As many of you know, my father emigrated from the Philippines in the mid-1950s after medical school and completed a general surgery and urology residency. At the American Urological Association (AUA) meeting last year, my friend, colleague, and fellow Filipino, Jim Sylora, MD, was instrumental in allowing me to deliver a presentation at the first joint meeting in the United States of the Philippine Urological Association (PUA) and the AUA. During that gathering, I had the good fortune to meet a number of our colleagues from the Philippines, and when the opportunity presented itself to speak at their national meeting on the topic of advanced prostate cancer last November over the Thanksgiving holiday, it was an invitation I could not decline. 

For those of you who have traveled overseas and had the good fortune of interacting with our international colleagues, it is really quite an educational and cultural experience. We are all quite aware of the manpower shortage of urologists in the United States and this is, unfortunately, a ubiquitous problem faced by many countries. The PUA offers only 15 accredited spots for residents in urology annually. This is for a country of 98 million inhabitants. (Compare that with the United States, where we matriculate approximately 300 residents every year with a total population of 320 million people.) The ingress of technologic advances and therapeutics is very limited. Thus, the inability to care for their patients in a fashion that we are accustomed to is quite striking.

However, what is laudable, especially as it pertains to oncologic management, is that the urologist delivers and controls the therapies for prostate and bladder cancer. As previously mentioned, although they may not have approval or access to some of the agents we routinely use, especially in metastatic castration-resistant prostate cancer (mCRPC), it does fall to the urology community for overall delivery. Their search for knowledge and how to better diagnose and manage these patients was quite evident.

One solution that has been put in place to better share information, and is not just relegated to medical care, is the creation of the Association of Southeast Asian Nations (ASEAN). Founded in 1967, this consortium consists of 10 member countries including Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam. From the urologic perspective, they would like to function very much like our brethren in the European Association of Urology (EAU). Getting there, especially in light of the limited economic resources of many of these nations, is going to be a very steep hill to climb. However, their desire and willingness to further educate themselves in order to raise the standards of care and better manage urologic disorders cannot be questioned.

I think it is incumbent on all of us to make real attempts to fill the vast lacuna of knowledge that exists in urology across all of our disease states. We discuss this constantly as it relates to the complexity of urologic malignancies and therapies that have exploded upon us over this past decade. The promotion of physician champions, whether it be for prostate/bladder cancer, overactive bladder, pelvic health, benign prostatic hyperplasia, etc, is becoming the norm. With the introduction of new technologies and panomic testing, it is virtually impossible for us to be renaissance urologists and expect that we can master every aspect of urology and provide state-of-the-art care.

Certainly, this becomes more important in the post-MACRA (Medicare Acess and CHIP Reauthorization Act of 2015) world where outcomes and quality of life for our patients comes with a premium. We have encouraged the creation of centers of excellence within community practice, very much akin to the environment that our academic colleagues have created. There is a realization that at some point our residency programs will need to be revamped as our specialty becomes less invasive. I will also submit, given that we live in the most advanced healthcare country in the world and have access to cutting-edge technology, we owe it to the rest of the world to advance and educate their providers, as well.

Articles

Raoul S. Concepcion, MD, calls for increased oncology education and information sharing among the urology community across the globe, as urologists play a critical role in delivering and managing cancer treatment.
 

A Call to Educate

For many patients with advanced prostate cancer, especially those who live in rural areas, access to cutting-edge clinical trials is a hardship from a travel and financial perspective. Clinical trials are often conducted at large, academic medical centers, and the demanding regimen that accompanies trials can place patients and caregivers in a difficult situation.

Lancaster Urology, one of the largest—if not the largest&mdash;urology practice in western Pennsylvania, fills the geographic void between Pittsburgh and Philadelphia by providing the whole spectrum of urologic care. From genomic testing and diagnosis, to partial nephrectomies and prostatectomies, to drug regimens and clinical trials, Lancaster Urology has been serving the needs of this population since the 1960s.

Lancaster Urology is committed to furthering research and providing the latest care to its patients through a wide variety of clinical trials. “The unique things we’ve offered in the cancer space is not so much new techniques, but with new drugs that aren’t on the market that people are looking for,” says Paul Sieber, MD, FACS, Lancaster Urology’s medical director for research and laboratory. Instead of traveling a great distance and spending more time than they would like seeking treatment, patients can come to Lancaster Urology for the same care. He also sees patients who research clinical trials online, and who are looking “particularly for M0 trials for prostate cancer, which involves patients with rising PSAs and difficult to find metastases. In the past, we’ve also done some renal cancer studies, some trials for people who have peroneus issues, and we did the original Botox trials.”

