Mostly surgical/urology content posted from Melbourne, Australia. Plus all episodes of GU Cast. Professor Declan Murphy is Urologist & Director of GU Oncology at Peter MacCallum Cancer Centre, Australia's leading Comprehensive Cancer Centre. www.declanmurphy.com.au www.gucast.org
I did not understand why I had to suffer a biopsy. PSA 2000, bone scan showed extensive mets to upper skeleton, I mean everywhere. PSMA PET Scan after biopsy simply confirmed the bone scan and showed-up a met in a pelvic lymph node. The biopsy was done after the bone scan for what? All it did was raise my PSA to 3500 and I was put on ADT immediately anyway. Result of the biopsy - I couldn't sit down for a week and needed a catheter for six weeks afterwards. It's eventual removal was horrendous for two days after, pissing pure blood, then pushing clots until it cleared up. I sometimes wonder if you doctors and the guidelines you follow understand anything. From what I can make out all it did was give me a Gleason 9 diagnosis, SoC sucks.
Had a RP in April, 4 lymph nodes removed as well. Path Report GG4, Gleason score 8, pT3aN1. Three month PSA coming up soon. I realize the risk is pretty high for metastasis, if I need radiation can i do it without ADT? Thank you, Joe
Regarding Dr. Flesher's lutetium PSMA-Germany story, I find it interesting that Dr. Hofman did a sabbatical with Dr. Richard Baum at Zentralkinik Bad Berka in 2016. Seems like we have Germany and doctors like Richard Baum to thank for the spread of PSMA RLT throughout the world.
If systematic biopsy is still recommended for focal treatment planning, what happens if the initial focused biopsy turns up PCa that requires treatment? Does the patient then have to undergo a systemic biopsy for focal treatment planning?
I greatly appreciate the best academic minds giving their opinions. Being an 85 yr old retired specialist physician with metastatic prostate cancer I am glad to hear increasing discussion on how to assist patients decide with their oncologist or urologist what is the best treatment approach. Developing a regularly performed quality of life assessment would help. Patients need to know what side effects they may suffer and for how long. Also what is the expected life extension with various treatments based on the data from studies.
Thanks so much for the comment, and we wish you all the best with your cancer management. We couldn't agree more, In our recent podcast with Dr Alicia Morgans (a top expert on Survivorship and QoL), we heard some really good views on this. Best of luck! Declan and Renu
Sequencing ARPIs in a control arm isn't debatable. It's unethical, based on Phase 2 data showing that the response rate for sequencing abiraterone followed by enzalutamide is only 30%, and for enzalutamide followed by abiraterone, a dismal 5-7%. Sequencing abiraterone and enzalutamide has shown it does not improve overall survival in several clinical trials. Using ARPI sequencing as a control arm because its suboptimal overestimates the benefits of whatever is being studied in comparison. Ensuring that control arms consistently represent the best current standard of care is essential to protecting patients and maintaining the integrity of the clinical trial process.
Amazing new research and great to see Declan keeping us up to date with current clinical research over seas. Ongoing refinement and as always a man has to meet the criteria to access these treatments.
I appreciate the open minded discussion rather than blind fixation on a standard of care mantra. We are all different so there is no one size fits all.
Thank you! Outstanding episode. Super relevant to me. Diagnosed at 52 with Gleason 9, oligometastatic (lymph nodes plus one bone met) disease. Did triplet therapy plus radiation to prostate, pelvic LNs and bone met. I’m about 2 years into it and fighting the quality of life issues with long term ADT.
Sorry to hear that Bob. So tough but hope you are doing great. You might enjoy listening to our two previous podcasts with Tim Baker. He was diagnosed with metastatic prostate cancer aged 49 and has some amazing insights into ADT and managing side-effects. Sending you our best wishes. Declan and Renu
I had brachytherapy and 16 external beam radiation sessions as well as 4 mos of ADT in Oct. 2022. I was so miserable after six months that I begged my urologist to let me start TRT. It's been a year and my testosterone has gone from 32 to 720 and my QOL is night and day. I did have a single tumor in a single lymph node found with a PSMA Pet scan after my PSA rose from 1.5 to 3.9. I had 17 lymph nodes removed on April 17, 2024 and in addition to the tumor, they found four with microscopic Pca. I will get another PSA test in four weeks to see if the residual PSA has washed away, and then I assume start active surveillance to see if the PSA once again rises. I've told my cancer team that I would prefer 8-10 great years (I am a world class master's athlete) than 15-20 so-so years, where I am constantly fighting various side effects. I am 70. Love your podcasts here in the states. Seems you guys are ahead of the curve in some ways.
