Events

Videos

Podcasts

Articles

Genitourinary Cancers Symposium (ASCO GU)

Small renal masses identified in elderly patients can be safely managed by surveillance and maintain the same mortality risk as those who undergo surgery, suggesting that surgery could be avoided altogether in many patients, according to the results of a study presented at the 2013 American Society of Clinical Oncology Genitourinary Cancers Symposium.

A retrospective analysis of more than 8300 elderly patients with small renal masses showed that surveillance versus surgical resection of the masses led to a similar rate of kidney cancer-specific mortality — about 3% over a median 59 months of follow-up. Moreover, the study found that patients managed with surveillance had a lower risk of cardiovascular complications and death from all causes compared to those managed with surgery.

“Although surgery is the current standard of care for small renal masses, our analysis indicates that physicians can comfortably tell an elderly patient, especially a patient that is not healthy enough to tolerate anesthesia and surgery, that the likelihood of dying of kidney cancer is low, and that kidney surgery is unlikely to extend their lives,” said lead author William C. Huang, MD, assistant professor in the Department of Urology at New York University Langone Medical Center, New York City.

Huang said that it is difficult to tell which of the small tumors will become lethal, so surgery should remain the treatment of choice for elderly patients in good health with an extended life expectancy, while surveillance would be preferred for elderly patients with a short life expectancy and those with considerable morbidities.

The study was based on the Surveillance, Epidemiology, and End Results (SEER) registry data linked to Medicare claims for patients aged 66 or older diagnosed with renal masses that were under 4 cm in diameter. Of 8317 patients, 7148 had a pathological diagnosis; 78% underwent surgery and 22% were managed by surveillance.

At a median follow-up of 59 months, 21% of patients had died, with 3% of deaths attributed to kidney cancer. The cancer-specific mortality was the same in both groups.Â  Overall, 24% of patients experienced a cardiovascular event during follow-up.Â  Over time, surveillance was associated with a significantly lower risk of experiencing a cardiovascular event compared with surgery (hazard ratio [HR] = 0.51; 95% CI, 0.44 — 0.60; 

 > .00001) and a lower risk of death from any cause, with a lowered hazard ratio observed between 7 and 36 months (HR = 0.70) and an even lower ratio observed beyond 36 months (HR = 0.37).

Huang speculated that the surgery, even partial nephrectomy, may be a causal event leading to cardiovascular problems via a reduction in kidney function that accelerates chronic kidney disease.

The authors conclude that surveillance with modern imaging techniques is a safe option for management of small renal masses in elderly patients.

“The majority of these small tumors are incidental and found by CT scan for other reasons,” said Bruce Roth, MD, Washington University in St. Louis, MO, moderator of the presscast where these findings were released “Lesions of this size can be indolent or malignant. We would like to avoid unnecessary surgery in this group of patients. It is important that this study showed no negative impact on increasing kidney cancer mortality with following the lesions. Surgical intervention, however, carries increased risk of cardiovascular events and death. Watchful waiting is reasonable.”

	Huang WC, Pinheiro LC, Russo P, et al. Surveillance for the management of small renal masses: utilization and outcomes in a population-based cohort. Presented at: 4th Annual Genitourinary Cancers Symposium; February 14—16, 2013; Orlando, FL. Abstract 343.

View coverage from the 2013 GU Cancers Symposium

Small renal masses identified in elderly patients can be safely managed by surveillance and maintain the same mortality risk as those who undergo surgery, suggesting that surgery could be avoided altogether in many patients.

Small Renal Masses in Elderly Can Be Managed by Surveillance

Deepak A. Kapoor, MD, president of the Large Urology Group Practice Association, chairman and CEO of Integrated Medical Professionals, PLLC, discusses the implications of a large study looking at the detection of prostate cancer using prostate biopsies.

The study examined the overall positive biopsy rates in 437,937 biopsies between 2005 and 2011. Samples were examined in both national reference and urology practice laboratories. Overall, the study found that positive rates were similar in both groups, at 40.3%. In addition to positive rates, the trial examined the number of vials collected per biopsy, which reached approximately 10 by 2011.