The group is conducting a study called EMBARK, a trial for people who have not received prior hormone therapy, but have rapidly rising PSAs and no metastases. The study is looking at a standard androgen-deprivation therapy (ADT) versus leuprolide (Lupron) in combination with enzalutamide (NCT02319837). “I think that has some intrigue, in that I wonder whether hitting patients harder [in the beginning of their treatment] would make a difference,” Sieber says.

Other studies Sieber finds interesting are the M0 studies they are conducting, with 3 ongoing (2 closed and 1 still enrolling) for patients who are hormone-treatment naïve, but have rapidly rising PSAs and no metastases. Again, the point of interest is whether early, aggressive interventions make a difference in overall and progression-free survival.

Patients are often incentivized to enroll in clinical trials when they run into financial diffculties with their treatments because their participation grants them access to free drugs. The Affordable Care Act (ACA), Sieber comments, drives many of the patients he sees to high-deductible insurance plans, with the notion that they are going to set up a Health Savings Account to cover the difference, although the amount set aside in savings is not often enough. This leads to many of his patients being unable to afford their ADT, or worse yet, “the cost to start the advanced therapeutics like sipuleucel-T (Provenge) or some of the newer, oral agents which leads to big out-of-pocket expenses they have to cover in terms of their pharmacy deductibles, and patients can’t cover it,” says Sieber.

Sieber also explains that while there is a push to have the drug companies lower their prices, however much they lower them, the drugs are still unaffordable for the average patient. Lancaster Urology sees many elderly patients on retirement pensions, and this presents a financial challenge many patients cannot overcome. Sieber sees some patients who delay starting treatment, due to having to schedule their co-payments strategically in order to make their medical bills’ ends meet. “So they’re not getting advanced care for their prostate cancer because they can’t afford it,” Sieber says. “That’s the big hurdle I see: patients not getting the treatment because they can’t afford it, and I don’t know how to get it for them.”

Therefore, patients are often happy to be able to enroll in one of the many clinical trials Lancaster Urology offers. Sieber stresses that the problem is not on his practice’s end, but rather with the prices of many drugs, and he certainly does not want to “dangle financial incentives” in front of his patients. The best he and his colleagues can offer, at least for the time being, is a stellar clinical trial program.

Another ongoing challenge for Lancaster Urology is maintaining their independence as a practice while competing with hospitals in the area. “We’re seeing that as [other] groups dwindle in size, they’re having even more trouble with recruiting,” Sieber says, and these practitioners are running into issues when they leave their practice.

The number of urologists in the area has started to dwindle, and Sieber thinks the solo practices are not going to merge, but instead are going to hand over their practices, “and that’s going to be a logistical problem for all of us because we don’t want to spend the day driving an hour or an hour and a half to a satellite clinic. And how do we manage those patients in an emergency? We’re not going to cover the local emergency rooms, so we would have to send our patients out, and I think that’s going to be the case for more of our patients,” Sieber explains.

This presents an issue in terms of hospitals hiring urologists, as well. There are issues with recruiting new doctors to smaller practices because the hospitals are enthusiastic to employ them first. “Everyone in my group is continuously getting headhunter ads in e-mails, all the time,” Sieber comments. This breeds a sort of animosity toward hospitals, since they offer large salaries initially, which attracts a lot of younger practitioners. Then after a few years of high pay, the hospitals may change the salary to reflect only as much as those practitioners are bringing in.

Especially in the Lancaster area, a new doctor recruited in this fashion will pay a price in a lack of work/life balance. “You’re always on call,” according to Sieber. In a private practice, Sieber says, you have more control of these factors, whereas in a hospital, it functions more like a corporation. “We’re already seeing that the hospitals have already bought up other practices, so there’s a lot of doctors leaving [hospitals in the area] this year. A number of employed physicians by the hospital have quit this year,” Sieber reports.

The goal, not only for Lancaster Urology but for other independent urology practices, is to learn how to thrive in an environment where the hospitals are competing against them. The largest hospital near Lancaster Urology was recently bought out by the Penn Medicine Health System, and Sieber, and his colleagues, wonder how this will affect their practice.

