News & Views in 2016

Understanding risk factors for prostate cancer is an important step towards personalized, risk-adapted early detection and prevention. Epidemiological studies, which are commonly used to identify risk factors, are prone to detection bias. This bias could substantially affect the observed relationship between putative risk factors and prostate cancer diagnosis.

Onabotulinumtoxin A and sacral neuromodulation are options for treating women with refractory urge urinary incontinence. Both of these treatment options provide symptomatic relief and have advantages and drawbacks. Discussion with patients regarding the risks and benefits of each therapy is critical for informed treatment choice.

Multiple BCG strains are used for intravesical instillation treatment of non-muscle-invasive bladder cancer but no large randomized studies comparing these strains are available. To enable creation of new BCG-related agents that overcome the instabilities of the current formulations, molecular examination of BCG's mechanisms of action is required.

Surgeon–scientists have made fundamental discoveries that have revolutionized medicine. A recent report raises the spectre of a future without surgeon–scientists, owing to an increasing need for clinical productivity and burdensome administrative responsibilities. A pathway forward is needed, to protect and nurture the surgeon–scientist — a critical participant in academic medicine.

The compliance of physicians to current guidelines for asymptomatic microhaematuria is limited and the evidence supporting asymptomatic microhaematuria as an effective screening tool for the early detection of bladder cancer is weak. Medical or surgical treatment is indicated in 13–35% of patients with asymptomatic microhaematuria, albeit mostly for benign conditions, which are more commonly the cause. The high prevalence of asymptomatic microhaematuria in the general population means that this condition poses a considerable challenge to the health-care system.

Large-scale randomized trials in early-stage prostate cancer are rare. Data from the recent ProtecT trial enables a cautious endorsement of active monitoring for early-stage, screen-detected prostate cancer: cancer-specific survival was high regardless of treatment approach (monitoring, surgery or radiation). How these findings apply to contemporary prostate cancer care requires careful evaluation.

Recent evidence from series of small renal mass biopsy samples and methodologically robust meta-analyses provides improved guidance on cost–benefit trade-offs for diagnosis and management of this disease. Renal mass biopsy sampling should be reserved for situations in which it will affect management decisions – which it will not do for all patients.

Resistance to abiraterone or enzalutamide is a major medical burden — the duration of benefit is highly variable and cross-resistance often occurs when these two agents are given sequentially. Blood-based analysis of androgen receptor splice variants and AR copy number gain or mutations could enhance understanding of the mechanisms of resistance and improve management of patients with castration-resistant prostate cancer.

Now that patients with metastatic castration-resistant prostate cancer have multiple therapeutic options, the question naturally arises as to how these therapies should be sequenced. The genitourinary group at Johns Hopkins has attempted to answer this question by investigating abiraterone and enzalutamide sequencing information in their database.

A newly published report, indicating a high level of use of active surveillance (AS) is encouraging; however, the substantial variability in levels of implementation indicate that some urologists remain uncertain of this approach. This report encourages the standardized implementation of AS and improved counselling of patients that are eligible for such monitoring.

Achieving the best possible practice in the management of patients with penile cancer is hampered by a lack of evidence owing to the rare occurrence of this disease. New population-based data from the USA show improved surgical and medical practice patterns but also highlight challenges in providing optimum care to all patients.

Most guidelines recommend integration of estimated life expectancy into the routine decision-making process in prostate cancer treatment. This article underlines the use of both age and comorbidities to calculate life expectancy, which is highly dependent on the health status of the individual patient.

A recent study in Cell undertook a bold phosphoproteomic data interpretation and functional integration approach to develop a clinically relevant hierarchy of therapeutic kinase targets and actionable pathways of individual patients with metastatic castration-resistant prostate cancer. Each patient's personalized kinase signature can be used to guide clinical decisions and predict drug combinations, minimizing toxicity and optimizing precision-targeted treatment.

Some urologists might be surprised that the urinary tract is not sterile, and bacteria might have important roles in a number of urological conditions such as urge incontinence. This paradigm shift, which has been further illustrated by data from a recent study, has implications for how urologists diagnose disease and treat patients.

METastasis Reporting and Data System for Prostate Cancer (MET-RADS-P) is the first effort to provide the burgeoning field of whole body-MRI (WB-MRI) with minimum standards of image acquisition, interpretation, and reporting; it should act as a catalyst for promoting the use of this promising method.

The American Urological Association, the Society of Urologic Oncology and the European Association of Urology have recently updated their guidelines for diagnosis and treatment of non-muscle-invasive bladder cancer. Several studies show that adherence to these guidelines is low, especially in North America. Physicians should try to comply with these guidelines to ensure optimal quality of care.

In kidney transplantation, the tremendous shortage of organs is a major problem and an ongoing concern is whether any procured but discarded kidneys could have been successfully transplanted. A recent study investigated whether kidney procurement rates from deceased donors are reduced and discard rates are increased at the weekend.

Testosterone therapy for men with prostate cancer is a controversial topic. A recent study retrospectively reviewed a single-centre experience in treating hypogonadal men with prostate cancer with exogenous testosterone therapy and found it to be safe.

The speed with which PSMA PET–CT has been adopted for prostate cancer imaging is unprecedented. This technique's clinical value in recurrent disease is uncontested, but its role in initial staging is unclear. Two studies now provide important data on the value of PSMA PET–CT at this management stage.

Given a recent update from the PLCO trial reporting that over 90% of men in the 'usual care' arm underwent some degree of PSA testing, the PLCO can no longer accurately be called a trial of screening versus no screening — nor can it be included as such in meta-analyses or guideline statements.