Approximately four years after the FDA approval of two powerful new oral androgen-targeting agents for metastatic castration-resistant prostate cancer (mCRPC), an analysis raised issues complicating treatment with the two drugs, as well as what oncologists don’t yet know.

 serves to heighten clinical awareness of the potential for both under-treatment and over-treatment with abiraterone acetate, as well as potential drug-drug interactions with both abiraterone acetate and enzalutamide.

Common Drug-Drug Interactions May Be Manageable

The study also takes a position on a discrepancy between the labeling approvals by the FDA and EMA. While regulatory agencies of both regions suggest that clinicians should avoid using enzalutamide along with strong CYP3A inducers such as oxycodone or methodone, the FDA suggests that an elevated dose of the cancer drug may be feasible when such co-administration cannot be avoided. In the article, the authors hypothetically adopt the FDA’s position.

“Prostate cancer patients tend to be in their sixth, seventh, and eighth decades of life, so some of them are on many medications,” said Robert Dreicer, MD, professor of medicine and urology at the University of Virginia, who commented on the paper in an interview with Urologists in Cancer Care. “But I don’t look at this as a deal breaker. Most of the time the interactions can be managed without having to stop the other drugs.”

Abiraterone acetate and enzalutamide are thought to work by blocking secondary processes for prostate cancer growth. The primary treatment for patients with prostate cancer is to block the production of testosterone (the hormone that initially drives the tumor), but all patients will ultimately develop resistance. “As to how cancer cells become resistant to the lack of testosterone, there are many hypotheses,” said Jorge Garcia, MD, department of Hematology and Oncology, Cleveland Clinic.

“The first source of growth for the tumor is the androgen receptor, an antenna activated by the male hormone testosterone, but in the absence of that hormone, how can you still have growth through that antenna? Another pathway is the adrenal gland, which produces early androgens that can mimic testosterone and therefore activate the receptor,” explained Garcia, who is the principal investigator in an ongoing clinical trial of enzalutamide following radical prostatectomy (NCT01927627).

While oncologists have used androgen-targeting agents before, the two newer agents are more powerful, and unlike the previous intravenous drugs, are available in oral form. However, both drugs affect the CYP system of enzymes, and are metabolized in the liver.

“Many drugs do that, so if the drugs are competing for the same breakdown pathway, the drug may be metabolized more slowly,” explained Dreicer.

In conducting their review of available literature, researchers Benoist et al conducted a search of the PubMed and EMBASE databases for full-text articles in English describing studies conducted in humans, and published no later than February 22, 2016, for a total of 22 papers. Benoist and colleagues also included registration data from the regulatory agencies and data from the website Clinicaltrials.gov.

Other commonly used drugs which may have interactions with abiraterone acetate and enzalutamide include the commonly prescribed cholesterol agent gemfibrozil, rifampicin (prescribed for tuberculosis), the cough suppressant dextromethorphan, the diabetes drug pioglitazone, and, potentially, acid-reducing agents for GERD.

According to a drug interaction study carried out by Gibbons and colleagues, gemfibrozil, a CYP2C8 inhibitor, increased the exposure of enzalutamide 2.2-fold. Itraconazole increased the exposure 1.3-fold, and rifampicin decreased the exposure by 66%.

 Therefore, the dosage of enzalutamide should be reduced to 80 mg per day when used in combination with CYP2C8-inhibiting drugs, according to the reviewers.

While an older prostate cancer drug, ketoconazole, also has an inhibitory effect on abiraterone acetate, it is not commonly used in patients on the newer agent, so the effect is clinically irrelevant, the paper said.

Additionally, not only should care be taken when co-administering enzalutamide with anti-seizure medication, but enzalutamide has also been associated with seizures even in patients without a known seizure disorder, Gibbons et al wrote in the article. The authors noted that regulators had requested a postmarketing safety trial to assess the risk.

Dosing According to Bioavailability Factors

“Enzalutamide crosses the brain-blood barrier and competes with chloride channels in GABA receptors. Seizure activity was seen in the AFFIRM trial in 0.9% of patients on enzalutamide and 0.1% of patients, 1 to be exact, in the PREVAIL trial. However, the neurocognitive dysfunction from enzalutamide is far more important than seizure activity (just by incidence),” explained Garcia in an email interview.