Kapoor notes that from a practicing urologists standpoint this data confirms that optimal detection of prostate cancer requires the collection of 10 to 12 cores. Additionally, from a health policy standpoint, these results indicate that positive biopsy rates are the same at both a national and individual practice level. Furthermore, for patients, these results can provide comfort that a biopsy is being performed for an appropriate clinical purpose and not financial gain.

Deepak A. Kapoor, MD, president of the Large Urology Group Practice Association, discusses the implications of a large study looking at the detection of prostate cancer using prostate biopsies.

Dr. Deepak Kapoor on the Utilization of Prostate Biopsies

Shortening the course of androgen blockade (AB) therapy from 36 months to 18 months when combined with radiation therapy does not appear to compromise outcomes in patients with high-risk prostate cancer, according to results of a randomized, multicenter, Phase III study reported at the 4th Annual Genitourinary Symposium held February 14-16, 2013 in Orlando, Florida.

The study found that both overall survival (OS) and disease-specific survival (DSS) were similar in patients who received 36 or 18 months of treatment.

Hormone therapy is associated with uncomfortable and disturbing side effects that negatively impact quality of life. These include hot flashes, decreased libido, impotence, and fatigue, which are among a group of symptoms known as the “castration syndrome.” The ability to treat high-risk disease with a shorter course of hormone therapy could have a major impact on quality of life for these patients.

“A long list of side effects makes the lives of most of our patients quite miserable,” commented lead author Abdenour Nabid, MD, associate professor at Centre Hospitalier de Universitaire de Sherbrooke in Sherbrooke, Canada. “A shorter course could reduce the quantity and intensity of its unpleasant side effects as well as treatment costs. We hope these results will convince doctors that they can stop hormone therapy after 1.5 years instead of 2 to 3 years.”

The study enrolled 630 patients with node-negative, high-risk prostate cancer treated with radiotherapy to the pelvic area and prostate bed. They were randomized to either 36 months ( n = 310) or 18 months (n = 320) of AB therapy (bicalutamide 50 mg for 1 month plus goserelin 10.8 mg every 3 months) given before, during, and after radiation.

Patient characteristics were well balanced between the two arms, with a median age of 71 years, median PSA of >20 ng/mL, and a median Gleason score of  >7.  The majority of patients had stage T3-4 disease.

At a median follow-up of 77 months, the two groups had no significant difference in biochemical failure, metastasis, bone-only metastasis, and cause of death. Mortality rates were 22.9% (71 patients) in the longer-duration hormone therapy arm versus 23.8% (76 patients) in the shorter-duration arm.  Of 147 deaths, 116 were deemed unrelated to prostate cancer.

Five-year OS was 92.1% in the longer-duration arm versus 86.8% in the shorter-duration arm, and 10-year OS was 63.6% versus 63.2%, respectively. Five-year DSS was 97.6% and 96.4%, respectively, and 10-year DSS rates were 87.2% in both arms.

The main cause of death was second cancer (7.3% of patients); 4.9% died of prostate cancer, and 4.4% of cardiovascular disease.

Dr. Abdenour Nabid on a Shorter Duration of ADT in Prostate Cancer

“In localized prostate cancer patients treated with radiation therapy and androgen blockade, treatment with 18 months of androgen blockade is safe. This could represent a threshold for no further gain,” noted Nabid.

“This study could change the standard of care from 36 months to at least 24 months and perhaps 18 months, if the full, peer-reviewed publication bears these findings out,” said Bruce Roth, MD, Professor, Department of Medicine, Washington University, St Louis, Missouri, who moderated a press briefing February 12 where the findings were presented.

	Nabid A, Carrier N, Martin AG, et al. High-risk prostate cancer treated with pelvic radiotherapy and 36 versus 18 months of androgen blockade: results of a phase III randomized study. Presented at: 4th Annual Genitourinary Cancer Symposium; February 14-16, 2013; Orlando, FL. Abstract 3.

Shortening the course of androgen blockade therapy from 36 months to 18 months when combined with radiation therapy does not appear to compromise outcomes in patients with high-risk prostate cancer

Shortened Hormone Therapy Course Feasible for High-Risk Prostate Cancer

A large, retrospective study has found that high-risk prostate cancer that can only be detected through prostate-specific antigen (PSA) testing is more likely to occur among men over the age of 75 and in African Americans, according to research reported at the 2013 Genitourinary (GU) Cancers Symposium.