Sieber predicts that, in the future, smaller hospitals are going to disappear, become part of larger systems, and control costs by controlling the practitioners who work for them. “Urology is unique in that, since our numbers are shrinking, it’s hard to squeeze urologists because they’re hard to find,” Sieber notes. He recommends merging with larger independent groups in order to maintain independence and negotiating power in the market. He also notes that there is a general push for specialization, which keeps individual doctors, and by extension their practices, in demand and different from larger hospitals. “You’re going to have to think about yourself, and what special talent you bring to the table that makes you valuable,” Sieber says.

Lancaster Urology was not always a single group practice. Initially, there were 2 groups, and when the founding urologists came to Lancaster in the 1960s, they established a network of 7 groups. Those 7 groups then lessened to 5 over time, as the groups started to consolidate. In 2012, they merged into a single group, with 3 offices located in Lancaster, Lebanon, and Ephrata, Pennsylvania. The majority of their business is conducted at their main Lancaster office. The group is now comprised of 12 urologists, a part-time pathologist, a part-time radiation oncologist, and 2 nurse practitioners.

According to Sieber, they do occasionally have to send patients to another center, for complex cases that need more specialty treatments, like highly complex pediatric cases, testicular cancer patients, or a renal case where the patient requires major reconstructive surgery for a partial nephrectomy.

However, as Sieber comments, “There’s basically nothing between us and the Philadelphia area groups.” The urology group near Harrisburg is consolidated, and is roughly the size of Lancaster Urology, Sieber says. Other nearby urology practices are significantly smaller. With the next largest practices that offer clinical trials located in Ohio, the travel time for patients is often unreasonable. Lancaster Urology Group sees a number of patients who face this issue, and are glad for Lancaster Urology’s location providing an alternative to an academic center that may be out of reach.

The patients who come to Lancaster Urology, Sieber reports, are unusual compared with other patient populations. Sieber and his colleagues see a higher-than-average Medicare population in their marketplace, as well as more elderly patients. “Lancaster County has become a retirement mecca, and particularly these retirement communities that o er condos, detached houses, or apartments with skilled care, are incredibly numerous here, about 21 different retirement communities,” Sieber says. According to Sieber, they are attracted to the area for a number of reasons, including cheaper housing, no state income tax on pensions, no tax on clothing, and little crime.

Sieber also notes that the Medicare population itself is somewhat different than others, in that the patients he sees tend to be more health conscious. He notices that the majority of his patients have often retired from New York and New Jersey, and because they are relatively more familiar with and close to larger urban areas, they tend to have a relatively progressive mindset about their healthcare. “Especially since we have these elderly patients,” Sieber says, “they don’t want to drive an hour and a half to Baltimore [for an academic treatment center], so if they can get treatment locally, that’s valuable.” “ADT Tuesday” A notable feature of the practice is their clinic for patients with metastatic prostate cancer, providing a variety of treatment options, including ADT. They run what Sieber and his colleagues call “ADT Tuesday.” Roughly 8 years ago, before the practice merged into one, the group purchased its own DEXA scanner, so that they could perform them in house. This led to their initial bone clinic for metastatic prostate cancer patients.

After the group started integrating the scans into their process, it became apparent to Sieber that there was insufficient follow-up for the patients who had abnormal scans, or for whom it was difficult to understand the risk of cancer. It was also clear that maintaining patients on ADT was becoming more difficult, since they had more patients on intermittent therapy. “With that in mind, and also to become more efficient in managing those patients, we morphed our bone clinic into an ADT clinic,” says Sieber.

At the time it was being set up, about 4 years ago, there was some hesitancy, according to Sieber. However, now it has become an integrated routine in Lancaster Urology; if a patient needs to start leuprolide acetate, they are sent to the ADT clinic.

Sieber goes on to explain that “ADT Tuesday” was created, in part, due to issues the practice ran into with insurance. He notes that, in the past, if a patient needed to start on Lupron, they would be able to administer the injection that day. However, prior authorization is now required, and that made it difficult to schedule treatments on Mondays. Thus, Tuesdays became the ideal day to run their ADT clinic. On Mondays, everything is lined up so the patients can receive their treatment in a timely and efficient manner.

Having the treatment administered on a regular schedule has also made keeping track of patients easier, since everybody is scheduled promptly for their next visit. This is especially helpful, Sieber says, since ADT agents are all administered in 4-week, 12-week, 16-week, and 24-week cycles, making scheduling a challenge. Patients and their treating urologists will have vacations, conflicts, or life events that occur in those long spans of time, conflicting with their treatment regimen. Having a consistent scheduling day for ADT administration eliminates this conflict in Sieber’s practice.