Not only are drug interactions a potential issue for abiraterone acetate and enzalutamide, but research shows that several factors beyond co-administration may affect the drugs’ activity, opening up the possibility for a wide variety of dosing strategies that have not yet been sufficiently researched, according to the review. Due to a wide variation in the bioavailability of abiraterone, “hypothetically, a subgroup of patients will be undertreated at the normal dose of 1000 mg once daily,” researchers noted.

On the other hand, according to several studies cited by the article, the bioavailability of the drug was between 2 and 17 times greater in patients who took the drug after a meal, compared with those who took the drug without food, although regulators recommend that abiraterone acetate be taken in fasting conditions. These findings merit further research, according to the article.

The authors noted that oncologists have sometimes used a drastically reduced dose of abiraterone in patients with severe hepatic impairment. In one such study, patients with severe liver impairment received a greatly reduced dose (125 mg) compared with the healthy volunteers (2000 mg), the article noted. Other research showed that the half-life of the drug only increased by a little over three hours, even in patients with severe renal impairment. Notwithstanding the dosing and drug interaction issues, these two agents have provided a much-needed line of treatment options for patients with advanced disease. Yet, neither drug is a cure.

“These drugs are pretty amazing; they’ve really revolutionized the way we treat prostate cancer,” said David Jarrard, MD, professor of urology at the University of Wisconsin Carbone Cancer Center. “Both are well-described and have been studied in tens of thousands of patients. The interactions can be managed just by keeping an eye on the patient’s liver function tests to make sure patients don’t get in trouble.”

Neither age, testosterone levels, nor BMI have been shown to affect abiraterone exposure, and the drug appears to have the same pharmacokinetics in Asians as in Caucasians. But research is lacking for other biomarkers, the article said, noting that “[n]o formal studies have been conducted to assess the influence of age, weight, height, or genetic polymorphisms on drug exposure and treatment response.”

“The biggest questions right now are, ‘What is the appropriate sequence and what is the right phenotype?’” explained Garcia. For example, in a 2014 study of 62 men with prostate cancer patients, researchers showed that a mutation in the androgen-receptor isoform encoded by splice variant seven, which lacks the ligand-binding domain that enzalutamide and abiraterone target, plays an important role in the effect of both drugs.

 “They proved that if patients have that variant, the likelihood of benefit from either drug is close to zero,” noted Garcia. “Both drugs are in a myriad of clinical trials, particularly in combination with other novel agents such as sipuleucel, radium 223, and likely upcoming studies with PARP inhibitors,” added Dreicer.

Benoist G, Hendriks R, Mulders P, et al. Pharmacokinetic aspects of the two novel oral drugs used for metastatic castration-resistant prostate cancer: abiraterone acetate and enzalutamide. [Published online April 22, 2016.]

Gibbons JA, de Vries M, Krauwinkel W, et al. Pharmacokinetic drug interaction studies with enzalutamide.

European Medicines Agency. European Public Assessment Report (EPAR): Zytiga (abiraterone acetate). London: European Medicines Agency; 2016.

Antonarakis ES, Lu C, Wang H, et al. AR-V7 and resistance to enzalutamide and abiraterone in prostate cancer. 

Articles

Approximately 4 years after the FDA approval of 2 powerful new oral androgen-targeting agents for metastatic castration-resistant prostate cancer, an analysis raised issues complicating treatment with the 2 drugs, as well as what oncologists do not yet know.

Second-Line Therapies for mCRPC Complicated by Drug Interactions and Dosing Issues

A group practice that adopts an eat-what-you-kill mentality in which compensation is grounded in activity-based cost-accounting practices, can benefit even more by expanding its collaborative and cooperative efforts. In eat what you kill, physicians are paid based on how much revenue they produce and expenses are paid individually.

An advantage of this mentality is that it combats the issue of medical group inertia, which is brought on by unproductive and uncompensated activities related to financial squabbling. The bickering and sniping can drag group morale down, along with income levels. Physicians, who are generally highly independent people, can get caught in the doctrines and quirks of group dynamics that run counter to their natures.

This philosophy won’t work for groups that lack a shared sense of obligation and culture.

As a group, Rio Grande Urology shares a sense of obligation and culture. Its leaders have embraced an integrative model approach and sees the advantages of it. It was formed by 4 urology practices merging to build a main campus that houses the cancer center and radiation therapy center. The group includes 16 physicians, 4 mid-level practitioners, and over 130 employees in El Paso, Texas, and Las Cruces, New Mexico.

