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AUA Annual Meeting

Raoul S. Concepcion, MD, the Director of Clinical Research and a Urologic Surgeon at Urology Associates, PC, in Nashville, Tennessee, discusses the new guidelines on prostate cancer screening that were issued by the American Urological Association (AUA).

These guidelines are largely in response to recommendations made by the US Preventive Services Task Force (USPSTF) against PSA screening. Concepcion expects these guidelines to be controversial, since they seem to contradict the USPSTF.

The overarching theme, Concepcion believes, is a need for transparency with patients. The new guidelines are more individualized, stressing the importance of discussing options with patients. Moreover, Concepcion notes, it remains important to ensure that high-risk patients are aware of early detection programs.

View more from the 2013 AUA Annual Meeting

Raoul S. Concepcion, MD, from Urology Associates, PC, discusses the new guidelines on prostate cancer screening that were issued by the American Urological Association.

Dr. Concepcion on the AUA PSA Screening Guidelines

Leonard G. Gomella, MD, professor and chair of the Department of Urology at the Thomas Jefferson University Hospital Kimmel Cancer Center, discusses the clinical guidelines released by the American Urological Association (AUA) at its 2013 Annual Meeting.

The new guidelines for patients with castration-resistant prostate cancer (CRPC) are an important highlight from the AUA meeting, Gomella states. These guidelines include recommendations on PSA screening and the use of radiation therapy following radical prostatectomy. The guidelines on PSA screening will likely continue to fuel controversy on this topic, Gomella expects.

Overall, Gomella feels, the topics included in these guidelines will attract a great deal of national attention, since they address many of the challenges that physicians are currently facing in the treatment of men with prostate cancer.

Leonard G. Gomella, MD, from the Thomas Jefferson University Hospital Kimmel Cancer Center, discusses the clinical guidelines released by the American Urological Association at its 2013 Annual Meeting. 

Dr. Gomella on AUA's New Prostate Cancer Guidelines

The urology workforce will fall more than 50% short of projected needs by 2025, according to a study reported Sunday at the annual meeting of the American Urological Association (AUA) in San Diego, California.

An estimated 16,000 urologists will be needed to provide specialty care, but estimates of the number of urologists likely to be in practice at that time range between 6800 and 7400.

An analysis based on workforce data from 2009 indicated that the total number of urologists would decline by 29% and full-time equivalents by 25% by 2025.

An existing lack of urology services in underserved areas, particularly rural areas, will worsen as the urology workforce declines, researchers believe. About 12% of practicing urologists are in rural areas, where about 20% of the population of the United States lives.

“There is a widening chasm occurring in the supply of urologists in the United States, especially in rural areas,” Raj S. Pruthi, MD, director of Urologic Oncology at UNC Health Care, University of North Carolina at Chapel Hill, said during a press conference at the AUA meeting.

Multiple factors are contributing to the problem, said Pruthi and press conference moderator Christopher M.  Gonzalez, MD, MBA, a professor of Urology at Northwestern University Feinberg School of Medicine in Chicago.

Since Medicare funding for medical education has been frozen since 1998, a growing proportion of urology residency positions have been funded by alternative sources, usually revenue from clinical services. The growing population of older patients will continue to strain urology services and resources, as will the increasing prevalence of several urologic conditions, including nephrolithiasis, benign prostatic hyperplasia, incontinence, and urologic malignancies.

Demographically, urology is an older medical specialty, Pruthi noted. The mean age of urologists in the United States is 52.5 years. From 1981 to 2009, the proportion of urologists older than age 55 increased from 24% to 44%, and the proportion older than age 70 from 3.4% to 7.4%.

The declining urology workforce in rural areas portends potentially dire clinical consequences, said Gonzalez. Currently, about 58% of all counties in the United States have no practicing urologists. Studies have shown a significantly higher mortality rate for patients with bladder, renal, and prostate cancers in areas not served by urologists. Moreover, rural urologists are about two years older than their urban counterparts, suggesting that retirements will drain the existing workforce.

Proposed legislation in Congress would increase residency positions by 15%, still far below the projected demand. Some estimates indicate the number of urology residency slots needed by 2025 will increase by more than 40%.

“This contraction in the workforce may affect patient suffering and outcomes,” said Pruthi. “A lower density of urologists may lead to increased mortality in patients who have urologic cancers. Issues such as demand, access, and outcomes will be important contributors, but they are beyond the scope of this study.”

