










































www.siu-urology.org

#B2BGUCancerTriad

Prostate Cancer

Proceedings from the  
SIU B2B Uro-Oncology:  
GU Cancers Triad  
Virtual Meeting 
May 21–22, 2021

https://www.siu-urology.org
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B2B: Prostate Cancer Summary

30

PROCEEDINGS FROM THE SIU B2B URO-ONCOLOGY: GU CANCERS TRIAD • MAY 21–22, 2021 – SIUJ VOLUME 2, SUPPLEMENT 1, JULY 2021

Stacy Loeb,a,* Peter C. Black,b,† Alexander W. Wyatt,c Yaw A. Nyame,d,e Neal Shore,f Derya Tilki,g,h Elena Castro,i 
Matthew Cooperberg,j Veda Giri,k Maria J. Ribal,l,m Giovanni Lughezzani,n,o Rafael Sánchez-Salas,p Caroline M. 
Moore,q Art Rastinehad,r Linda Kerkmeijer,s Hashim U. Ahmed,t Shusuke Akamatsu,u Alexandre de la Taille,v 
Martin Gleave,b Simon Tanguayw,‡

aDepartment of Urology and Population Health, New York University School of Medicine and the Manhattan Veterans Affairs Medical 
Center, New York City, United States bDepartment of Urologic Sciences, University of British Columbia, Vancouver, Canada cVancouver 
Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada dDepartment of Urology, 
University of Washington Medical Center, Seattle, United States eDivision of Public Health Sciences, Fred Hutchinson Cancer Research 
Center, Seattle, United States fCarolina Urologic Research Center, Myrtle Beach, United States gMartini-Klinik Prostate Cancer 
Center, Hamburg, Germany hDepartment of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany iSpanish National 
Cancer Research Center, Madrid, Spain jSchool of Medicine, University of California, San Francisco, United States kSidney Kimmel 
Cancer Center, Thomas Jefferson University, Philadelphia, United States lUro-Oncology Unit, Hospital Clinic, University of Barcelona, 
Barcelona, Spain mEAU Guidelines Office, Arnhem, the Netherlands nDepartment of Biomedical Sciences, Humanitas University, 
Pieve Emanuele, Italy oDepartment of Urology, Humanitas Clinical and Research Hospital – IRCCS, Rozzano, Italy pDepartment of 
Urology, Institut Mutualiste Montsouris, Paris, France qDivision of Surgical and Interventional Science, University College London, 
London, United Kingdom rDepartment of Urology, Lenox Hill Hospital, Northwell Health, New York City, United States sDepartment of 
Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands tImperial Prostate, Department of Surgery and 
Cancer, Imperial College London, London, United Kingdom uDepartment of Urology, Kyoto University Graduate School of Medicine, 
Kyoto, Japan vUrology Department, CHU Mondor, Assistance Publique des Hôpitaux de Paris, Créteil, France wDivision of Urology, 
McGill University, Montreal, Canada *Co-Chair of the Scientific Programme Committee (PCa) †Chair of the Scientific Programme 
Committee ‡Co-Chair of the Scientific Programme Committee (RCC)

The Bench-to-Bedside Uro-Oncology GU Cancer Triad Meeting was organized by the 
Société Internationale d’Urologie and was held online on May 21st and 22nd, 2021. The 
session on prostate cancer (PCa) took place on the morning of Saturday, May 22nd, and 
was chaired by Dr. Stacy Loeb (United States) and Dr. Peter C. Black (Canada). This session 
covered advances in the diagnosis and management of localized, locally advanced, and 
metastatic PCa, as well as three case-based panel discussions on biomarkers, focal therapy, 
and systemic therapy in PCa. Additionally, the programme included presentations on the 
state of the art of liquid biopsy, COVID-19 impact, and digital health in urologic oncology.

The first talk was led by Dr. Alexander Wyatt, who 
presented the state of the art of liquid biopsy in uro-
logic oncology. In particular, he discussed the use of 
plasma circulating tumour DNA (ctDNA) as a biomarker 
in PCa. Plasma ctDNA comprises short fragments of 
post-apoptotic tumour DNA in the blood that are 
mixed with cell-free DNA from noncancer cells, such as 
leukocytes. Generally, ctDNA abundance is associated 
with tumour burden and more advanced disease[1]. 
While several non-genomic biomarkers, such as serum 
prostate-specific antigen (PSA), are already well-estab-
lished in PCa management, ctDNA-based biomarkers 
may be particularly useful for predicting treatment 
efficacy, especially in the metastatic setting.

