What’s hot at the AUA annual meeting (Monday)?

With many hundreds of prostate cancer-specific posters and oral presentations each day at the meeting, even trying to pick the sessions one wants to cover can be a challenge, but some general trends are becoming evident.

In the first place, while data are being presented from many series of patients to evaluate the impact of particular treatments on prostate cancer-specific mortality compared to overall (all-cause) mortality as a specific endpoint, it is disappointing how few of these series are giving the same level of attention to the onset of clinically evident metastatic disease as an endpoint of comparable significance.

We know that men with metastatic disease are at very high risk for prostate cancer-specific mortality, but we also know that the time from onset of metastatic disease to death has been slowly increasing over the years. The data from the numerous large series of men who have now been followed for 10, 15, and even 20 or 25 years since initial treatment can be broken down by risk factors, clinical stage, Gleason score, etc., and it should therefore be possible to use these data to get better information on time for treatment to both time to metastasis and time to prostate cancer-specific mortality based on initial risk category and precise treatment over time. Unfortunately, few series seem to being sufficiently carefully analyzed based on such criteria, but this information may be particularly important in the treatment of men initially diagnosed with clinical stage T2 to T4 disease.

Secondly, while there is a general acceptance that endorectal coil-based magnetic resonance imaging (eMRI) may be helpful in the initial work-up of at least some patients prior to treatment, there appears to be no consensus on the type of MRI imaging that should be used nor on exactly which patients should be given an MRI. This topic was the subject of a debate this morning between Dr. Ash Tewari (Weill Cornell Medical College; favoring MRI for all patients) and Dr. Joseph Smith (Vandervilt University; favoring MRI only for carefully selected patients).

The question is of course colored by the question of whether one might be able to save money by recommending non-treatment of appropriately selected patients after an eMRI if one gives an eMRI to all patients or whether the cost of giving an eMRI to every patient is exorbitant.

Since (as far as we are aware) there are no well-structured, randomized clinical trials that are either ongoing or planned to address the questions that underlie such a problematic issue, it may well be difficult to resolve an issue like this (whether we can afford all the eMRIs or not).

The urology community still needs to work out ways to explore some of these issues in a much more cooperative matter if we are to be able to see the development of practice standards that all urologists are expected to meet in the management of early stage prostate cancer.

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