finasteride

This year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine. We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

The September #urojc International Urology Journal Club discussion on twitter was based on the paper “Long-Term Survival of Participants in the Prostate Cancer Prevention Trial” published in the New England Journal of Medicine a few weeks earlier.

In 2003, the Prostate Cancer Prevention Trial (PCPT) proved what it set out to do. It significantly reduced the risk of PCa. Unfortunately, the champagne was never even taken off ice, as finasteride was also associated with an increased risk of high-grade prostate cancer. In June 2011, US FDA ordered the drug’s warning label to be updated to state that finasteride may increase the risk of high grade prostate cancer. As a primary prevention drug for PCa, despite many published, favorable subgroup analyses, finasteride was quite flaccid in the eyes of many urologists.

Now, ten years after the PCPT was published and with up to 18 years of follow-up, would these long-term results be the catalyst to force an FDA backflip? Or would the specter of erectile dysfunction rise? Amongst the first tweets that were fired (no prizes to guess who it was)

Tweeted link by @LoebStacy

To summarise, this post hoc analysis – that wasn’t pre-specified in the original protocol – analysed rates of survival among all original PCPT study participants including those with prostate cancer. Prostate cancer incidence amongst PCPT candidates was collected for an additional year after the original report and the Social Security Death Index was searched to assess survival status until 31^st October 2011.

In all 18,880 men, PCa was diagnosed in 10.5% of the finasteride group and 14.9% of the placebo group (RR in finasteride group, 0.70; 95% CI, 0.65 to 0.76; P<0.001). Furthermore, 333 (3.5%) in the finasteride group and 286 (3.0%) in the placebo group had high-grade cancer (GS, 7 – 10, RR, 1.17; 95% CI, 1.00 to 1.37; P=0.05). Fifteen-year survival rates of 78.0% (finasteride) and 78.2%, (control) were reported in the men who died. Unadjusted hazard ratio for death in the finasteride group was not significant. Ten-year survival rates were 83.0% (finasteride) 80.9% (placebo) with low-grade PCa and 73.0% and 73.6%, respectively, with high-grade prostate cancer.

The authors as well as the #urojc community were quick to identify limitations.

Indeed, since information regarding the mode of death for patients who passed away was unavailable, PCa specific mortality could not be reported by this study. In amongst the discussion regarding limitations, it was important to see twitter etiquette observed.

There was some discussion on whether high grade “finasteride” prostate cancer was morphologically identical to “placebo” prostate cancer or different?

But at the end of the day, it doesn’t matter how it is discussed, packaged or assembled…

In an underpowered study, not designed to look at PCa-specific mortality, there was always going to be conjecture as to the benefit of reducing low grade PCa by 30% (in an era of increased active surveillance) whilst giving 1 in every 200 men offered finasteride high grade PCa.

Erectile dysfunction was an ever present factor during our discussion, although was generally thought of as #firstworldproblems

At times, when drawing conclusions, our intellectual, verbatim-driven minds give way to pictorial clarity; in other words a picture tells a thousand words. I still wonder how many a tweet is worth… In my very humble opinion, my conclusions are

1) 5 ARIs decrease low grade PCa, but low grade PCa doesn’t necessarily equal death, so…

2) Primary prevention for PCa would need to be robust, 5ARIs are too far from the mark

3) I thought appropriately chosen patient with bothersome LUTS, a large prostate with elevated PSA (proved to be cancer free or low volume GS 6) should go green (I can already feel the holmium lasers, microwave emitters and diode beams aimed behind my head, but that is a conversation for another time…)

The king summed it up well I think,

This month’s prize has been generously donated by Urological Society of Australia and New Zealand, one full registration to USANZ ASM 2014 in Brisbane! There was a clear winner who was novel in tweeting an image that said it all.

Congratulations to Dr Todd Morgan!

A warm thank you is extended to all who participated in this month’s #urojc discussion. All of you are encouraged to participate in next month’s discussion starting on 4^th-5^th October depending on your time zone.

Analytics for for this month’s discussion:

Dr George Koufogiannis is an Australian Urology Trainee, currently based at Port Macquarie Hospital. @DrVasano78 Vasano = torment, 78 = 1978, the year I began to torment my mother, who gave me the nickname.

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