The fraction of ctDNA (as a proportion of total cell-
free DNA in plasma) is a strong prognostic factor for 
disease outcomes. In two randomized phase 2 trials, 
ctDNA fraction correlated with overall survival (OS), 
with patients exhibiting poorer survival outcomes 
with increasing ctDNA fraction, independent of clin-
ical prognostic factors[2,3]. In addition, changes in 
ctDNA fraction during treatment may indicate not 
only response but also pending relapse in the met-
astatic castration-sensitive PCa (mCSPC) and meta-
static castration-resistant PCa (mCRPC) settings[3,4]. 
Understanding the prognostic value of ctDNA frac-
tion may also help to guide treatment decisions. The 
ongoing open-label phase 2 PROTRACT trial aims to 

DOI: 10.48083/ZJLZ6285



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B2B: Prostate Cancer Summary

provide insights on whether ctDNA fraction can assist 
treatment selection for second-line androgen receptor 
pathway inhibitor (ARPI) compared to taxane-based 
chemotherapy[5].

Dr. Wyatt emphasized the key differences between 
tumour tissue and plasma ctDNA sequencing. 
Sequencing of tumour tissue is only performed in 
samples with high tumour content (>20%) to lower 
the chance of false negatives. By contrast, the tumour 
content (ctDNA fraction) of plasma cell-free DNA sam-
ples cannot be discerned prior to sequencing and 
must instead be determined via bioinformatics after 
sequencing. Importantly, the precise ctDNA fraction 
dictates which tumour alterations can be identified. 
For example, practical limits of detection are around 
1% ctDNA for most somatic mutations, but can be as 
high as 20% for certain changes in copy number[4,6]. 
In a phase 2 clinical trial of the poly(ADP-ribose) pol-
ymerase (PARP) inhibitor rucaparib in mCRPC, BRCA 
alterations were identified in patient-matched tissue 
and plasma, with a relatively high concordance of 
75%[7]. Several homozygous BRCA2 copy number 
losses were not identified by plasma testing, likely due 
to insufficient ctDNA fraction. Dr. Wyatt highlighted 
that around 25% of patients with mCRPC can have 
very low ctDNA fraction, which means that testing 
results must be carefully interpreted to understand 
if low ctDNA may prevent the detection of certain 
somatic alterations.

Just as tissue samples with low tumour content are 
triaged prior to sequencing, when using ctDNA to 
detect the mutational status of genes of interest, it 
is important to triage samples that have low tumour 
content in the plasma. In a recently published study of 
879 patients with metastatic PCa, samples of only 635 
patients had sufficient ctDNA fraction to allow iden-
tification of both somatic and germline mutations[8]. 
Importantly, however, this approach allowed the mini-
mally invasive detection of homologous recombination 
repair (HRR) gene mutations, such as BRCA2, ATM, and 
CDK12, in over 15% of patients. These mutations were 
identified across 94% of serial ctDNA samples as well 
as in all available archival primary tissues, suggesting 

that DNA repair gene status does not change over time 
in patients with metastatic PCa.

Studies of ctDNA in mCRPC are also revealing 
emerging biomarkers, such as the independently 
prognostic impact of TP53 mutations[2]. Androgen 
receptor (AR) copy number amplification as a contin-
uous variable shows promising results as a biomarker 
to influence treatment selection between chemother-
apy and ARPI[3,9]. The next steps for development of  
ctDNA-based predictive biomarkers is to prove clinical 
utility. A prospective biomarker-driven phase 2 trial 
led by the Canadian Cancer Trials Group is aiming to 
address this need[10]. Currently, over 425 patients with 
mCRPC have been screened in this trial, using ctDNA 
to stratify treatment arms.

