The lack of cooperation and inability to compromise, at the expense of our country’s best interests, has resulted in gridlock.
Raoul S. Concepcion, MD
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. N Engl J Med. 2016 [Epub ahead of print].