News & Views in 2019

New data show that prostate-specific membrane antigen (PSMA) PET–CT can reveal the anatomical location of prostate cancer recurrences in patients diagnosed with nonmetastatic castration-resistant disease according to conventional imaging. The findings necessitate a new evaluation of the role of PSMA PET–CT in this setting compared with standard-of-care imaging and treatment approaches.

Data from a new study suggests that prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) imaging is superior to ¹⁸F-fluciclovine PET for detecting biochemical recurrence in men with prostate cancer. However, whether one of these radiotracers improves patient survival over the other is unknown and further research is needed to determine which has the greater effect.

The relationship between testosterone therapy and prostate cancer continues to challenge historic and current beliefs. A new cohort analysis revealed a ~33% reduction in prostate cancer incidence in men with increased testosterone use. The mechanisms underlying this protective effect are unclear, but these findings challenge current paradigms and warrant further investigation.

A recent study showed a correlation between clinical patient features and antibiotic resistance in patients with urinary tract infection (UTI). As resistance to antibiotics cannot be reversed, managing its emergence is of the utmost importance. Improving surveillance data will enable selection of appropriate antibiotics and help reduce the development of resistance.

The ideal first-line treatment of cisplatin-ineligible patients with metastatic urothelial carcinoma (mUC) remains unknown pending results of randomized trials. Although mUC tumours are sensitive to chemotherapy, response durations are short. A new retrospective study provides data on the effectiveness of first-line PD-1/PD-L1 inhibitors compared with carboplatin-based chemotherapy in this setting.

Oxytocin antagonists seem to have potential as a treatment option for premature ejaculation (PE), but the parameters of their use are vague. Two recently published studies highlight the need for large-scale trials to elucidate the value of these drugs in the treatment of PE.

Clinical and pathological risk grouping defines management in localized prostate cancer. Recent work suggests men with high-risk prostate cancer can be further subdivided into three risk groups (favourable high-risk, standard high-risk and very-high-risk) and that these groups correlate with measures of genomic risk, testing of which is increasingly being integrated into risk prediction.

In a recently published study, surveys of transgender individuals on hormone therapy provide insight into the self-reported effects of medication where previous thinking was only speculative. Still, controlled studies are required to avoid overinterpreting the clinical significance of specific findings in the context of what might be expected in the general population.

The US Preventive Services Task Force has issued a grade A recommendation that clinicians offer pre-exposure prophylaxis (PrEP) to people at high risk of acquiring HIV. Currently, many fewer individuals receive PrEP than those who would benefit from it; whether PrEP can have a real impact on reducing the global burden of HIV is yet to be determined.

Intensifying systemic therapy improves outcomes in metastatic prostate cancer. As apalutamide and enzalutamide join abiraterone and docetaxel as treatment options for patients, the choice of therapy for individual patients becomes more complex. We anticipate precision targeted and immune therapies will build on the advances of recently completed large-scale trials.

Immune checkpoint therapy is beneficial for patients with advanced bladder cancer; however, trials generally exclude patients with comorbidities or uncommon histologies. The SAUL trial demonstrates that atezolizumab is safe and efficacious in a patient population that more accurately reflects the real-world scenario, but its benefit might still be limited in historically poorly performing populations.

A new ecological analysis has shown that antimicrobial consumption is positively associated with decreased antimicrobial susceptibility in Neisseria gonorrhoeae across European countries. Efforts at the policy, provider and community level need to be strengthened to address and help mitigate the continued emergence of antimicrobial resistance in N. gonorrhoeae.

The concept that resistance against androgen receptor (AR) signalling inhibitors is explained by AR variants (ARVs) has spread as a seductive meme. However, two problems have delayed the translation of these findings to clinical practice: the complexity of the mechanism of action and the challenging development of clinical decision-making tools involving ARVs.

A new study describes antitumour cell activity inherent in the extracellular matrix of porcine urinary bladder, which is not the result of direct tumour cell killing but is indirectly mediated through immune cells. The findings highlight opportunities to explore shared interests of the tissue engineering and regenerative medicine and the immunology and cancer communities.

The PROSPER, SPARTAN, and ARAMIS trials demonstrated the efficacy of enzalutamide, apalutamide, and darolutamide, respectively, to extend metastasis-free survival in men with nonmetastatic castration-resistant prostate cancer. However, questions remain regarding patient selection for these agents, particularly concerning adverse effects, patient PSA doubling time, and cost and formulary considerations.

In the absence of standards of care and defined best treatments for localized prostate cancer, Internet search engines provide patients with first information — or often misinformation. Clinicians need to guide patients to sources of high-quality evidence on focal ablative treatments for prostate cancer.

The FDA’s approval of the first point-of-care total PSA test for prostate cancer has the potential to improve patient care by streamlining PSA testing. However, a Clinical Laboratory Improvement Amendments waiver is needed before this test can be fully integrated into clinical care.

Health-related quality of life encompasses a wide range of experiences and is especially relevant for men with prostate cancer. A recent study reports that across disease stages, overall self-reported health status and urinary and bowel function were good, but sexual function was poor. Overall, men face prostate cancer with resilience.

Results of recent trials have shown the superiority of mpMRI to TRUS-guided systematic biopsy for detecting clinically significant prostate cancer. However, only performing an mpMRI risks missing MRI-invisible lesions and, therefore, there might be added value in performing both targeted and systematic biopsies in biopsy-naive patients.

In patients with metastatic renal cell carcinoma, risk stratification according to the Memorial Sloan Kettering Cancer Center or the International Metastatic Renal Cell Carcinoma Database Consortium classification systems is a crucial part of clinical assessment and essential for guiding management. New research has now demonstrated that disagreement in risk-group classification is common and prognostically relevant.