“The integrative practice makes everything centralized,” said Jeffrey Spier, MD, managing partner. “It’s a model that we’re building upon. The future of medicine reduces duplication of services, so we’re seeing a lot of cuts in test ordering. Patients are noticing an increase in the seamless care that we provide.”

Discussions about patient care can encompass radiation oncology, medical oncology, urology, and now, in a unique situation, gynecologic oncology. Spier said the relationship between urologic oncology and gynecologic oncology is significant. “They are pelvic surgeons and so are we, so we collaborate about surgical issues.”

There were a number of reasons that partnering with a gynecologic oncologist made sense, said Spier. He points toward the radiation model, which helps to draw the entire group together. “First, many of gynecology oncologist’s patients receive radiation therapy, and his practice is in the same complex as our radiation center. This enhances our collaborative efforts. Second is the convenience factor for his patients. They are able to have access to consultants, including medical oncology and our radiation oncologist, as well as imaging options that include computed tomography and ultrasound located on the same campus. And third, the gynecologic oncologist can continue to teach in the academic setting, but maintain a private practice.”

The collaboration can also open up future opportunities. “We have begun using high-dose rate (HDR) radiotherapy for pelvic tumors that involve different types of gynecological cancers. The capacity to collaborate revolves around that cancer front,” said Spier.

The integrative mindset has taken hold across the country, said Spier, whose partners have bought into this group structure. Going back to a solo practice or small practice would not be an option, although Spier admits there is greater autonomy associated with a small practice. The collaborative model does require giving up a certain amount of autonomy.

But in today’s healthcare reform environment, a collaborative mindset can improve patient outcomes. He points out, for example, the opportunity to optimize the use of referrals within the practice. “Should I continue to perform a robotic prostatectomy, which I may schedule once monthly, or should I refer to a colleague who has done the procedure hundreds of times? What’s important here is the patient outcome. Leave the ego at the door,” he said.

There are further opportunities for the initial referring urologist, said Spier. “This allows me to open my practice up to more general urology, for example.” In the practice, subspecialization is readily embraced. No one urologist can be the best in all aspects of delivering care, and the structure of the group permits and encourages referrals.

“Originally, our group had a top-down structure, with a CEO at the top,” he said. “It did not work out as well as we hoped because physician involvement in administering and running the practice was lacking. We learned that the practice functions better when physicians have ownership. In the past 2 years, we incorporated a managing partner and medical director. We’ve seen practices that rely solely on administrators, with no physician involvement, slowly go away, and we didn’t want that to happen here.”

One of the characteristics of a large practice is the breadth in treatment it brings to men with low- and high-grade prostate cancer.

“Active surveillance has changed the dynamics in low-grade prostate cancer,” said Spier. “We’re seeing greater use of genomic testing that helps clinicians make decisions to benefit the patient. We probably have overtreated patients in the past, but we did not have many of the tools today at our disposal.”

For the patient with high-grade prostate cancer, the establishment of an advanced prostate cancer clinic allows the urologist to treat the patient from the time of diagnosis to the time that hospice has to be arranged, Spier said. “We have promoted the use of a physician champion in which 1 physician manages those patients who are castration-resistant. It cuts down on duplication of services because that physician prescribes the correct medication, understands the diagnostic and therapeutic limitations, and does not overtreat.”

Medical oncologists have a role, said Spier, but “prostate cancer should be and can be treated by those urologists trained in treating prostate cancer. We are not taking the medical oncologist out of the picture, but we feel competent enough to engage in care from start to finish.”

The urology group expects to roll out their in-house pharmacy in December. Spier said that Texas has stricter regulations in terms of pharmacist hiring, with a full-time pharmacist onsite. Their specialized pharmacy will be able to dispense oral oncolytics, such as abiraterone and enzalutamide, which will complement treatments already offered, including radium-223 and sipuleucel-T.

 Through their partnership with the gynecologist oncologist, Spier expects the group to expand their services to include an infusion center. Eventually, he would like to include docetaxel and chemotherapy for prostate cancer, and, potentially, treatment for other urologic tumors.

“The advanced prostate cancer clinic serves as an impetus to explore other centers that can be built—a men’s health clinic, women’s clinics, an infertility clinic. All these centers can be integrated into a large practice.”