Wow Matthew that's quite the story! Hopefully your most recent surgery will help avoid the need for more ADT.Your words on the misery of ADT really chime with us. And going on testosterone replacement is something we should do more of as we talked about in this episode. Your story very compelling. You might enjoy listening to our podcasts with Tim Baker who has written a great book about his experience with ADT having been diagnosed with metastatic prostate cancer in his 40's. The book is called "Patting the Shark" and his most recent GU Cast is here ru-vid.com/video/%D0%B2%D0%B8%D0%B4%D0%B5%D0%BE-cBL4iisksLk.htmlsi=5vau1N-D2xpq7e2_
Excellent show Declan as usual. No doubt you took the lead in establishing good rapport with nuclear medicine and uro oncology in Australia and now propagating this concept all over the globe.
As a patient undergoing the treatment discussed (first line for locally advanced MIBC) I found this discussion extremely helpful in answering questions I had regarding its clinical application and even heard some provocative questions posed that I would very much enjoy seeing addressed in a future podcast. I am documenting my journey on the blog on my website.
@@gu_cast Was booked in for Surgery... But at the last minute cancelled and went with SABR Radiation treatment... I was back surfing after 1 week...Surfing every day NOW!..Just got to put up with the Wee n Poo changes... SurfForLife. Cheers Ross.
Audio is MORE IMPORTANT than image quality in a video. Your guest's audio has consistently been lackluster. It's due to excessively low volume (gain). To fix, consider: 1. Route the audio from your guest through the Rodecaster Pro. 2. Adjust the guest's audio level using one of the **sliders** on your Rodecaster Pro to match the hosts' levels. Rode Microphones is in Australia. Have them help you.
Respectfully, this can be a slippery slope. In 2020 I had a rapidly rising PSA. I had a PSA - 4K test, which showed high likelihood of significant cancer. I then had a 3 Tesla MRI, which showed a single lesion by the anterior apex. Knowing. Understanding that this location is hard to reach with a TRUS biopsy, even an MRI guided one, I elected to have a stereotactic perineal mapping biopsy. The results showed only a single core affected core Gleason, 3+3. I elected to have focal brachytherapy on one side of the prostate. My nadir PSA was 2.2. 33 months later in March 2023, my PSA rose to 3.41. My radiologist/oncologist thought it was a “bounce” and told me to have my PSA rechecked in 90 days. He was mistaken. He also quit practicing due to health problems. My PSA continue to rise. Fast-forward to December 2023 when I finally found another healthcare provider to take over where he left off. My PSA had risen to seven. I had a PSMA- PET scan and 3T MRI with contrast. The cancer returned with a vengeance on the right side that was treated with brachytherapy 2020 and also a new lesion on the left side. Gleason 9 and Gleason 8 respectively. Lymph node involvement on the right side. Stage 3 N1. I was devastated. A standard course of treatment was originally planned with radiation and ADT. However, the MRI revealed that the cancer was bordering the internal urethra and radiation would probably result in the need for a diversion. It’s 68 years old I had a high level of fitness for my age, low, BMI, no other underlying health issues and arguably athletic. I underwent a salvage radical prostatectomy in January 2024. Radiation to the lymph node bed will be next along with up to two years of first and second generation ADT. The prognosis for MFS for 5 to 10 years is 70% likelihood and I’ll take those odds. The surgeons, radiologist, and oncologist that reviewed my MRI and biopsy from 2020 all feel that the biopsy missed significant high-risk cancer and erroneously gave me a 3+3 Gleason score. To add insult to injury, the MRI from 2023 indicated a high likelihood that the brachytherapy seeds weren’t located in the location consistent with the lesion shown in the MRI of 2020. The reason I’m writing all of this is because while I agree that there is a reasonable argument for calling Gleason six something other than cancer, the reality is that biopsies aren’t perfect and one can never be 100% certain that a Gleason six diagnosis later won’t have to be revisited as more significant and high risk cancer.