During the Q&A, Dr. Wyatt discussed why some 
cancers shed more ctDNA than others. Differences 
in tumour shedding are seen not only across different 
cancer types, but also within the same form of cancer. 
In PCa, higher proliferative tumour burden is associ-
ated with increasing ctDNA shedding, although there 
are clearly some underlying biological mechanisms 
that are not yet understood. Next, Dr. Wyatt discussed 
future applications of ctDNA biomarkers in earlier dis-
ease stages, which he believes is a logical approach, 
although challenging. As Dr. Wyatt pointed out, there 
are good biomarkers already available in earlier PCa 
settings to determine minimal residual disease or 
even early diagnosis. He advised caution for rushing 
to implement any new ctDNA-based biomarkers in 
this space to avoid the risk of overdiagnosing or over-
treating. Dr. Wyatt then commented on differences in 
allelic percentages reported by commercially available 
tests. According to him, these differences are likely due 
to the sampling probability for rare variants in small 
volumes of blood. In general, the field is moving away 
from reporting very rare variants (allelic frequencies 
much lower than 1%) that may not be reflective of the 
cancer and instead represent other somatic clones 
in circulation. Dr. Wyatt also provided his insights on 
advances for ctDNA on the horizon. He highlighted 
the potential for analysis of serial ctDNA samples col-
lected over time to understand mechanisms of disease 
evolution and progression[11].



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B2B: Prostate Cancer Summary

The next presentation was by Dr. Yaw Nyame 
(United States), who discussed racial disparities in 
PCa and a patient-centred research framework for 
addressing inequities in PCa care and outcomes. A 
health disparity is defined as a higher burden of illness, 
injury, disability, or mortality experienced by one 
group relative to another. PCa is a profound example 
of a cancer health disparity, particularly in the United 
States. Disparities in PCa reflect interactions between 
social, health, and biologic factors. For instance, the 
worst outcomes in PCa in the United States are concen-
trated in counties in the southeastern United States[12] 
that form the historic cotton belt—a region where the 
highest production of cotton occurred in the 19th 
century. Cotton production during this time period 
was a major economic trade in the United States and 
was associated with the slave trade. The cotton belt is 
also home to the highest proportion of men of African 
American ancestry in the country[13]. This example 
demonstrates the complexity of socio-geographic and 
economic factors.

Despite a 50% reduction in PCa mortality in the 
United States since the introduction of PSA screen-
ing in the late 1980s, Black men have consistently 
demonstrated a two-fold greater risk of dying from 
the disease compared to men of all other races (gen-
erated with data from[14]). This disparity appears to be 
even higher among younger males, in which 40- and 
50-year-old Black men are at an up to four-fold higher 
risk of dying from PCa compared to white men[15]. 
Similar trends appear to occur worldwide in regions 
with not only large populations of African American 
ancestry but also in areas of the developing world[16]. 
Regarding PCa natural history, Black men are likely to 
develop PCa at younger ages and are at higher risk 
of progression to metastatic disease by the time of 
diagnosis compared to the general population[17].

What are some of the drivers of disparity in PCa 
outcomes? In the early 2000s, the World Health 
Organization (WHO) popularized the concept of 
social determinants of health, which include economic  
stability, neighbourhood and physical environment, 
education, access to food, the community and social 
context, and the healthcare system[18]. These deter-
minants dictate healthcare utilization and patient 

outcomes. Social determinants of equity (i.e., eco-
nomic and structural barriers) inform how each social 
determinant of health impacts PCa risk[19]. PCa dis-
parities, particularly in the United States, form what 
Dr. Nyame calls a “perfect storm”: it is a disease with 
higher incidence, in which a variety of social factors, 
structural and societal barriers, mistrust, and health 
system barriers further impact outcomes.

How can racial disparities in PCa be reduced? To 
answer this question, Dr. Nyame and colleagues have 
developed a conceptual model to help identify criti-
cal checkpoints in the PCa journey that may improve 
patient outcomes. For example, the model demon-
strates that PCa screening can be a powerful tool that 
may lead to early detection and mortality reduction. 
In this setting, access to PSA testing and biopsy may 
lead to distinct improvements in health inequities. 
As a patient progresses to treatment, there are mul-
tiple timepoints where differential utilization of care 
influences outcomes, including: access and quality of 
care, modifiable risks, and treatment preferences in 
the localized setting; quality of surveillance following 
definitive treatment; and access to salvage therapy and 
clinical trials if PCa progresses.

PCa screening has an important benefit for mor-
tality rate reduction. In a recent study, the benefit of 
PSA screening was evaluated over a period of more 
than 24 years since patients had been randomized 
in clinical trials[20]. Results demonstrated a positive 
impact of PSA screening on PCa mortality beyond 
16 years, highlighting a particular benefit in young 
and healthier men. Given that Black men present with 
PCa at a younger age and with more disparate out-
comes, earlier screening may be particularly valuable 
in this patient population[21,22]. By contrast, the 2012 
U.S. Preventive Services Task Force recommenda-
tion against routine PSA testing led to a decrease in 
PCa screening that was markedly seen among Black 
men[23].