The group is looking to launch a men’s health clinic to include treatment of erectile dysfunction, benign prostate hyperplasia treatment, and low-testosterone treatment. “We are seeing a lot of ramifications of health clubs treating men with low testosterone levels in our area, especially when these men are not followed appropriately.”

When the partnership with the gynecologic oncologist is ironed out, the group expects to eventually launch a female incontinence clinic to treat overactive bladder and to manage women with pelvic floor dysfunction. Spier views urology as a model for other subspecialties to demonstrate the importance of physician collaboration. He believes that through collaboration, the patient ultimately will benefit.

“We should not feel handcuffed to explore how we can better our practice because expanding our reach will only serve to improve the lives of our patients.”

As a group, Rio Grande Urology shares a sense of obligation and culture. Its leaders have embraced an integrative model approach and sees the advantages of it.

Rio Grande Urology Expands With Gynecologic Oncology Collaboration

Patients with renal cancer who underwent cytoreductive nephrectomy (CN) and targeted therapy (TT) had improved survival compared with patients who did not undergo the surgery, according to research from the Dana-Farber Cancer Institute and Brigham and Women’s Hospital.

 Historically, only 3 in 10 such patients undergo the procedure.

The researchers reported that patients who underwent the procedure survived for a median period of 17.1 months compared with 7.7 months for those who didn’t receive the surgery. The finding corroborates the survival benefit of CN with TT in previously reported studies. The 1-, 2-, and 3-year overall survival (OS) rates were 62.7% (95% CI, 61.3%-64.1%), 39.1% (95% CI, 37.7%-40.6%), and 27.7% (95% CI, 26.3%- 29.1%) versus 34.7% (95% CI, 33.7%-35.8%), 17.1% (95% CI, 16.2%-17.9%), and 9.8% (95% CI, 9.1%-10.5%) for CN and non- CN patients, respectively.

“As we’ve learned about the molecular pathways that drive the disease, drugs that specifically target those pathways have come into wide use,” said the co-lead author, Toni Choueiri, MD, in a statement. “It hasn’t been clear whether this has led to a reduction in CN, whether the procedure improves survival in patients being treated with targeted therapy, and whether some categories of patients are more likely than others to receive the surgery,” continued Choueiri, clinical director of the Lank Center for Genitourinary Oncology and director of the Kidney Cancer Center at Dana-Farber Cancer Institute.

Most current guidelines call for CN to be performed in conjunction with TT for patients deemed to be good candidates for the procedure. Studies have shown that patients with poor survival outcomes or with rapidly advancing cancer are less likely to benefit from the surgery. In his study, Choueiri and his associates identified 15,390 patients with metastatic renal cell carcinoma (RCC) who had been treated with TTs between 2006 and 2013. Only 5374 of those patients, or about 35% of the total, underwent CN, the researchers found. The study is the largest sample size to date showing that CN has an OS benefit in patients treated with TT, while adjusting for other factors, according to the researchers. The investigators also found that patients who were younger, privately insured, treated at an academic medical center, and had smaller tumors were more likely to have the surgery performed.

 showed that CN patients had improved OS compared with non-CN patients treated with vascular endothelial growth factor (VEGF) therapy (19.8 vs 9.4 months; HR, 0.44; 

 showed that the median OS of patients with metastatic RCC treated with TT with CN versus without CN was 20.6 months vs 9.5 months, respectively (

The reason why surgery provides a survival benefit for many patients is unclear, said the researchers, but they theorize that the primary tumor may be especially aggressive and drive metastatic growth elsewhere in the body. Removing it may therefore slow the spread of the disease.

Limitations of the study include its retrospective analyses and the National Cancer Database (NCDB) used for the study. The NCDB does not contain information on important preoperative laboratory variables that have been shown to be independent prognostic factors and does not list the exact TT used (eg, VEGF or mammalian target of rapamycin inhibitors), said the researchers. Future investigations will focus on identifying which patients are most likely to benefit from the surgery.

“The study underscores the importance of careful selection of patients who are good candidates for this surgery,” said Maxine Sun, PhD, the co-lead author of the study. “As we become better able to identify patients likely to derive the greatest benefit from surgery, survival rates may further improve.”

Hanna N, Sun M, Meyer CP, et al. Survival analyses of metastatic renal cancer patients treated with targeted therapy with or without cytoreductive nephrectomy: a national cancer data base study [ePub ahead of print]. 