Solving the workforce problem will require creative solutions, which the AUA is exploring and will continue to investigate with other interested parties that have a stake in the issue, said Gonzalez.

	Kirby W, Ferguson J, Johnson D, et al. Future supply of urologists: projected to decrease dramatically between 2009-2025

. 2013;189(4):e171-e172(suppl; abstr 422).

View coverage from the 2013 AUA Annual Meeting

An estimated 16,000 urologists will be needed to provide specialty care by 2025, but estimates of the number of urologists likely to be in practice at that time range between 6800 and 7400.

Dramatic Shortage of Urologists on Horizon

Patients with castration-resistant prostate cancer (CRPC) should receive treatment supported by the best evidence for specific disease characteristics, according to a clinical guideline developed by the American Urological Association (AUA).

The guideline, the AUA’s first for the treatment of CRPC, outlines a course of action based on six “index patients,” ranging from men with asymptomatic, nonmetastatic CRPC to those with symptomatic, metastatic disease, poor performance status, and previous exposure to docetaxel chemotherapy. The guideline was presented today during the AUA’s 2013 Annual Meeting in San Diego, California.

“The timing was right for a guideline, because there is a lot going on in the field of prostate cancer, including the recent approval of four new therapies for castration-resistant prostate cancer and the hope that more new agents are coming,” said guideline committee chair Michael Cookson, MD, of Vanderbilt University in Nashville, Tennessee.

“When you have a lot of management or treatment options that are extending the life and improving the quality of life of these patients, it’s confusing for practitioners in terms of when to use them, knowing when the agents are appropriate,” Cookson continued. “In developing this guideline, we hoped to cast a net, look into what’s available, and then put the information into a user-friendly clinical algorithm for practicing physicians.”

Historically, men with metastatic CRPC (mCRPC) have had a median survival of less than 2 years. However, the approval of four new agents in a span of less than 3 years has helped improve survival, even though mCRPC remains an incurable disease, Cookson said in his introduction to the guideline at the AUA meeting.

“While greater availability of effective agents benefits patients, multiple options and sequencing may complicate decision making,” he said.

Following an extensive literature review that extended to February 2013, members of the guideline-writing committee assembled a clinical algorithm that recommended certain therapies at different stages of the disease. The authors organized the information and recommendations according to the applicability of therapies to six types of patients.

The index patients and their guideline therapies are based on presence or absence of metastatic disease, degree and severity of symptoms, performance status, and prior docetaxel therapy. The clinical document also addresses protection and preservation of bone health in all six types of patients.

Index patient 1 has asymptomatic, nonmetastatic CRPC, for which the AUA recommends observation with continued androgen deprivation therapy. Physicians may offer first-generation antiandrogens or androgen synthesis inhibitors to selected patients who are unwilling to accept observation. Physicians should not offer systemic chemotherapy or immunotherapy, except within the context of a clinical trial.

Index patient 2 has asymptomatic or minimally symptomatic mCRPC and no history of exposure to docetaxel. For this patient, treating physicians should offer abiraterone + prednisone, docetaxel, or sipuleucel-T, assuming the patient has good ECOG performance status. Because the agents have not been compared directly in head-to-head clinical trials, sequencing should be guided by toxicity profile, beginning with the least toxic agent, according to the AUA.

Patients who do not want or cannot be treated with a standard therapy can be offered first-generation antiandrogen therapy, assuming they have good performance status.

Index patient 3 has symptomatic mCRPC, good performance status, and no prior exposure to docetaxel. According to the guideline, clinicians should first offer docetaxel to these patients, if they have good performance status. Alternatively, clinicians may offer abiraterone + prednisone. If such a patient does not want or cannot be treated with standard therapies, clinicians may offer ketoconazole + steroid, mitoxantrone, or radionuclide therapy. According to the AUA, physicians should not offer estramustine or sipuleucel-T to patients who meet index 3 criteria.

Index 4 patients have symptomatic mCRPC and no prior treatment with docetaxel but have poor performance status. The AUA advises clinicians that they may offer abiraterone + prednisone to these patients or, if the patients refuse or are unable to receive that course of treatment, ketoconazole + steroid or radionuclide therapy.

In select index 4 patients whose performance status is directly related to the cancer, clinicians may offer docetaxel or mitoxantrone but should not offer sipuleucel-T.