As previously mentioned, Sieber and his colleagues offer a wide array of options for their patients. They perform robotic-assisted prostatectomies, prostate cryotherapy, and modest amounts of brachytherapy, since many urologists no longer perform brachytherapy to treat patients with prostate cancer. For patients with kidney cancer, they routinely perform partial nephrectomies and renal cryotherapy. They also offer a variety of medications, like with their ADT clinic, to accommodate each patient’s needs.

The patient volume for metastatic prostate cancer at Lancaster Urology is, as Sieber puts it, “booming.” He notes, in particular, that their use of Lupron and the enrollment in clinical trials studying prostate cancer is unusually high.

“I was talking to my billing manager, and she said, ‘I just can’t believe how many patients we’re giving Provenge, Lupron, and degarelix [Firmagon] to,’ and unfortunately the lack of screening is leading to, for us, robust numbers [of prostate cancer incidence],” Sieber says. The ICD-10-CM code for prostate cancer, C-61, has become the number 1 diagnostic code in their office.

Sieber goes on to explain that the focus on active surveillance falls at for his practice, since he sees a prevalence of aggressive cancer, and therefore, it is nearly impossible for him to see patients for active surveillance when they have metastatic disease. “The number of people that I’m managing now, who have metastatic disease, has just boomed, and others are seeing the same thing... The price we pay for not screening at all is that we’re going to have more people die from this disease,” Sieber comments.

Although he sees more patients with prostate cancer for treatment, these patients have failed on previous chemotherapies and sipuleucel-T, and this presents a greater challenge when trying to treat them. “I think we will see, as has been estimated before, that by 2020, our death rate will be back where it used to be [for prostate cancer],” Sieber notes.

Sieber also believes that diagnosing and treating prostate cancer is going to become more complex because of genomic profiling in high-risk patients. This will be especially challenging when coaching patients who have a family history of prostate cancer. “Now I’m starting to see patients who are BRCA positive, who don’t have prostate cancer yet, but what do we do with that information? I think the next big step is looking at genomics to understand patients’ risks, and I think that’s going to be part of the whole puzzle in the management of prostate cancer in terms of doing specific diagnostic tests,” Sieber says. 

Lancaster Urology, one of the largest urology practices in western Pennsylvania, fills the geographic void between Pittsburgh and Philadelphia by providing the whole spectrum of urologic care. 

Lancaster Urology Brings Clinical Trials to Community Setting

New guidelines involving the immunotherapies nivolumab (Opdivo) and interleukin-2 (IL-2) have been issued by The Society for Immunotherapy of Cancer (SITC) to help practicing clinicians manage patients with renal cell carcinoma (RCC). The updated guidelines are needed because 10 agents have been approved for the treatment of patients with metastatic clear cell RCC, which accounts for 75% to 85% of all cases of metastatic RCC (mRCC) during the past 11 years. Meanwhile, new immunotherapies continue to enter the clinical arena.

For many years, immunotherapies, including interferon-alpha (IFN) and IL-2, have been used to successfully treat patients with mRCC. Newer therapies have been on the rise, however, such as vascular endothelial growth factor (VEGF) inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and immune checkpoint inhibitors.

“Kidney cancer has always been considered to be a disease amenable to immunotherapy but until recently, there had never been any guidelines about the use of IL-2 or nivolumab and some of the emerging agents, so the guide- lines are designed to lay the groundwork as these agents get further developed in RCC,” said Brian Rini, MD, professor of medicine at Cleveland Clinic’s Taussig Cancer Institute and 1 chair of the 20 members of the task force assembled to create the guidelines. This consensus statement is the second publication to come out of SITC’s Cancer Immunotherapy Guidelines initiative, which was expanded in 2014 to include genitourinary malignancies. Currently, SITC has immunotherapy guidelines for prostate and kidney cancer, with guidelines for bladder cancer coming soon.

Unlike the National Comprehensive Cancer Network (NCCN)’s guidelines, which feature a broad range of treatment regimens, the guidelines from SITC’s task force are meant to demonstrate how treating urologists should assess and guide immunotherapy treatments for eligible patients under their care. The intention is also to set the stage for future immunotherapeutic developments in RCC.

“Although the NCCN guidelines are a list of drugs across mechanisms within a particular disease,” Rini says, “this is really meant to focus on immunotherapy and also how it fits into that big picture [of kidney cancer treatment].” This also gives the guidelines a more pointed focus, rather than retreading on known procedures.