Choueiri TK, Xie W, Kollmannsberger C, et al. The impact of cytoreductive nephrectomy on survival of patients with metastatic and renal cell carcinoma receiving vascular endothelial growth factor targeted therapy. 

Heng DYC, Wells JC, Rini BI, et al. Cytoreductive nephrectomy in patients with synchronous metastases from renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium. 

Patients with renal cancer who underwent cytoreductive nephrectomy and targeted therapy had improved survival compared with patients who did not undergo the surgery.

Survival Improved With Surgery/Targeted Therapy Combo in Renal Cell Carcinoma

I would suspect that the majority of us have watched with increasing disgust and disdain the partisan politics that have gripped our nation’s capital over the past decade. The lack of cooperation and inability to compromise, at the expense of our country’s best interests, has resulted in gridlock. Perhaps more significant, as a result of this political standoff, we are now facing a presidential election in November where the 2 candidates nominated by the major parties are unattractive to the majority of the US population. Are these really the best candidates that we can offer up to be Commander-in-Chief of a country of 320 million people? Stay tuned as interesting times are ahead for all of us, regardless of your political affiliation.

Unlike the current political climate, the urologic community has recognized the need for cooperation amongst the specialties in order to optimally provide benefit and survival advantage for our patients.

Over the past few years, in this publication and others, we have extolled the need for the field of urology to manage our prostate cancer patients from diagnosis to death. It hasn’t been easy. Along the way, there has been significant resistance to this notion, especially when it comes to delivering therapies for men with advanced prostate cancer.

The Halsteadian principle of radical surgery is not applicable in the metastatic setting, and many of our colleagues have maintained an unwillingness to go beyond what is traditional and comfortable as classically trained surgeons. However, progress is being made as many of the large integrated groups across the United States have created models and centers of excellence to deliver oncologic care under the urology umbrella.

This demand for collaborative efforts will only increase. We already work closely with our radiology brethren to assist us in our efforts to better diagnose significant prostate cancer by utilizing multiparametric MRI for fusion biopsy. The interventional radiologists continue to play a significant role in the management of small renal masses and this, too, will increase as we push for more core biopsy for molecular testing in appropriately selected patients. Advanced imaging techniques and the potential for targeted therapy using some of these newer agents (eg, prostate-specific membrane antigen or the synthetic L-leucine analog FACBC) are currently being developed and may yet offer another therapeutic option for some of our patients with metastatic disease.

Many groups in the country have successfully developed radiation centers within their practice. As we know, the ability to offer all forms of therapy for prostate cancer, not just one modality, provides for our patients the opportunity to have true informed consent when it comes to managing their disease. More importantly, by having radiation oncology colleagues as part of the care team, patient cases are reviewed internally without patients having to schedule another appointment with a physician apart from the urology office, where, more than likely, he has been followed for many years. The next extension with this model is now the ability to also deliver radiopharmaceutical agents, which as our readers know can only be administered by radiation oncologists or nuclear medicine physicians.

As many of us realize, the present opportunity (and challenge) that we need to address is the delivery of all the new targeted agents and immunotherapies that are now flooding the market on what seems to be a weekly basis. For prostate cancer, we have enthusiastically embraced the use of autologous immunotherapy in the form of sipuleucel-T. This has become a foundation of therapy for men early in the disease process of metastatic castration-resistant prostate cancer. For our patients affected by muscle-invasive bladder cancer and those with advanced renal cell carcinoma, the number of agents has expanded dramatically. Pembrolizumab, nivolumab, and atezolizumab, all PD-1/PD-L1 inhibitors, have been approved by the FDA over the past year for GU cancers as we enter this era of immune therapy. Some of these agents are also being tested in combination with historic intravesical agents in the nonmuscle- invasive space. The potential for all these agents to be used in combination with other oncolytics that are mechanistically different presents a challenge, but also hope for our patients.

Molecular testing will be driving much of these therapeutic choices across all tumor types. We are cognizant of the array of splice variants in the androgen receptor as it relates to their role in resistance mechanisms in patients with castration resistant prostate cancer. Herculean efforts by the Stand Up to Cancer and Prostate Cancer Foundation Dream Team have identified somatic and germ line mutations, many of which will be actionable.1 We are gaining a better understanding of basal versus luminal cell types amongst patients with muscle-invasive bladder cancer and how they may/ may not respond to platinum-based neoadjuvant chemotherapy. Core biopsy of small renal masses (<4 cm) is gaining traction for better risk stratification, and genomic sequencing to help determine aggression will soon be forthcoming.

