Shore Unpacks Treatment Advances for Patients With Urologic Cancers

Neal Shore, MD, FACS, highlights the effect of genetic testing on the treatment paradigm of prostate cancer and the evolving treatment landscape for metastatic castration resistant prostate cancer.

Neal Shore, MD, FACS

As updates in genetic testing methodology, new targeted drug development, and advances in imaging techniques continue to evolve in genitourinary medicine, clinicians are pressed to stay up to date to continue providing optimal care for patients.

Neal Shore, MD, FACS, chair of the continuing medical education (CME) session at the Large Urology Group Practice Association (LUGPA) conference, spoke on the upcoming program and topics that will be featured at the conference occurring November 10-12, 2022, in Chicago, Illinois.

“[The programming] dovetails to our excellence in our annual programming of health policy and administrative excellence,” Shore said. “[It covers] all of the different stakeholders that are involved in the independent practice of urology in medicine.”

In an interview with OncLive®, Shore, medical director of the Carolina Urologic Research Center in Myrtle Beach, South Carolina, and US Chief Medical Officer of Surgery and Oncology at GenesisCare USA, highlighted the effect of genetic testing on the treatment paradigm of prostate cancer and the evolving treatment landscape for metastatic castration resistant prostate cancer.

How has genetic testing affected treatment decisions in prostate cancer?

I often get asked, ‘Why should I bother to do genetic testing?’ Quite a few years ago, this was more of a theoretical construct and not an unfair question. But today, approximately 10% of our patients, depending upon the series, who present with either high risk localized disease, inclusive of metastatic disease, and/or a significant family history, 10% to 12% will have a homologous recombinant repair [HRR] gene alteration.

This is important because it has cascade family testing implications. It is great to know if you are passing generation to generation a BRCA gene or one of the other HRR genes that would help a family member get tested and pick up not only an early prostate cancer, but an early breast cancer, colorectal cancer, pancreatic cancer, [or] ovarian cancer.

[In terms of] additional testing on the somatic side, we pick up another 50% of patients who are negative on the germline who ultimately develop resistant disease. If we do somatic testing, either tissue or blood based, we will pick up circulating tumor DNA in another 50% of patients. So, we have the indication for an entire new class of molecule, PARP inhibitors, where we have HRR-positive mutations.

We have an entirety of interesting gene alterations where we are doing selected clinical trials on PI3K/AKT, patients who have PTEN loss, ATM, and other specific gene alterations. The bottom line is that there is a lot of clinical utility [for testing]; there are familial implications and there are clinical trial implications. I am a big proponent of trying to universalize [or] democratize germline testing.

We are getting there, and we have to help our colleagues understand additionally not only the why but the how, including, how to interpret the reports and how to think about using it from a targeted standpoint of already approved therapies.

What are some of the key updates regarding treatment decisions that will be discussed for patients with metastatic castration resistant prostate cancer?

[In terms of] advanced prostate cancer clinic optimization, we will be talking about patients who present with both de novo and/or recurrent castration sensitive disease. We are going to be reviewing level 1 evidence for couplet therapy and triplet therapy.

Likewise, in castrate-resistant prostate cancer, we recognize that patients will benefit if they get more than 1 line of therapy. Oftentimes patients only receive 1 to 2 lines of therapy before they unfortunately succumb to the disease. We will be reviewing opportunities to combine life-prolonging agents, sequencing judiciously, so that patients are given the best opportunity for prolonged survival, and at the same time preserving their quality of life and preventing complications of therapy. That will all be in the context of understanding optimizing biomarker testing as well as the appropriate imaging.

What are some of the topics that will be covered at this year’s LUGPA conference?

We [will] have a panel that includes leaders in advanced oncology practices; advanced leaders in benign prostatic hyperplasia [BPH], incontinence, stone disease. This year [will also include] a novel and innovative topic module titled, ‘Optimizing Ambulatory Surgery Center Utilization.’ The topics that we will be covering [include]robotic procedures within outpatient ambulatory surgery centers, potentially including prostatectomy and nephrectomy.

We will be highlighting advances in percutaneous upper track management. Historically it has been stone disease, but now [it is] urothelial carcinoma as well, [in addition to] outpatient urethral reconstruction, focal therapies, and the ever-important penile implant advances for our patients with erectile dysfunction.

[Another] topic that is bread and butter to urology is BPH in lower urinary tract treatments. [The session is called], ‘De-Obstructing the Mouse Traps.’ There are so many different types of ways to deobstruct the prostate including historical pharmacologic [approaches] and we are going to be looking at prostatic arterial embolization. We are going to be addressing all the different ablative technologies as well.

That will be followed by PSMA [prostate-specific membrane antigen] PET. Everyone recognizes the era of next-generation imaging has markedly changed and we will be addressing not only the clinical, but also the economic utilization [of this technique]. Many of our practices are very cutting edge in terms of procuring over the years CT and MRI [equipment], but now we are looking at the potential for a PSMA-PET.

We are [also] going to have a very innovative session called, ‘Appreciating Diversity in Urology Care.’ I am the most excited about this session because we have never had anything like it. We are honored to have a leader in gender affirming surgery, Bradley Figler, MD, FACS, from the University of North Carolina as well as, Channa Amarasekera, MD; and Diana Bowen, MD, [from Northwestern] who have done an incredible amount of cutting-edge work in urology for our patients in the LGBTQ+ population.

I realize that for many of our colleagues this is something they are completely unfamiliar with. We certainly did not get much of this in training for those who have been out in practice for 10 years and more, but this is an extremely important area to understand how you can optimize your clinic for these patient populations and understand the challenges that are ongoing in gender affirming evaluation.

We typically always have within our CME 2 sessions on optimization of advanced prostate cancer clinic and optimization of advanced bladder cancer clinic and, by extension, the advanced kidney cancer clinic. We have phenomenal faculty, including Alicia Morgans, MD, MPH; Evan Y. Yu, MD; Emanuel Antonarakis, MD; Colin Denny, MD; Arlene Siefker-Radtke, MD; Joshua Meeks, MD, PhD; and more.

This is an opportunity for our colleagues to understand what are the most recent contemporaneous advances, the most important trials that have been presented in the last year and published, and what is on the horizon. We will be going through a review of complete genetic profiling, the importance of both germline and somatic testing—when to do it, how to do it, and why to do it.

Finally, we are going to have a session I call, ‘Spacer Wars.’ It is about the use of spacers in the perirectal space for our patients undergoing radiation therapy. Historically, we have had only the SpaceOAR [Hydrogel] for the last several years. Recently we have had the approval of another spacer. It has some differences in different nuances and administration applications, it's known as barrigel.

There is a third device, it is not yet FDA approved, it’s pending approval potentially in 2023, and it is known as the BioProtect [Ballon spacer] device. What is going to be fun about this last presentation is we will have 3 radiation oncology experts highlighting and debating the differences amongst these 3 different spacer technologies. Importantly, we will have LUGPA radiation oncology members Neil Mariados, MD; and Shawn Zimberg, MD, on the panel leading the question-and-answer section.

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