Stage IV Renal Cell Carcinoma (RCC) Immunotherapy Treatment Algorithm

Stage IV renal cell carcinoma (RCC) immunotherapy treatment algorithm. All treatment options shown may be appropriate. The final selection of therapy should be individualized based on patient eligibility and the availability of each therapy at the treating physician’s discretion.

“Risk” refers to prognostic risk group per Memorial Sloan Kettering Cancer Center (MSKCC) and/or International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) classification.

For patients with small-volume, indolent metastases, an initial period of observation can be considered accounting for patient age/comorbidities, patient preference, and toxicity of available therapy.

A clinical trial, including those that are immunotherapy-based, should be considered in all RCC patients in all lines of therapy.

As noted in the manuscript, HD IL2 should be considered and discussed with mRCC patients with clear cell histology and good performance status.

For patients with advanced non-clear cell renal cell carcinoma (RCC), if available a clinical trial is the preferred initial treatment option, including trials of checkpoint inhibitors for which limited data exists regarding efficacy in non-clear cell RCC. If unavailable, then a VEGFR tyrosine kinase inhibitor (TKI) is preferred given results from two small randomized trials showing a slight advantage over mTOR inhibitors in this setting. 

Nivolumab is an appropriate initial recommendation in refractory RCC in the absence of contraindications given the overall survival benefit and tolerability. Other options (TKI, HD IL-2 and mTOR inhibitors) can be considered depending on patient performance status, comorbidities, prior therapy received and preference.

 Reprinted from SITC consensus statement on immunotherapy for the treatment of renal cell carcinoma, originally published in the

One main focus, Rini goes on to explain, is “the role of IL-2, the selection of patients for that particular therapy, and the same for nivolumab; how it’s going to be used, duration of treatments, and optimal application of both of those agents, which are obviously the main immunotherapies used in kidney cancer.” Optimal sequencing is becoming even more important in order to provide patients with the greatest chance of durable disease control and survival that is free from symptoms of disease or treatment.

For using high-dose IL-2 therapy, the task force detailed the clinical and biological criteria that should be assessed, as ranked from highest priority to lowest. They considered several physiological features, prior tyrosine kinase inhibitor (TKI) use, Memorial Sloan Kettering Cancer Center risk group, lack of liver or bone metastases, carbonic anhydrase IX protein status, and lack of sarcomatoid histology. The consensus recommendation emphasizes that the histology of the tumor should be the first consideration, in terms of biological factors to consider. The majority of the task force members felt that only patients with clear cell histology should be considered for high-dose IL-2: when discussing whether patients with tumors having sarcomatoid features should receive IL-2, 40% of participants would exclude such patients, whereas 60% would consider patients in this group, depending upon the proportion of sarcomatoid features noted and the biologic behavior of the disease.

Regarding the role of systemic therapy for resected stage II/III RCC, the task force was in agreement. Although clinical trials of high-dose IL-2 and IFN were conducted as adjuvant therapy, results did not support their use in this setting, and the VEGF TKIs sorafenib and sunitinib did not demonstrate bene t relative to placebo in the E2805 ASSURE trial. Therefore, the task force agreed that the current standard of care in the adjuvant setting is either observation or enrollment in a clinical trial.

For mRCC, many treatment centers recommend high-dose IL-2 as the initial treatment, depending on the patient’s clinical condition and ability to tolerate this regimen. Although the task force was divided about the degree of the role that high- dose IL-2 has in initial treatment of mRCC, the overall opinion was that appropriate patients with mRCC who have undergone nephrectomy, either in the past or as a cytoreductive intervention, should have IL-2 as an option and be referred to specialist centers for further discussion when appropriate.

There was additional deliberation on the duration of treatment with high-dose IL-2, with the guidelines noting that although chemotherapy treatment in oncology utilizes repetitive treatment cycles, the necessary treatment duration for immunotherapy continues to be evaluated. Ultimately, the members were split in their recommendation, and 80% of the task force agreed that patients responding 12 weeks following high-dose IL-2 should receive a second 2-week course of therapy.

In terms of disease progression following high-dose IL-2, opinions differed regarding options at progression, even if a patient’s response to IL-2 lasted at least 6 months: 73% of the Task Force members would proceed to another therapy, whereas 13% would recommend another course of high- dose IL-2. This is based on long-term follow-up data from IL-2 studies that show patients with complete responses after surgery continue to demonstrate long term remission and studies that show bene t in patients who progressed on cytokines, according to the guidelines.

The final recommendation was for patients who have a major response to 2 courses of IL-2 and residual oligometastatic disease should be managed with surgical resection of residual disease (73% of the task force agreed), another course of IL-2 therapy (20%), or switch to a TKI (7%). The guidelines caution, however, that all the data considered was anecdotal and so clinical judgment should be the deciding factor.

