(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Ali Nasrallah discussing the BRAVO study assessing white versus blue light cystoscopy in non muscle invasive bladder cancer (NMIBC) among veterans in an equal access setting. Bladder cancer is the 6^th most common cancer in the United States, with 83,190 new cases expected in 2024. Recent studies have shown conflicting evidence regarding the utility and impact of blue light cystoscopy on oncologic outcomes such as recurrence.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Gal Saffati discussing exposures and bladder cancer risk among military veterans. Bladder cancer is a significant concern among veterans, with approximately 3,200 U.S. veterans diagnosed annually, making it the fourth most diagnosed cancer within the Veterans Affairs (VA) system.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on kidney cancer, featuring a presentation by Dr. Kelly Bree discussing indications and outcomes for ablation therapy in renal masses. Dr. Bree notes that each of the AUA, EAU, and NCCN make statements in their guidelines regarding ablation of renal masses. The following is supported by the AUA:

• Statement 25: Clinicians should consider thermal ablation as an alternate approach for the management of cT1a solid renal masses <3 cm in size. For patients who elect thermal ablation, a percutaneous technique is preferred over a surgical approach whenever feasible to minimize morbidity. (Moderate Recommendation; Evidence Level: Grade C)
• Statement 26: Both radiofrequency ablation and cryoablation may be offered as options for patients who elect thermal ablation. (Conditional Recommendation; Evidence Level: Grade C)

The following is supported by the EAU:

• Offer active surveillance or tumor ablation to frail and/or comorbid patients with small renal masses (Strength rating: Weak)
• Perform a percutaneous renal mass biopsy prior to, and not concomitantly with, thermal ablation (Strength rating: Strong)
• When thermal ablation or active surveillance are offered, discuss with patients about the harms/benefits with regards to oncological outcomes and complications (Strength rating: Strong)
• Do not routinely offer thermal ablation for tumors > 3cm and cryoablation for tumors > 4 cm (Strength rating: Weak)

The following is supported by the NCCN guidelines:
 
Ablation is an ideal treatment option for small renal masses in (i) patients who are unfit or refuse surgery, (ii) patients with a prior ipsilateral partial nephrectomy, (iii) those with limited reserve (severe CKD, solitary kidney), (iv) those with genetic predisposition syndromes (ie. von Hippel Lindau). Outcomes of ablation are excellent, with 5 year cancer specific survival rates of ~95% for cT1a tumors. Thus, survival is often not dependent on partial nephrectomy versus radiotherapy versus ablation, but on comorbidities and competing risks of mortality.

There is currently no level 1 evidence comparing modalities, with previous studies having failed to reach accrual targets (ie. SURAB, CONSERVE). The recent NEST trial demonstrated feasibility of recruiting to a cohort-embedded randomized clinical trial comparing cryoablation versus partial nephrectomy:¹

For the remainder of the presentation, Dr. Bree discussed the specific ablative techniques: cryoablation, radiofrequency ablation, and microwave ablation. Starting with cryoablation, Dr. Bree discussed a study from Breen et al. [2] assessing 3- and 5-year outcomes of cryoablation in 220 patients with biopsy-proven RCC. Local recurrence free survival was 93.9% (all recurrences successfully treated with repeat ablation), metastasis free survival was 94.4%, and the major complication rate (Clavien-Dindo 3+) of 4.9%.

In a recent systematic review and meta-analysis performed by Gao et al.,³ they compared the efficacy of cryoablation versus robot-assisted partial nephrectomy in the treatment of cT1 renal tumors. This study included a total of 10 studies comprising 2,011 patients. Compared to robotic partial nephrectomy, the cryoablation group had a shorter hospital stay, less blood loss, and fewer overall complications, but a higher recurrence rate [OR 7.83; 95% CI 4.32 to 14.19; p < 0.00001]. There were no significant differences between the two groups in terms of operative time, minor complications (Clavien-Dindo Grade 1-2), major complications (Clavien-Dindo Grade 3-5), changes in renal function at 12 months post-operation, recurrence-free survival, and overall survival:
Discussing radiofrequency ablation, Dr. Bree highlighted a study from Abdelsalam et al.⁴ assessing the 20-year outcomes of radiofrequency ablation for solitary T1a RCC. Among 243 patients, the median tumor size was 2.5 cm, and the median follow-up was 44 months. The local recurrence free survival rate was 96.5% (ablation zone recurrences treated with ablation n = 3; partial nephrectomy n = 3; active surveillance n = 1; median time to detection: 8.5 months), metastasis free survival rate was 100%, and major complication rate (Clavien-Dindo 3+) of 4.1%. Rates of recurrence after radiofrequency ablation are higher than partial nephrectomy, however, cancer specific survival remains excellent:

Dr. Bree also noted that as a tumor increases in size by 1 cm, the likelihood of residual tumor is 2.19 times higher (95% CI 1.74 – 2.76). Moreover, cryoablation is associated with increased risk of bleeding compared to radiofrequency ablation, with the likelihood increasing with tumor size, central location, and the number of probes used. Microwave therapy is newer and less commonly used than cryoablation or radiofrequency ablation. In a small study of 26 patients, with a mean tumor size of 2.3 cm, and a median follow-up of 19.1 months, local recurrence free survival was 100%, cancer specific survival rate was 94%, and major complication rate (Clavien Dindo 3+) was high at 11.5% (included one death from complications following retroperitoneal hemorrhage, with other complications secondary to complications from bleeding after resuming anticoagulation).

At MD Anderson Cancer Center, Dr. Bree and colleagues follow the algorithm below for deciding on ablation approach:
Previous work from Andrews et al.⁵ assessing 1,422 patients with cT1a renal tumors demonstrates that 5-year local recurrence is rare: 97.7% for partial nephrectomy, 95.9% for radiofrequency ablation, 95.9% for cryoablation:
Additionally, 5-year cancer specific survival were the same in those treated with surgery versus ablation: 99.3% for partial nephrectomy, 95.6% for radiofrequency ablation, and 100% for cryoablation:

Dr. Bree concluded her presentation discussing indications and outcomes for ablation therapy in renal masses with the following take-home points:

• Ablation is a useful tool for the treatment of small renal masses: it avoids a major operation in those patients with comorbidities or a complex surgical history
• Local recurrence is rare, and when needed salvage treatment is often feasible with repeat ablation or surgery
• High grade complications are infrequent and can generally be managed without surgical intervention
• Cancer specific survival is excellent

Presented by: Kelly Bree, MD, Urologist, The University of Texas MD Anderson Cancer Center, Houston, TX

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 South Central American Urological Association (AUA) Annual Meeting, Colorado Springs, CO, Wed, Oct 30 – Sat, Nov 2, 2024.

References:

1. Neves JB, Warren H, Santiapillai J, et al. Nephron Sparing Treatment (NEST) for Small Renal Masses: A Feasibility Cohort-embedded Randomized Controlled Trial Comparing Percutaneous Cryoablation and Robot-assisted Partial Nephrectomy. Eur Urol. 2024 Apr;85(4):333-336.
2. Breen DJ, King AJ, Patel N, et al. Image-guided cryoablation for sporadic renal cell carcinoma: Three- and 5-year outcomes in 220 patients with biopsy-proven renal cell carcinoma. Radiology. 2018 Nov;289:554-561.
3. Gao HY, Zhou L, Zhang JB, et al. Comparative efficacy of cryoablation versus robot-assisted partial nephrectomy in the treatment of cT1 renal tumors: A systematic review and meta-analysis. BMC Cancer. 2024 Sep 16;24(1):1150.
4. Abdelsalam M, Awad A, Baiomy A, et al. Outcomes of Radiofrequency Ablation for Solitary T1a Renal Cell Carcinoma: A 20-Year Tertiary Cancer Center Experience. Cancers (Basel). 2023 Jan 31;15(3):909.
5. Andrews JR, Atwell T, Schmit G, et al. Oncologic outcomes following partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur Urol. 2019 Aug;76(2):244-251.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on kidney cancer, featuring a presentation by Dr. Tyler Robin discussing indications and outcomes for radiation therapy in renal masses. Dr. Robin started his presentation by highlighting the current state of the data for stereotactic ablative radiotherapy for primary renal cell carcinoma.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Chad LaGrange discussing the case for radical cystectomy as treatment for high risk non muscle invasive bladder cancer (NMIBC). According to the AUA guidelines, high grade urothelial carcinoma has the following features:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Cheryl Lee discussing the case for bladder sparing therapy for high risk non muscle invasive bladder cancer (NMIBC). Radical cystectomy offers excellent local control for NMIBC patients, with local recurrence rates of <5%. It also remains the most effective monotherapy for muscle invasive bladder cancer, with a 50%-70% overall survival rate for clinical T2 disease, and 85%-90% overall survival rate for those downstaged after cystectomy to pathologic NMIBC. However, there remains concern for the morbidity of radical cystectomy, which may be as high as a >50%-60% complication rate, as well as a compromised quality of life.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Cheryl Lee discussing the top 10 reasons why BCG as a monotherapy will cease to exist.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Colin Dinney discussing that BCG will always be first line therapy for high risk non muscle invasive bladder cancer (NMIBC). Based on his opinion and experience, Dr. Dinney notes that it is important to understand risk of NMIBC:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Danica May discussing whether there is an end to the BCG shortage in sight. Dr. May notes that BCG is utilized in high risk patients with CIS/high grade T1/high risk Ta urothelial carcinoma with a six week induction course. Importantly, we should avoid use in patients with low or intermediate risk disease:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on bladder cancer, featuring a presentation by Dr. Neema Navai discussing emerging treatments for non muscle invasive bladder cancer (NMIBC).

(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Elizabeth Wulff-Burchfield discussing clinical trial updates for treatment of metastatic prostate cancer. Dr. Wulff-Burchfield started her presentation by highlighted that she would be discussing recent, high impact systemic therapy trials for three different disease states:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Xiaosong Meng discussing focal therapy in prostate cancer. In 2024, there were an estimated 299,010 new cases of prostate cancer diagnosed in the United States, and of these new cases ~60-70% will be low to intermediate risk disease. Supported across multiple guidelines, there are various accepted treatment modalities for the different prostate cancer risk groups:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Lisa Lowenstein discussing transitioning men to watchful waiting for prostate cancer. There is a plethora of literature regarding the safety of active surveillance and the importance of not over-treating nonlethal prostate cancer, however, less is clear regarding how and when to transition men to watchful waiting. Generally, watchful waiting (or observation) is defined as a less intense type of follow-up that includes fewer tests and that relies more on changes in a patient’s symptoms to decide if treatment is needed.

(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Aaron Laviana discussing the con approach for active surveillance among patients with low volume Gleason Grade Group 2 disease. Dr. Laviana started his presentation by highlighting that the NCCN defines favorable intermediate-risk prostate cancer as having all of the following criteria:

(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Lisly Chery discussing active surveillance for intermediate-risk prostate cancer. Dr. Chery notes that it is quite clear that Gleason Grade Group 3-5 prostate cancer requires treatment, and that Gleason Grade Group 1 prostate cancer should be managed with active surveillance.

The 2024 ASTRO annual meeting included a session on prostate cancer, featuring a presentation by Dr. LaToya McLean discussing feasibility, safety, and toxicity of hyaluronic acid rectal spacer in locally recurrent prostate cancer with prior radiation receiving stereotactic body radiotherapy.

(UroToday.com) The 2024 ASTRO annual meeting included a session on novel prognostic tools in prostate cancer, featuring a presentation by Dr. Anna Dornisch discussing P-CARE, a model to stratify risk of any, metastatic and fatal prostate cancer. Prostate cancer screening is controversial and there are many guideline-based recommendations:
Common tenets of prostate cancer screening guidelines include shared decision-making and individual risk assessment. However, subjective risk assessment based on family history and race is neither accurate nor consistent. A polygenic hazard score based on 290 genomic variants (PHS290; calculated from a single saliva sample) is strongly associated with age at diagnosis of aggressive prostate cancer in large datasets, including the racially and ethnically diverse Million Veteran Program:¹

Moreover, PHS290, ancestry, and family history are each independently associated with lifetime risk of metastatic prostate cancer. At ASTRO 2024, Dr. Dornish and colleagues presented data assessing development and validation of a new integrated model for use in the primary care setting, called Prostate Cancer integrated Risk Evaluation (P-CARE). 