As we prepare for the transition from volume- to value-based medicine, I am convinced that urologists are well positioned to be the primary caregivers for the tumor types we treat across the entire care cycle. We will need the assistance of our colleagues in order to achieve better outcomes for our patients. By definition, achieving better outcomes is the key to value-based medicine and will be our charge moving forward.

Pritchard CC, Mateo J, Walsh MF, et al. Inherited DNA-repair gene mutations in men with metastatic prostate cancer.

The lack of cooperation and inability to compromise, at the expense of our country’s best interests, has resulted in gridlock.

In Politics, Not Everybody Works Well Together

As summer comes to a close, I want to turn your attention to the upcoming 34th Annual Chemotherapy Foundation Symposium: Innovative Cancer Therapy for Tomorrow®, which takes place in New York City, November 9-11, 2016. We will be introducing the recipients of the 2016 Giants of Cancer Care®, an award bestowed to honor the tireless efforts of oncology specialists who have dedicated their careers to saving, prolonging, caring for, and improving the lives of the patients affected by this disease.

During the symposium, 10 new Giants will be revealed in breast cancer, gastrointestinal cancer, genitourinary cancer, hematologic cancer, lung cancer, melanoma, radiation oncology, scientific advances, surgical oncology, and community outreach. We will also be kicking off the 2017 Giants of Cancer Care initiative during the symposium and we look to our readers for their thoughtful nominations for the next class of Giants.

To get you into the Giants mindset, we highlight the career of Patrick Walsh, MD, who dedicated his life to improving the surgical techniques of radical prostatectomy to reduce the mortality and morbidity associated with the surgery. His work conducted at the Brady Urological Institute at Johns Hopkins University refined radical prostatectomy and transformed the procedure into a safe, effective, and tolerable surgery, one that has not only extended countless lives, but has also preserved quality of life. If you are feeling the need to be inspired, I cannot emphasize more this Giant’s story.

In other features, the pharmacokinetic benefits of abiraterone acetate and enzalutamide are weighed in, “Second-Line Therapies for mCRPC Complicated by Drug Interactions and Dosing Issues.” Writer John Otrompke highlights the findings from a study published in Clinical Pharmacokinetics, which heightens clinical awareness of the potential for both under-treatment and overtreatment with abiraterone acetate, as well as potential drug-drug interactions that accompany both agents.

These agents represent a much-needed line of treatment options for patients with advanced disease. Yet, neither is a cure. Although the paper did not provide a definitive answer about superiority, the authors’ results do suggest the next focus of ongoing research: identifying the appropriate sequence and finding the right phenotype of the patient to respond to treatment.

Our Conference Coverage section highlights presentations made at the 2016 State of the Science Summit—Genitourinary Cancer. The meeting brought together community- and academic-based physicians and healthcare professionals across key disciplines in medical and surgical oncology. It has become readily apparent that the treatment landscape for genitourinary malignancies is undergoing a rapid change with emerging immunotherapies making a significant impact in urothelial and bladder cancer.

Our Practice Profile feature in this issue highlights the large urology group Rio Grande Urology, based in El Paso, Texas. The group is excited about its newest collaboration with a gynecologic oncologist and the therapeutic options that it can offer to patients. Viability and physician collaboration is emphasized under the leadership of Jeffrey M. Spier, MD. He believes that integrative urologic group practices should serve as the model for other subspecialties because “when physicians come together and share their experiences and successes, the patient ultimately benefits.”

We look forward to receiving your feedback and comments on the topics covered in this issue and any topics that you would like addressed in future editions.

As summer comes to a close, I want to turn
your attention to the upcoming 34th Annual
Chemotherapy Foundation Symposium: Innovative
Cancer Therapy for Tomorrow®, which takes place in New
York City, November 9-11, 2016.

August 2016 | Oncology Live Urologists in Cancer Care®

Second-Line Therapies for mCRPC Complicated by Drug Interactions and Dosing Issues

Rio Grande Urology Expands With Gynecologic Oncology Collaboration

Survival Improved With Surgery/Targeted Therapy Combo in Renal Cell Carcinoma

In Politics, Not Everybody Works Well Together

Inspiring Stories Emerge From the Giants of Cancer Care Initiative