Regarding definitive treatment, a recent multi-
ple-cohort study analyzed data from the Surveillance, 
Epidemiology, and End Results (SEER), the Veterans 
Affairs health system, and the National Cancer 
Institute-sponsored Radiation Therapy Oncology 
Group[24]. Results demonstrated that access to care 



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B2B: Prostate Cancer Summary

and standardized treatment, as seen in clinical trials, 
are associated with decreased disparities in PCa 
outcomes among Black men. In a cohort of men with 
high-risk PCa, another study evaluating data from the 
Cleveland Clinic, Johns Hopkins Institute, and MD 
Anderson Cancer Center showed no differences in 
outcomes with standardized treatment, regardless 
of ethnicity[25]. Nevertheless, the rate of definitive 
treatment for PCa is lower in Black men compared to 
other ethnicities[26]. As highlighted by Dr. Nyame, 
even more troubling is the fact the Black men are 
underrepresented in clinical trials, at roughly 3% of 
current practice-informing studies[27].

How can barriers to research participation and clini-
cal care among Black men be overcome? In the United 
States, people of African American ancestry have been 
the subject of medical experimentation without their 
consent throughout history[28]. The trauma in this 
population is transgenerational and shapes medical 
mistrust and cultural health beliefs. In addition, poor 
and minority populations were long considered “med-
ical material” for training in the clinical practice, which 
poses a barrier to the participation of these individuals 
in contemporary clinical trials.

In such a challenging context, what can be done 
to close the gap in PCa racial disparities? Dr. Nyame 
believes the focus must be in building communities 
and empowering patients. A patient-centred research 
approach is paramount and should be founded on 
the principles of reciprocal relationships, coopera-
tive learning, partnership, transparency, honesty, and 
trust[29]. This novel approach is crucial to reduce racial 
disparities in PCa and other diseases. 

In the Q&A session, Dr. Nyame expressed the need 
for appropriate representation to mediate effective 
communication between the medical community 
and patients. This is deeply affected by the under-
representation of several populations in practice-in-
forming clinical trials. Dr. Nyame discussed the role of 
the WHO and artificial intelligence (AI) in correcting 
health disparities. According to Dr. Nyame, the WHO 
has mobilized funds to help flight health disparities, 
particularly in developing countries where even access 
to PSA testing may be scarce. With regards to AI, he 
advised caution, as many platforms use real-world data 

that may lead to biased results and increased disparity. 
Next, Dr. Nyame explained how to assess the effec-
tiveness of community-based research. In this case, Dr. 
Nyame relies on SEER data and emphasized that the 
ultimate goal is to produce significant improvements 
in the mortality curves. Lastly, Dr. Nyame discussed 
whether single-nucleotide polymorphism (SNP) 
approaches are a legitimate tool for inferring race from 
genetic data. He believes that these approaches are 
beneficial and may ultimately help to demystify the 
association of PCa risk and ethnicity.

Next, Dr. Neal Shore (United States) presented the 
five PCa practice-changing advances on the horizon, 
As emphasized by Dr. Shore, these advances require 
an understanding of genetic profiling not only to 
guide treatment decision-making, but also to better 
counsel patients regarding their own and their family’s 
risk of developing cancers. First, Dr. Shore discussed 
advances in overcoming AR resistance in PCa. Despite 
rapid and dramatic responses to androgen depriva-
tion therapy (ADT) as monotherapy or in combination 
with an ARPI, all patients with PCa eventually develop 
castration resistance[30]. Some of the mechanisms 
underlying this process include AR alterations, such 
as AR gene or gene enhancer amplification, AR point 
mutations, and autocrine tumour androgen produc-
tion[30]. Currently, there are several strategies under 
investigation to overcome AR resistance and improve 
treatment outcomes. One of these strategies involves 
the use of proteolysis targeting chimera (PROTAC) 
protein degraders to target ARs by engaging the 
ubiquitin proteasome system (UPS), which is used by 
cells to degrade proteins and maintain homeostasis. 
This approach was recently investigated in a phase 1 
clinical trial and demonstrated promising results in 
patients with mCRPC for treatment with ARV-110, a 
PROTAC with high AR-degradation activity in preclin-
ical models[31]. Another strategy under investigation 
is targeting of the DNA damage response (DDR) 
system with ATR inhibitors to prevent replication of 
defective cells with tumourigenic potential[32]. This 
approach may prove particularly useful in patients with 
mCRPC who harbour ATM mutations and are likely 
more susceptible to ATR inhibition. The EZH2 pathway 
may also offer a novel therapeutic target in mCRPC, 
given its involvement in important aspects of cancer 



