David F. Penson, MD, MPH, is the Paul V. Hamilton, M.D. and Virginia E. Howd chair in Urologic Oncology and Professor of Urologic Surgery and Medicine at Vanderbilt University Medical Center at Vanderbilt University Medical Center in Nashville, TN.
He is director of the Center for Surgical Quality and Outcomes Research in the Vanderbilt Institute for Medicine and Public Health.
His primary research interest is in population-based cohorts and assessing patient-reported outcomes in conditions treated with surgical procedures, specifically prostate cancer.
Cancer Therapy Advisor asked Dr. Penson for his views about key recent developments in prostate cancer management.
If you had to pick the most important advance in prostate cancer management in the past 10 years, what would it be?
Dr. Penson: I think the most important advance we have seen in the past decade in prostate cancer management has been the discovery and approval of numerous agents that have been shown to prolong survival in castrate-resistant disease.
While none of these individual agents is “curative” on its own, all represent important steps in that direction. I can only imagine what will happen when we start combining therapies and adding other newly discovered agents.
A number of studies have demonstrated that multiparametric MRI can improve the accuracy of prostate cancer detection. Should clinicians use it routinely in the diagnostic work-up if it is available?
Dr. Penson: I completely agree that MRI has become an important adjunct to prostate biopsy that is improving our ability to detect prostate cancer. This is particularly true when the MRI is used in conjunction with ultrasound to perform a so-called fusion biopsy. I don’t know if we should be using it routinely in all men at risk for prostate cancer, however.
This may not be the most cost-effective way to approach prostate cancer detection. In my practice, I try to reserve MRI-fusion TRUS [transrectal ultrasound] biopsy for men who have a rising PSA and a prior negative TRUS biopsy or men who I am following on active surveillance.
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I am particularly excited about MRI as it is applied to active surveillance, as it may ultimately allow us to avoid some repeat biopsies. That being said, we still need more research in this space.
It remains unclear whether robotic-assisted radical prostatectomy (RARP) results in better oncologic control, but evidence suggests this approach offers advantages over traditional surgery in terms of recovery of potency and urinary continence. Do these advantages by themselves justify the preferential use of RARP?
Dr. Penson: At this point, the question is effectively moot. Roughly 85% to 90% of prostatectomies performed in the United States use the robotic-assisted laparoscopic (RALP) approach, so from a purely quality of care perspective, RALP is preferred because it is the usual approach of most urologists in 2015.