefully studied to establish their safety and efficacy parameters. Adjuvant strategies to enhance focal ablation are under development.

Engaging the primary care community to encourage appropriate prostate cancer screening

Prostate-specific antigen (PSA) screening for prostate cancer remains a controversial topic, particularly in the primary care community. Our multidisciplinary prostate screening panel at Duke University Health System, USA created a nuanced PSA screening algorithm, implemented it into the Electronic Health Record of Duke Primary Care, and conducted outreach meetings with primary care practices to support its rollout. Through this project, we identified areas of concern among primary care clinicians regarding PSA screening that we structured into two major categories: ideological opposition and logistical opposition. We outlined specific concerns in each major category and described how our team responded to those concerns. As communication between primary care clinicians and prostate specialists is vital to the success and safety of PSA screening programs, we hope that describing primary care concerns and our responses to them will help other health systems thoughtfully and efficiently implement appropriate PSA screening programs moving forward.

Primary care perspective and implementation of a multidisciplinary, institutional prostate cancer screening algorithm embedded in the electronic health record

PURPOSE In response to controversy regarding prostate cancer (CaP) screening recommendations, a consolidated Duke Cancer Institute (DCI) multidisciplinary algorithm for CaP screening was developed and implemented. We conducted an online survey within the year following its implementation to assess primary care provider (PCP) attitudes and adoption as well as to evaluate how this program affects screening rates. METHODS A web-based 18-item survey was programmed and was electronically mailed to practicing PCPs at clinics affiliated with the Duke Primary Care system. The survey assessed provider practices and attitudes regarding CaP screening, factors that influenced their general screening recommendations and the confidence related to communicating with patients about screening. The rate of PSA screening before and after implementation of the algorithm was reported across age and race categories. RESULTS In sum, 94 of 106 respondents (88.6%) reported discussing the benefits and harms of screening and let their patients decide (52.8%) or recommended for (31.1%) or against (4.7%) screening. Three-fourths of respondents followed a specific panel recommendation such as the United States Preventative Services Task Force (USPSTF) (48.1%), DCI (20%), or the American Urological Association (AUA) (7.4%) guidelines. After integrating this algorithm into the electronic health record, the rate of prostate screening increased between 11% and 20.4% and 15.6% and 16.4% among different age and race categories, respectively. Overall, 79.2% of PCPs felt very confident regarding their ability to communicate the topic of CaP screening with patients. CONCLUSION The DCI multidisciplinary CaP screening algorithm was well adopted among PCPs shortly after its implementation. The rate of screening increased among all age and race categories thereafter. The majority of PCPs involved in this survey felt confident regarding their CaP screening knowledge and most discuss this topic with patients in a shared decision-making model.

Multiparametric Prostate MR Imaging: Impact on Clinical Staging and Decision Making

Meaningful changes to the approach of prostate cancer staging and management have been made over the past decade with increasing demand for high-quality multiparametric MR imaging (mpMRI) of the prostate. This article focuses on the evolving paradigm of prostate cancer staging, with emphasis on the role of mpMRI on staging and its integration into clinical decision making. Current prostate cancer staging systems are defined and mpMRIs role in the detection of non-organ-confined disease and how it has an impact on the selection of appropriate next steps are discussed. Several imaging pitfalls, limitations, and future directions of mpMRI also are discussed.

Instruments for Upper Tract Biopsy and Treatment

From the introduction of endoscopic approaches to genitourinary disease at the beginning of the nineteenth century to advances in 1970s that ushered in the current era of Endourology, the field has undergone continuous growth based on improved visualization, advances in scope design and instrument innovation. Currently available techniques offer access to the entire urinary tract via a retrograde ureteral or antegrade percutaneous approach for the inspection, biopsy, and treatment of the spectrum of benign and malignant pathology. While urine studies and cross-sectional imaging are utilized in the initial evaluation, direct visual inspection, and biopsy is required for the assessment of any abnormal findings. The current generation of digital flexible ureteroscopes are lighter and less cumbersome than their predecessors with better image quality. Instruments including forceps, baskets, and resection loops are available to maximize the diagnostic yield of endoscopic biopsy. Despite progress, it is critical to recognize that undergrading and understaging remain a significant concern even for experienced practitioners. This can best be tempered with a comprehensive evaluation of the entire urothelium, systematic approach to specimen collection and close clinical follow-up. In this chapter, we review basic endoscopic techniques for the biopsy of upper urinary tract lesions.