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PROCEEDINGS FROM THE SIU B2B URO-ONCOLOGY: GU CANCERS TRIAD • MAY 21–22, 2021 – SIUJ VOLUME 2, SUPPLEMENT 1, JULY 2021

B2B: Prostate Cancer Summary

genetics, acquired drug resistance, and regulation of 
anti-tumour immune response through gene silenc-
ing[33]. Inhibition of EZH2 leads to the re-expression 
of silenced genes and shows potential for combination 
with ARPIs to overcome AR resistance. Finally, another 
strategy under investigation is targeting the PI3K/AKT 
pathway, which shows crosstalk with AR pathways. 
Targeting both pathways with an AKT inhibitor and 
ARPI shows potential to increase antitumour activity, 
particularly in PCa tumours with PTEN loss[34].

Then, Dr. Shore detailed the potential of bispe-
cific T-cell engager (BiTE®) immunotherapy in PCa. 
BiTE is a novel class of therapeutic molecules that are 
able to activate an anti-tumour immune response by 
engaging the patient’s own T cells[35]. AMG 160 is a 
BiTE molecule that selectively targets prostate-specific 
membrane antigen (PSMA), which is highly expressed 
in PCa cells. In an ongoing phase 1 clinical trial, 
AMG 160 showed tolerable efficacy in patients with 
mCRPC[36]. Cytokine release syndrome (CRS) was the 
most common adverse event (AE) observed, which is 
commonly associated with the mechanism of action of 
BiTE immunotherapy.

The next practice-changing advance in PCa relates 
to the use of PSMA positron emission tomography 
(PET) imaging, which has profound diagnostic and 
therapeutic implications due to its high expression in 
PCa tumours and metastases. In the end of 2020, the 
U.S. Food and Drug Administration (FDA) approved 
68Ga PSMA-11 for PET imaging[37]. More recently, 
the positive results of the phase 3 CONDOR trial[38] 
and the phase 2/3 OSPREY trial[39] have led that to the 
approval of a second PSMA PET agent, 18F-DCFPyL, in 
the United States. As these new imaging approaches 
become standard of care in the United States and other 
countries, it is critical that urologists understand how 
this additional information may influence treatment 
decision-making.

As highlighted by Dr. Shore, one of practice-chang-
ing potentials of next-generation PSMA PET imaging is 
visualization of disease sites that can then be targeted 
with radiopharmaceutical agents. To date, 223Ra is 
the only radiopharmaceutical approved in the mCRPC 
space[40], although it remains underutilized. A new 
generation of radiopharmaceuticals that couple the 

radioactive β-emitter 177Lu to a PSMA-targeted mol-
ecule is underway and has showed promising results 
in the phase 3 VISION trial[41,42]. Important consider-
ations that emerge with new theranostic approaches 
include not only understanding how these will fit in 
the current systemic therapy landscape but also how 
to optimally select patients for these new treatments.

Lastly, Dr. Shore discussed the potential of com-
bining PARP inhibitors with other agent classes, such 
as ADT, to target PCa cells. Because the AR and the 
HRR pathways are interconnected, combining ADT 
and PARP inhibition may result in synthetic lethality, as 
suggested by preclinical studies[43]. A similar rationale 
may be applied not only to PARP inhibitor combination 
with ADT, but also with other therapies in mCRPC, such 
as chemotherapy, radionuclide therapies, and immune 
checkpoint inhibitors (ICIs), as well as AKT and ATR 
inhibitors (reviewed in [44]).

During the Q&A, Dr. Shore provided his insights on 
practice-changing advances coming to the localized 
PCa setting. Several patients with high-risk localized 
PCa who present with grade 3 to 5 disease may relapse 
after radical prostatectomy or radiation therapy. In this 
setting, Dr. Shore emphasized the upcoming results 
of the phase 3 ATLAS trial, which has evaluated the 
role of radiation therapy in combination with ADT or 
apalutamide in this patient population[45]. Similar 
strategies in neoadjuvant and adjuvant strategies are 
also under investigation in patients who undergo rad-
ical prostatectomy.