The findings come amid a continuing debate over the merits of PSA screening, particularly after the US Preventive Services Task Force (USPSTF) recommended against routine screening for the general male population last May based on the finding that the harms of overdiagnosis outweigh the potential benefits of screening.

The results of the study presented this week suggest that PSA testing can be useful in identifying an aggressive form of prostate cancer in asymptomatic men with early disease that is not detectable by physical exam or other tests.

In their population-based study, researchers from the University of Rochester Medical Center in New York determined that elderly men account for approximately 40% of all cases of high-risk, PSA-detected prostate cancer and are 9.4 times more likely than men under the age of 50 to be high risk. African-American men of any age are more likely than white men to have high-risk disease.

In addition, intermediate-risk prostate cancer was more likely to occur among elderly and African-American men, the study found.

“To the best of our knowledge, this is the largest analysis exclusively consisting of PSA-detected prostate cancer (T1cN0M0 disease). We found that men age 75 and older and African Americans are at highest risk of intermediate or high-risk disease,” stated lead author Hong Zhang, MD, PhD, an associate professor of Radiation Oncology at the University of Rochester, during a press conference where the results were announced.

“If we stop PSA screening altogether, there is no other method to detect this form of prostate cancer sufficiently early to have the best chance of helping this group of high-risk patients,” Zhang said. “The findings of this study will help physicians and certain patients make more informed decisions on whether or not they want to proceed with PSA testing, although more research (and longer follow-up) is needed to determine the effects of early detection and intervention on outcome in these high-risk patients.”

The study included 70,345 men with early-stage, node-negative prostate cancer diagnosed between 2004-2008 enrolled in the Surveillance, Epidemiology and End Results (SEER) database.

PSA criteria and Gleason stage were utilized to determine the probability of developing low-, intermediate-, and high-risk prostate cancer. Low risk was defined as PSA <10 ng/mL and Gleason score ≤6; intermediate risk was defined as PSA 10-20 ng/mL and/or Gleason score 7; and high-risk disease was defined as PSA >20 ng/mL and/or Gleason score ≥8.

Among the study population, 47.6% had low-risk disease; 35.9% had intermediate-risk, and 16.5% had high-risk.

Men age 75 or older were 4.47 times more likely to develop intermediate-risk disease and nearly 9.4 times more likely to develop high-risk prostate cancer compared with patients under the age of 50 (

African-American men were also significantly more likely to develop intermediate- and high-risk disease compared with white men; they were 1.5 times more likely to develop intermediate-risk prostate cancer and 1.84 times more likely to develop high-risk prostate cancer (

By comparison, white men age 75 or older accounted for 11.8% of this population, including 24.3% of intermediate- and 26.1% of high-risk disease.

Bruce J. Roth, MD, who moderated the press conference where these data were discussed, said the study showed that numeric age probably is not the most important determinant of who should be screened and that perhaps life expectancy within an age group should be taken into consideration.

The American Society of Clinical Oncology (ASCO) provisional clinical opinion call for men with a life expectancy of more than 10 years to discuss PSA screening with their physicians.

“Screening recommendations have been all over the map, ranging from ‘everyone should be screened’ above the age of 50 to ‘no one should be screened’,” said Roth, who is a professor of Medicine at Washington University in St. Louis, Missouri. “The answer is somewhere in between, and this study gives us some important information but adds to the complexity of this issue.”

The GU symposium is co-sponsored by ASCO, the American Society for Radiation Oncology, and the Society of Urologic Oncology.

	Zhang H, Travis LB, Messing EM, et al. PSA-detected prostate cancer in the United States: a population-based study of 70,345 men with AJCC stage T1cN0M0 disease. Presented at: 4th Annual Genitourinary Cancers Symposium; February 14-16, 2013; Orlando, FL. Abstract 50.

A large, retrospective study has found that high-risk prostate cancer that can only be detected through PSA testing is more likely to occur among men over the age of 75 and in African Americans.

Genitourinary Cancers Symposium (ASCO GU) | Conference

Small Renal Masses in Elderly Can Be Managed by Surveillance

Dr. Deepak Kapoor on the Utilization of Prostate Biopsies

Shortened Hormone Therapy Course Feasible for High-Risk Prostate Cancer

Aggressive Prostate Cancer Risks Higher in Elderly, African-American Men