Transcription:
Prostate Cancer Highlights From 2021 SUO Annual Meeting

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to join us as we discuss the Society of Urologic Oncology Annual Meeting highlights. Joining me is Dr. Ashley Ross. He's an Associate Professor of Urology at Northwestern Medicine.

Dr. Ross, thank you so much for joining us today. So tell us about the prostate cancer highlights from the 2021 Annual Meeting of the Society of Urologic Oncology. What stood out to you? What was it like?

Dr Ashley Ross: Well, it was a great meeting this year. One of the major areas of focus was about how we approach the diagnosis of prostate cancer. And specifically, it was discussing how we do prostate biopsies and some of the issues around there and some of the stepwise evolutions we've seen. At the meeting, Dr. Edward Schaeffer, who's the chair of Urology at Northwestern, talked a little bit about the landscape of bacteria in the colon and how it affects prostate biopsies.

In the past, prostate biopsies were most commonly performed with transrectal ultrasound guidance and needles that traversed the rectum into the prostate. And Dr. Schaeffer pointed out that there has been an increase in fluoroquinolone-resistant enterococci. These are bacteria that are normally colonizing our guts. And there's been an increase in their frequency of being resistant to ciprofloxacin and other fluoroquinolones, which are antibiotics we commonly give for these transrectal ultrasound-guided prostate biopsies.

So he pointed that out and then as the session continued, we talked about advances in doing transperineal prostate biopsies, which are now commonly performed in the clinic at Northwestern and at many other institutions. And these biopsies go through the skin as opposed to the rectum. And as they do that, they have much less infectious risks and they do not require the use of antibiotics.

Now, currently at Northwestern, Dr. Schaeffer and other physicians from around the US like Dr. Hu at Cornell are conducting a comparative effectiveness trial that looks at this type of biopsy, this through-the-skin transperineal needle biopsy, and compares it to the traditional transrectal biopsy to really flush out is the diagnostic yield the same, is the patient comfort the same, and what do we see in terms of infectious risks? But this was a highlight of the meeting, the sessions around how we do prostate biopsies. And I think that it's a harbinger of what we're going to see an evolution towards, which is the clinic-based transperineal transrectal ultrasound-guided prostate biopsy, which as I noted is one of the more common ways that we do the prostate biopsy at Northwestern.

So that was a big focus. And then another focus of the meeting was talking about management of lower risk prostate cancer patients with clinically localized disease. Dr. Catalona helped push forward a debate about the management of these low risk patients in our understanding of active surveillance. Active surveillance is the observation of prostate cancer, which is thought to be of lower risk with the deferment of treatment until the disease appears to be substantial enough to require it, because the treatments we have for prostate cancer often have some morbidity, whether it be in the sexual domains or urinary domains.

In this debate, he highlighted that there's a heterogeneous group of men that have low-risk disease and that we have to do personalized approaches towards determining who's a good candidate for surveillance and who may want to seek upfront treatment. So it was an excellent session. And I was happy to see a lot of my colleagues on the stage, furthering knowledge in prostate cancer.

Melanie Cole (Host): Thank you for sharing that answer. So now, I'd like you to tell us some of the key takeaways from your presentations. And Dr. Ross, you as well as your Northwestern colleagues, Dr. Schaeffer, who you mentioned and Dr. Catalona were among the featured speakers at this conference. So tell us some of the key takeaways from your presentation too.

Dr Ashley Ross: I think my presentation was about how to operationalize a transperineal prostate biopsy in the clinic. And, in the past, a lot of people would think that transperineal prostate biopsies were longer procedures that required a large area of the perineum to be anesthetized and would be done with what's called a stepper and a grid type apparatus. And because of that, it would have to be done in the operating room. It would be a more onerous procedure.

My presentation basically discussed things that I had learned over the last year in operationalizing it in my clinic and other things that I'd learned from the literature and basically put forth the idea that we can pretty easily do these procedures in clinic, in about a 15-minute timeframe with a patient in the door, to out the door of the clinic being less than 30 minutes.

And what I talked about was a tethered needle guide, which the one we use at Northwestern is called PrecisionPoint, which allows the operator, myself, more flexibility to do the procedure in a more expeditious manner. And then additionally, we touched a little bit on and it was shown in some other presentations our better understanding or renewed understanding in the perineal anatomy and innervation to the prostate, such that we could make patients comfortable in this procedure without using anything except for 1% lidocaine as analgesia.