Remember No jab No job. We must never forget WHO coerced and emotionally blackmailed the children for use as shields, to temporarily and marginally "protect" adults. Thou shall not use pregnant women as Granny shields. Risking the young to "save" the old is rotten to the core..,
We need doctors like Dr. Prasad, who provides intellectual critiques in an imbalanced and biased clinical trial industry. He probably wouldn't get any attention if he wasn't as aggressive as he is. Many clinical trials are designed to show favorability of a drug at the expense of integrity. Dr. Prasad helps keep people honest, even if it's painful.
Hi there...I have Unfavorable Intermediate Localised Prostate Cancer with a Gleason 4+3. Just had a PSMA Pet Scan and the results were Good. i'm 64 Yrs Old and Fit and Healthy..My Urologist wants to do Surgery. Im very interested in SBRT Therapy...My Urologist said he would do the Gel Spacer/Gold Seed procedure if i go with the Oncologist. I am still very undecided and confused on the next step.. Would Love your input! Thanks... Ross from the Gold Coast Australia.
Sorry to hear about your diagnosis and hope that you are getting well supported. Great to hear that your PSMA PET/CT brought good news. Unfortunately we can't give individual advice but we are always happy to offer second opinions (including telehealth) through our practice Cancer Specialists in Melbourne www.cancerspecialists.com.au. Wish you all the best with your cancer. Declan and Renu
So sorry to hear this. Hope that your questions are being answered. Make sure you are getting multidisciplinary options and second opinions are always helpful.
I have been meaning to add here that there’s no suggestion that writing therapy could or should replace conventional psychological counselling. But rather that it could be an effective adjuvant therapy and also fill a need where access to counselling services are limited by geography, cost or long wait times. Psycho therapy remains an essential part of my self care 🙏🏽
Hi, thank you for your videos which are great. A question: If the PSMA CAT scan shows cancer in the lymph nodes why recommend surgery when it cannot be curative? If you're going to have to use radiation anyway, why not use it now and try to take everything out?
Hi Paul. Thanks for the great question. Actually, a significant proportion of men with a small amount of cancer in their lymph nodes do very well with surgery on its own, and effectively it can be curative for some of these. We all have lots of these patients, more commonly in teh PSMA PET/Ct era which we have been in for ten years now, as this will detect tiny nodes not apparent on conventional imaging. Large (albeit retrospective) data show that patients with only 1-2 lymph nodes involved at the time of surgery often do as well as patients with no lymph nodes involved. So surgery definitely has a role in selected patients. Nonetheless, if we know ahead of time (eg on a PSMA PET/CT) that lymph nodes are likely involved, then we need to advise patients of the higher possibility that surgery on its own may not be sufficient. Therefore as ever, a multidisciplinary approach is important at the outset, so that patients can make informed choices about their management. Declan
Another very impressive, informative and really interesting Cast. Thanks to Declan and Renu and guests. Plenty of insight, history and info on current practice. Eoin Dinneen, London.
Great podcast! Do you think there will be a role for quadruplet therapy one day (e.g. for de novo high-volume M1b with intense PSMA avidity but with non-PSMA-avid large pelvic nodal disease)?
Thanks Emran! What quad do you have in mind? Radiotherapy to the prostate certainly gets used as a "triplet" with ADT and ARPI, but mostly for low-volume patients (by conventional imaging). Would anyone add RT to an ADT/ARPI/chemo triplet, especially if this was mostly for higher volume disease??