Candidate genetic variants in the literature with reported association with prostate cancer, aggressive prostate cancer, benign prostatic hyperplasia, or benign PSA elevation were considered for inclusion in the new PHS model. The investigators used genetic and phenotypic data from a diverse, population-based cohort (Million Veteran Program, n = 585,418). They then fit a LASSO-regularized PHS model using the age at diagnosis of prostate cancer as the time to event, and all the candidate genetic variants as predictors while covarying the first 5 principal components of genetic ancestry. Next, they combined the new PHS with family history and ancestry to create an integrated risk score, P-CARE, again using age at diagnosis of prostate cancer as time to event. Finally, they estimated the hazard ratio performance of the new PHS model and P-CARE using 10 iterations of a 10-fold cross-validation.  This study found 707 unique candidate variants, of which 601 were ultimately included in the updated polygenic score (PHS601). P-CARE combined PHS601, family history, and agnostic genetic ancestry. Risk stratification with PHS601 for the highest 20% risk (vs the lowest 80% risk) had a hazard ratio for metastatic prostate cancer of 6.69 (95% CI 5.70-7.62):

Risk stratification with P-CARE for the highest 20% risk (vs the lowest 80% risk) had a hazard for metastatic prostate cancer of 6.50 (95% CI 5.50-7.38):
The following shows the cumulative incidence curves, as well as highlighting that those men with high risk, have a 21.2% risk of developing prostate cancer by age 70:
Furthermore, the following shows the cumulative incidence curves, as well as highlighting that those men with high risk, have a 21.2% risk of developing metastatic prostate cancer by age 70:
Dr. Dornisch concluded his presentation discussing P-CARE, a model to stratify risk of any, metastatic and fatal prostate cancer with the following take-home points:

• P-CARE provides a single, objective score that can be used in the primary care setting to stratify patients for risk of meaningful prostate cancer
• The investigators will use P-CARE in a nationwide randomized clinical trial to evaluate precision prostate cancer screening in the VA healthcare system (ProGRESS: The Prostate Cancer, Genetic Risk, and Equitable Screening Study NCT05926102)

Presented by: Anna Dornisch, MD, Radiation Oncologist, UC San Diego, La Jolla, CA

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 American Society for Radiation Oncology (ASTRO) Annual Meeting, Washington, DC, Sun, Sept 29 – Wed, Oct 2, 2024.

Reference:

1. Pagadala MS, Lynch J, Karunamuni R, et al. Polygenic risk of any, metastatic, and fatal prostate cancer in the Million Veteran Program. J Natl Cancer Inst. 2023 Feb 8;115(2):190-199.

(UroToday.com) The 2024 ASTRO annual meeting included a session on novel prognostic tools in prostate cancer, featuring a presentation by Dr. John Nikitas discussing the interplay between acute and late toxicity among patients receiving prostate radiotherapy. Dose escalated external beam radiation therapy is the standard of care for localized prostate cancer, with excellent biochemical control rates. Unfortunately, both acute and late toxicity after prostate radiotherapy arises from normal tissue irradiation at the time of treatment.

The 2024 ASTRO annual meeting included a session on novel prognostic tools in prostate cancer, featuring a presentation by Dr. Shalini Moningi discussing the examination of the Decipher® prostate genomic classifier in patients with de novo metastatic disease from a large-scale real-world clinical and transcriptomic data linkage. Metastatic prostate cancer is a heterogeneous population, and disease volume and presentation impact patient prognosis:

(UroToday.com) The 2024 ASTRO annual meeting included a session on novel prognostic tools in prostate cancer, featuring a presentation by Dr. Kosj Yamoah discussing the VANDAAM Study, assessing the impact of Decipher® testing on treatment recommendations in African American and non-African American men with prostate cancer.