So my presentation was mostly about operationalizing perineal biopsies in the clinic. It really drew on a lot of things that I've learned at Northwestern. They had asked me to give the talk because about a year ago or so, before I joined Northwestern faculty, I was not performing this in the clinic. I was a little bit hesitant to do so because of these same fears about barriers of implementation. And on the planning for the SUO, they had asked me because I had gone through this process and now it's the most common way I perform biopsies in clinic, can I help teach the audience what was my learning curve? What were some of the barriers? How do we overcome it? What are the equipment and staff we need? And can we give any tips and tricks?

In my mind, even though there's a comparative effectiveness trial, and we want to look for the answers from that, this approach that requires no antibiotics at all, which means that we are doing excellent antibiotic stewardship and that, in my hands at least, and in the international reports, has had virtually no infectious complications, is likely to be the main approach in the next few years used by urologists across the US. And it's good to know that it can be done in an expeditious fashion in clinic and, more over, I think that it's good to know that there's a way forward that won't contribute to this higher frequency of resistant bacteria, that it's really an issue across spectrums of disease.

Melanie Cole (Host): How cool is that?

Dr Ashley Ross: It was a a great opportunity and I got great feedback from some of my friends around the US and from other attendees about the quality of that session, about us being able to disseminate knowledge that I had gathered here. And, in full disclosure, the person who taught me sort of how to operationalize this in my clinic was Schaeffer. And it was nice to move that knowledge forward. I took a lot of pride in it. This session itself was an important topic. And that and Dr. Catalona's session and others about personalizing medicine in prostate cancer, I think made the conference a very special one.

Melanie Cole (Host): So rewarding to be able to share what you've learned to really further the field. It's an exciting time in your field. And before we get to the wrap-up question, why don't you tell us a little bit, expand for us on Dr. Catalona's talk on personalized medicine because that's really a big buzz word in the field now?

Dr Ashley Ross: Well, I think he was talking about, again, surveillance for low-risk prostate cancer. Active surveillance for low-risk prostate cancer is a very good option, maybe preferred for most men with low-risk disease. He had actually acquired the largest series by collaborative efforts of patients on active surveillance across the US and he looked at the characteristics of those patients. And the reality is that the majority of the people that we survey or have surveyed in the last 20 plus years of experience that we've gathered there have been on the low end of the low risk spectrum. And it highlighted some points that, for men that are on the higher end of the spectrum of low-risk disease, meaning they have more volume of disease in their prostate and maybe have a stronger family history, they may have genetic drivers, that we have to often do careful decision-making with them about should they do surveillance as a strategy or not? How long do we expect them to be on surveillance before they will need treatment? And that can often determine whether or not it's a viable approach.

And so it was a good debate with him and Dr. Scott Eggener from University of Chicago, and it highlighted these ongoing issues as we continue to understand who we need to put towards treatment and who we need to survey with prostate cancer. And the major thing of personalized medicine is it's just getting away from the idea of one-size-fits-all. Each person has different disease risks, and even with common clinical factors, without anything fancy, you can put people into different bins and help treat them in a very individualized way.

Melanie Cole (Host): Well, certainly the wave of the future in healthcare as a whole, Dr. Ross. As we wrap up, is there anything else, any other important information or learnings from this year's SUO annual meeting that you want your colleagues who may not have been able to attend to know about?

Dr Ashley Ross: I think I'll wrap up kind of how I started and say that it was a great meeting. I think one of the things that was highlighted is this idea of transperineal needle biopsies. And I think a lot of us have to look at how we do diagnosis of prostate cancer, how we use things like MRI, et cetera. That's been around for a while, but there is going to be a sea change, in my mind, in how we do one of the most routine procedures we do for our patients with elevated PSAs in the clinic. That's why the organizers had dedicated a longer session to that and why two talks from Northwestern came in that area.

And I would tell my colleagues that weren't able to get, take a strong look at some of the literature that's already out there on transperineal prostate biopsies. And I'm sure there'll be more discussion of this at future national meetings during this year. But that I believe is going to be the wave of the future and we have to start thinking about how we adopt it across clinics in the US.

Melanie Cole (Host): Thank you so much for that really comprehensive overview of the annual meeting of the SUO. Thank you again, Dr. Ross, for joining us. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.