Index patient 5 has symptomatic mCRPC, good performance status, and a history of treatment with docetaxel. For these patients, clinicians should offer abiraterone + prednisone, cabazitaxel, or enzalutamide. In select patients who received abiraterone before docetaxel, clinicians should offer cabazitaxel or enzalutamide.

In situations wherein abiraterone, cabazitaxel, or enzalutamide are unavailable, ketoconazole + steroid may be offered. Index 5 patients might also be offered retreatment with docetaxel if they discontinued because of reversible side effects and were benefiting from the agent at the time of discontinuation.

Index patient 6 has symptomatic mCRPC, poor performance status, and prior docetaxel treatment. These patients should be offered palliative care, or, alternatively for selected patients, abiraterone + prednisone, enzalutamide, ketoconazole + steroid, or radionuclide therapy.

“Of course there is flexibility in the guideline, but clinicians should recognize that the level of evidence dictates the statements and recommendations we can make,” said Cookson. “The AUA has set the bar high in terms of supporting evidence, and we followed the criteria to ensure that clinicians get the most evidence-based information possible.”

The AUA recommends that clinicians address bone health for all patients, regardless of index status. Clinicians should offer preventive therapy for fractures and skeletal-related events (SREs). For patients with bony metastases, treating physicians may offer denosumab or zoledronic acid for prevention of SREs.

“Although our primary objective was treatment of the disease and true survival benefit, bone health is important to all patients with castration-resistant prostate cancer,” said Cookson. “We recognized this and addressed it in the guideline.”

	Cookson MS, Roth BJ, Dahm P, et al. Castration-Resistant Prostate Cancer: AUA Guideline. Presented at the American Urological Association Annual Meeting; May 4-8, 2013; San Diego, California.

The American Urological Association outlines clinical guidelines for sequencing castration-resistant prostate cancer therapies based on six "index patients" each with specific disease characteristics. 

AUA Offers Evidence-Based Guide For Sequencing CRPC Therapies

	Little Use of Neoadjuvant Chemotherapy Prior to Radical Cystectomy

The 108th American Urological Association (AUA) Annual Meeting held May 4-8 in San Diego, California, contained over 2,000 presentations focused on urologic medicine. This entry contains summaries of four abstracts focused on urothelial, testicular, and prostate cancer.

Despite offering several potential benefits, neoadjuvant chemotherapy prior to radical cystectomy remains underutilized, a review of a large surgical database showed.

From 2005 to 2010, 8.9% of almost 900 cystectomy candidates received preoperative chemotherapy. Analysis of 135 variables failed to identify any compelling arguments against neoadjuvant chemotherapy.

“There is no increase in overall complication rate associated with neoadjuvant chemotherapy on bivariable analysis,” David Johnson, MD, of the Division of Urologic Surgery, Department of Surgery, at the University of North Carolina at Chapel Hill, concluded at a presentation.

“On multivariable analysis, there is no difference in postoperative complications, reoperation rate, wound dehiscence, wound or organ-space infection, or operative time for patients receiving neoadjuvant chemotherapy versus those who did not get neoadjuvant chemotherapy when accounting for all significant confounding variables,” he continued.

	US Testicular Cancer Rates Increasing, Especially Among Hispanic Men

The favorable comparison makes a case for increasing the use of neoadjuvant chemotherapy prior to radical cystectomy, particularly given the well-documented 5-year survival benefit conferred by preoperative administration of platinum-based combination regimens, said Johnson. (

Another study reported at the AUA meeting documented a continued rise in the incidence of testicular cancer in the United States. Previous studies showed an increased rate of testicular cancer from 1992 to 2003.

Spanning the years 2003 to 2009, the new data from the National Cancer Institute Surveillance, Epidemiology, and End Results program showed that Caucasian men have the highest rate of testicular germ-cell tumors (8.6 cases/100,000 in 2009, compared with 7.5/100,000 in 1992. However, the largest increase occurred among Hispanic males (4.0/100,000 in 1992 versus 6.3/100,000 in 2009). Reasons for the increase are unknown, but speculation has included environmental factors and various types of 

 exposures, said Scott Eggener, MD, associate professor of Surgery/Urology at the University of Chicago Medical Center. (

	Better Survival With Radical Prostatectomy Over Radiotherapy

Long-term results from a Swedish study pointed to better survival with radical prostatectomy versus radiation therapy for prostate cancer. The analysis included 34,515 men with prostate cancer listed in a national registry. The study population consisted of 21,533 patients treated surgically and 12,982 treated by radiation therapy.