As far as nivolumab is concerned, the monoclonal antibody was recently approved by the FDA for mRCC following progression on a VEGF-targeted therapy. Phase III studies were not yet reported at the time of the task force meeting, so members voted on their preferred treatment for patients who have progressed on anti-VEGF TKI therapy. Of the task force members, 67% preferred anti—PD-1 agents in clinical trials, 13% would choose IL-2 in appropriate patients after TKIs, and 6.7% would recommend either axitinib or everolimus. Due to their more favorable toxicity profiles, the guidelines note, many patients and physicians would likely prefer immunotherapy with anti PD-1 agents compared with high-dose IL-2.

“The only data for nivolumab is in refractory patients. There’s no real data in untreated patients,” Rini comments. Hence, the recommendation is solely for refractory patients.

These guidelines will be a foundation on which to build more treatment recommendations moving forward. “One of the issues was that, by the time we could publish these guidelines, over the course of their development, things changed with the introduction of nivolumab, and I’m sure by the time we publish them again, there will be a lot of other changes,” says Rini. “There are many investigational therapies, and once they get approved—if that happens&mdash;the guidelines will need to be updated.”

Rini BI, McDermott DF, Hammers H, et al. Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of renal cell carcinoma. 

. 2016;4:81. doi: 10.1186/s40425-016-0180-7.

New guidelines involving the immunotherapies nivolumab (Opdivo) and interleukin-2 inhibitors have been issued by The Society for Immunotherapy of Cancer to help practicing clinicians manage patients with renal cell carcinoma.

First SITC Guidelines in RCC Address Continuing Role of Interleukin-2 and Emergence of Nivolumab

The field of genitourinary (GU) cancers is starting to undergo some of the same changes that have been shifting treatment paradigms so dramatically in other malignancies. The most significant change can be summed up in one word: immunotherapy.

In early February, the FDA moved in rapid succession to approve the PD-1 checkpoint blockade immunotherapy agent nivolumab (Opdivo) for the treatment of patients with metastatic urothelial carcinoma (mUC) after prior therapy and the agency is also considering pembrolizumab (Keytruda), which has the same mechanism of action, for 2 mUC indications under its priority review program. These actions come just months after the May 2016 approval of atezolizumab (Tecentriq), a PD-L1 inhibitor, for patients with mUC.

In short order, then, the armamentarium for treating patients with the most common form of bladder cancer went from a eld where not much had changed for several decades to one pulsing with fresh promise.

This issue of Urologists in Cancer Care® contains full reports of these exciting developments. The good news, however, goes beyond bladder cancer. Our cover story, titled “First-Ever SITC Guidelines in RCC Address Continuing Role of Interluekin-2 and Emergence of Nivolumab,” discusses current evidence-based use of immunotherapies in another GU malignancy.

Immunotherapy also may make an impact metastatic castration-resistant prostate cancer (mCRPC). A phase II study showed that the addition of pembrolizumab to enzalutamide (Xtandi) in patients with mCRPC progressing on the androgen receptor (AR)—directed therapy may be associated with durable responses. In an interview with Dana E. Rathkopf, MD, we learn a great deal about this study, as well as why it is so essential to understand AR resistance in patients with prostate cancer. “Our eld is running to catch up and gure out who is the best patient to get AR-targeted agents and what the mechanisms of resistance are,” said Rathkopf. “Perhaps we can do combinations with chemotherapy, immunotherapy, or DNA mismatch-repair agents. It’s a very exciting time for the eld.”

Despite these positive developments, there is a potentially concerning recent event. Sano will be discontinuing production of Bacillus Calmette-Guérin (BCG) for the US market mid-2017, leaving Merck as the only producer of the vaccine. Merck says it can meet the demand. We certainly hope that turns out to be the case.

As we move forward this year, we will be keeping you posted about all of these developments. As always, thank you for reading.

The field of genitourinary (GU) cancers is starting to undergo some of the same changes that have been shifting treatment paradigms so dramatically in other malignancies. The most significant change can be summed up in one word: immunotherapy. 

February 2017 | Oncology Live Urologists in Cancer Care®

A Call to Educate

Lancaster Urology Brings Clinical Trials to Community Setting

First SITC Guidelines in RCC Address Continuing Role of Interleukin-2 and Emergence of Nivolumab

Genitourinary Cancer Field Gets Off to an Eventful Start in 2017