Analysis of Conservative Treatment of Upper Tract Urothelial Carcinoma

A survey of literature on UTUC shows a mix set of results on efficacy and outcome of conservative treatment. There are no standardized templates for ureteroscopic or percutaneous resection techniques nor the adjuvant treatment options. The assumptions of what institutes a diagnosis or success after treatment also remain unclear. The conservative management of UTUC is a work in progress requiring a multicenter prospective evaluation to provide more clear parameters to follow.

Predictors of Rectourethral Fistula Formation After Primary Whole-Gland Cryoablation for Prostate Cancer: Results from the Cryo On-Line Database Registry

PURPOSE To define the incidence and risk factors associated with rectourethral fistula (RUF) formation following primary whole-gland cryosurgery using a multicenter centralized registry. PATIENTS AND METHODS The Cryo On-Line Data (COLD) registry was queried for men undergoing primary whole-gland cryotherapy between 1990 and 2014 who developed a RUF. Patient factors and disease parameters were correlated with RUF using chi-square and the t-test. Variables with p < 0.25 were entered into a binary logistic regression with stepwise backward elimination to determine the factors associated with RUF formation. RESULTS A total of 4102 men underwent primary whole-gland cryotherapy in the COLD registry at the time of analysis. Postoperative RUF was documented in 50 out of 4102 cases (1.2%). Patients with RUF had similar demographic data, prostate volume, preoperative prostate-specific antigen level, and clinical stage in comparison to those without fistula. On both univariate and multivariate analyses, postoperative urinary retention (odds ratio [OR]: 6.30; confidence interval [95% CI] 3.43-11.58, p < 0.001), preoperative Gleason score of ≥7 (OR: 1.92; 95% CI 1.08-3.43, p = 0.027), and preoperative incontinence (OR: 2.95; 95% CI 1.12-7.76, p = 0.028) were the most significant risk factors associated with RUF formation. CONCLUSION Primary whole-gland cryotherapy for prostate cancer is associated with a historically low rate (1.2%) of postoperative RUF formation. The rate decreased further to 0.55% over the last several years, suggesting better patient selection and technical improvement. Postoperative urinary retention, Gleason score ≥7, and preoperative urinary incontinence were the key demographic, clinical, and pathologic features associated with RUF formation in this study.

Is there any racial disparity in oncological outcome following primary cryotherapy for prostate cancer? A matched pair comparative analysis of the Cryo On-Line Data registry

Micro‐Abstract The purpose of the present study was to assess whether ethnicity can affect the oncologic outcomes of primary prostate cryotherapy. After a 2‐group matched‐pair analysis of 327 men, the oncologic outcomes of primary cryotherapy as a treatment modality for primary, clinically localized prostate cancer was similar among men of African‐American descent and non–African‐American descent. Background African‐American (AA) men have the greatest incidence of and disease‐specific mortality from prostate cancer of any racial group. Although encouraging oncologic and functional outcomes have been reported with prostate cancer cryotherapy, little is known about how ethnicity can potentially affect the oncologic outcomes of primary cryotherapy. We report the oncologic outcomes of primary cryotherapy in AA patients through a matched‐pair analysis. Patients and Methods A 1:2 (AA to non‐AA) cohort of patients was designed using the Cryo‐On‐Line Data Registry. The 2 arms were matched for patient age, prostate‐specific antigen level, Gleason score, and prostate volume. The oncologic outcome was defined in terms of the biochemical recurrence (BCR) rates after primary cryoablation using Phoenix criteria. The results of “for‐cause” post‐treatment biopsies and the BCR‐free survival rates were also analyzed between the 2 groups. Results The 1:2 cohort of AA and non‐AA men in the present study included 109 and 218 men, respectively. Their median age (69 vs. 71 years; P = .71), median prostate‐specific antigen level (6.5 vs. 6.8 ng/mL; P = .95), median prostate volume (32 vs. 30 cm3; P = .31), Gleason score distribution (P = .97), and prostate cancer risk group (P = .12) were similar statistically. The median postoperative follow‐up period was also comparable between the 2 groups (AA, 32 months vs. non‐AA, 27 months; P = .52). The BCR rates were similar between the AA and non‐AA men (14% vs. 17%; P = .52). Likewise, the rate of positive “for‐cause” prostate biopsy findings was similar between the 2 groups (AA vs. non‐AA, 25% vs. 36%; P = .44). Furthermore, the 5‐year biochemical relapse‐free survival rates were comparable for the AA and non‐AA patients (74% vs. 71%; P = .37). Conclusion When matched for tumor characteristics, cryotherapy as a treatment modality for primary, clinically localized prostate cancer offers men of African‐American descent similar oncologic outcomes to those of non‐AA men.