With a 15-year follow-up, the investigators found that prostatectomy improved survival for patients with localized prostate cancer, and results were similar between the two modalities for locally advanced/metastatic cancer.

	More Urinary Incontinence in Older Prostate Cancer Patients

Hazard ratios showed significant benefits for surgery with respect to prostate cancer-specific mortality in men with low- and intermediate-risk disease, younger patients, and those with lower comorbidity scores. Radiotherapy was superior for older men (65-74) with advanced cancer, Peter Wiklund, MD, professor, Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska  Institutet, Stockholm, Sweden and colleagues reported. (

An analysis of urinary incontinence and bother in older prostate cancer patients suggested a higher burden of urinary health problems than previously recognized. About 60% of 706 men 65 or older reported incontinence. Multivariate analysis showed that surgical management was associated with a prevalence ratio (PR) of 4.68 versus similar-age patients without prostate cancer, followed by those treated with androgen deprivation therapy (PR 2.01), active surveillance (PR 1.92), and radiation therapy (PR 1.64). Only radiation therapy was not associated with an increased rate of urinary bother, Ryan Kopp, MD, of the Division of Urology at the University of California, San Diego, and colleagues reported in a poster presentation. (

The 108th AUA Annual Meeting held May 4-8 in San Diego, California, contained over 2,000 presentations focused on urologic medicine. This entry contains summaries of four abstracts focused on urothelial, testicular, and prostate cancer.

AUA Abstract Roundup

Expectant management is widely underused in the treatment of prostate cancer in the United States, according to a paper presented today during the 2013 Annual Meeting of the American Urological Association in San Diego.

Fewer than 10% of American men with newly diagnosed prostate cancer opted for expectant management in the first 10 years of this century, including the low-risk and older men most likely to benefit from the strategy, an author of the paper, Matthew Maurice, MD, at Case Western Reserve University, explained during the presentation.

Expectant management includes active surveillance and watchful waiting, and is meant to minimize the overtreatment of prostate cancer, Maurice and co-author Hui Zhu, MD wrote.

“Given estimates of prostate cancer overdiagnosis as high as 40%, expectant management has been persistently underutilized, even in patients with low-stage cancers and limited life expectancy,” Maurice said. “This is an alarming trend, given the high-level evidence to support its use.

In an analysis of the National Cancer Database, the authors found that the annual use of expectant management in America remained stable at between 7.5% and 9.8% from 2000 through 2009. However, they reported, employment of the strategy increased significantly within the Veterans Affairs (VA) health system, where rises were seen in categories for which expectant management is most appropriate.

“VA hospitals led US hospitals in the use of expectant management, especially in men well-suited for this approach, while hospitals relying on third-party payers lagged behind,” Maurice said. “The reasons for this pattern are likely multifactorial, possibly involving economic factors, technology factors, and patient-driven factors.”

Maurice and colleagues queried the database—which included about 70% of newly diagnosed cancers in the United States&mdash;regarding prostate cancers diagnosed from 2000 to 2009 and the first-course therapy employed in each case. They evaluated the use of expectant management by patient risk, age, comorbidity burden, and practice setting.

The only major increase in expectant management occurred in the VA system, where the proportion of prostate cancer patients who opted for the tactic increased from 19.7% at the beginning of the study period to 30.8% at the end. The total use of expectant management in the VA system included 53.7% of all patients with stage I prostate cancer, 28% of patients 70 or older, and 27% of patients with two or more comorbid conditions.

In contrast, the lowest rates of expectant management were seen in comprehensive cancer centers, where the strategy was used in about 9% of stage I cancers, 9% of patients with two or more comorbid conditions, and 8.5% of patients 70 or older.

The authors suggested that “the type of reimbursement system may play an important role in EM adoption,” a possibility they said should be studied further to avoid the overtreatment of prostate cancer.

	Maurice M, Zhu H. Persistent Underutilization of Expectant Management for Prostate Cancer Last Decade in the United States. Presented at: The 2013 Annual Meeting of the American Urological Association; May 4-8, 2013; San Diego, California. Abstract 220.

Expectant management, which includes active surveillance and watchful waiting, is widely underused in the treatment of prostate cancer in the United States.

Use of Expectant Management Lags in Prostate Cancer

The 108th American Urological Association (AUA) Annual Meeting is being held at the San Diego Convention Center from May 4 - 8, 2013, and features research, guideline updates, and the latest advances in urologic medicine.

AUA Annual Meeting | Conference