@@gu_cast The decision to add RT for de novo high-volume partly PSMA-negative tumors depends on the tumoral burden of the PSMA-negative subtype. RT/MDT may be appropriate for PSMA-negative N1-only or oligo lytic M1b, while liver-directed therapy may be an option for isolated M1c. Additionally, a Cabazi-Carbo combo with doublet hormonal treatment may be appropriate for disseminated mixed NEPC. Given that Australian centers are pioneers in PSMA PET/CT imaging, there is potential to design a basket trial for these patients with a focus on covering the PSMA-negative phenotype. This approach could pave the way forward in addressing this subtype of tumors.
another relevant topic !!! as always.. excellent discussion ;) ..special shout out to Piet's answers - chef's kiss!!!! - the importance of shared decision making with the patients that we care for.
Have you been looking at Clarity's clinical trials with Cu64 and Cu67 double radio ligand approach, the initial numbers seem promising in the extreme. I see Dr. Osartor at the beginning of the video and I emailed him a couple shots of the initial numbers and a link to the SeCure clinical trials.
“The excess of non-fatal and fatal accidents among boys seems to be part of a pattern of poor motor and cognitive regulation in the developing male, leading to misjudgment of risk…Girls have better literary skills and are more aware of and explicit about their feelings, while boys tend to clam up, especially when their emotions are high, and just feel uncomfortable and awkward without knowing why.” www.ncbi.nlm.nih.gov/pmc/articles/PMC1119278/
Well done team, this is a fantastic treatment approach and so good to see collaboration between specialist instead of silos. Which demonstrates that the following statement holds true "If you want to go fast go solo, if you want to go far go with company"; or words to that effect. In the next 3-5 years men may not even being looking at a surgery, Yah:)
Sorry, but as a Gleason 6 with evidence of perineural invasion I found this discussion quite lightweight, with very little in the way of statistical support for either approach. The two younger males in the US are clearly trying to make a name for themselves. They would not be successful in that endeavour if they stuck with the orthodox approach.
Kudos to the Lutectomy trial team and may John Violet rest in peace. On one extreme, it may be worth considering Actinectomy as an alternative option. Additionally, ImmunoRLT could potentially be effective as well. Just a few hours before this podcast, Aggarwal et al. published their successful efforts in priming with a single-dose of Lu-PSMA and maintenance immunotherapy (which differs somewhat from the PRINCE trial) in the Lancet Oncology. The concept of Intra-arterial Lu-PSMA is truly fascinating, and interventional radiologists may have previously utilized angioembolization for the treatment of BPH. On the other end, there are some concerns on the long-term issues such as nephrotoxicity if RLT is applied upfront (Steinhelfer, JNM 2023). If phase 3 neoadjuvant RLT is planned, it might be beneficial to adjust for Ki-67 levels since this variable is an important predictor of BCR-FS, as indicated by the ARNEO trial.
We need to hear more from patients whose prostate pathology is reported as "wimpy cancer". There should be greater emphasis on the hardships they may face, such as repeated blood tests, mpMRI scans, and most importantly, re-biopsies or possibly subsequent surgery. Recently, the American Thyroid Association has also made efforts to recruit patients with the "Cadillac of cancers" and amplified their voices regarding their experience with DTC.
One of the best GU podcasts! I had to listen twice for some of the key challenging questions. According to what Tyler mentioned, according to the results of POP-RT trial, maybe we need a Briganti 2024 nomogram, to find the probability of M1a in high/very-risk localized disease. Also, Tyler did not mention that PSMA PET may be N1-positive in some patients not fulfilling the POP-RT criteria. 🤔
Interesting therapy, great discussion. At about 21:00 Dr. Tilki talks about treatment results and estimates therapy survival at three years. I assume this means PSA has increased to some level that would suggest further treatment is necessary. What PSA level would that be?
Thanks for the comment and question! That was actually Dr Maurer speaking (Dr Tilki was in the first half of the podcast). Dr Maurer was talking about the fact that although a number of patients after salvage lymph node surgery will develop biochemical recurrence (BCR) at 7-8 months following surgery, many of these will not yet need treatment so therefore can have a longer therapy-free survival. As for when they might need treatment, that is a clinical discussion with the patient and taking into account issues such as patient preferences, biopsy characteristics, PSA kinetics and PSMA PET/CT findings. But we can often just carefully monitor patients with BCR following salvage surgery. Hope that helps! Declan