The PCa session continued with a case-based panel 
on the use of germline vs. genomic biomarkers in PCa 
management. The discussion was moderated by Dr. 
Derya Tilki (Germany), with input from Dr. Elena Castro 
(Spain), Dr. Matthew Cooperberg (United States), 
and Dr. Veda Giri (United States). The first case was a 
74-year-old male who underwent prostatectomy. The 
final pathology revealed tumour with Gleason score 
(GS) 3+4, pT3a stage, no lymph node involvement, 
and focal positive margin. At his 2-month follow-up, 
the patient was using less than one pad per day and 
had undetectable PSA levels (<0.015 ng/mL). Since 
the patient presented with adverse pathology, should 
any additional biomarkers be assessed? In the post-
operative setting, genetic-based tests may provide 



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35

B2B: Prostate Cancer Summary

additional insight to guide follow-up and management 
decisions. The Decipher® Prostate Cancer Test is an 
option in this space and uses the expression of 22 
selected RNA markers to predict the risk of metastasis 
and cancer-specific mortality[46]. For the patient in 
this case, the Decipher score was 0.67, just above the 
high-risk threshold.

What is the role of genetic biomarkers in treatment 
decision-making in the adjuvant setting post-rad-
ical prostatectomy? In 2020, results of the phase 3 
RADICALS-RT, GETUG-AFU 17, and RAVES trials 
demonstrated no benefit between adjuvant radiother-
apy and salvage radiotherapy for patients with local-
ized PCa following prostatectomy[47-49]. However, 
Decipher score may guide management decisions 
in the presence of rising PSA levels. In a retrospec-
tive analysis, patients with high Decipher scores and 
differing PSA levels had improved outcomes when 
treated with adjuvant radiotherapy. By contrast, no 
benefit was seen in patients with low postoperative 
Decipher scores[50]. In addition, Decipher presents 
a GRID report, which provides predictive responses 
to different treatment approaches in presence of 
biochemical recurrence. A novel genomic signature 
approach based on 24 genes called PORTOS is under 
investigation to also predict response to postopera-
tive radiotherapy. In a matched retrospective study, 
men with high PORTOS had better outcomes after 
receiving radiotherapy compared to those who did 
not. Interestingly, the opposite was seen in patients 
with low PORTOS[51].

At 6 months following radical prostatectomy, the 
patient presented with rising levels of PSA at 0.13 ng/
mL. In this scenario, it may be beneficial to wait until 
the PSA level rises to 0.2 ng/mL to proceed to any 
additional interventions, according to the ARTISTIC 
trials[52]. In addition, this patient may benefit from 
germline genetic testing, given the high-risk PCa 
features. This decision could also be influence by the 
patient’s family history of cancer, which could lead to 
investigations for hereditary cancer syndrome. 

The second case was a 75-year-old male who pro-
gressed to metastatic PCa. The patient was initially 
treated with robotic-assisted prostatectomy. Rising 
PSA levels were observed postoperatively, upon which 

a PET/computed tomography (CT) scan revealed lymph 
node metastasis. At this point, the patient started on 
ADT, which led to PSA decline. This patient meets the 
criteria for germline testing in the metastatic setting, 
according to several guidelines worldwide (summa-
rized in [53]). Another important factor highlighted 
in the guidelines is the family history of cancer. In the 
case, a pedigree revealed that the patient’s family 
had a history of breast and colon cancers, and also 
uncovered Ashkenazi Jewish ancestry on both sides of 
the family, which is an additional criterion for germline 
testing. 

What genes should be analyzed for germline 
mutations? According to the Philadelphia Consensus, 
a broad panel that includes genes associated with 
cancer predisposition syndrome is recommended for 
patients with advanced PCa[54]. If this is not feasible, 
at least the presence of mutations in BRCA1, BRCA2, 
and mismatch repair genes should be investigated. 
Alterations in these genes have implications for therapy 
selection, such as PARP inhibitors and immunotherapy. 
Additional genes may also be included, according to 
the patient’s personal or family history of cancers. 

The patient underwent germline testing with a mul-
ti-gene panel that revealed a pathogenic mutation 
in BRCA2. While such patients may respond to ADT, 
they are at increased risk of progression and should 
be monitored closely. Upon progression to mCRPC, 
patients with germline BRCA2 may experience signif-
icantly improved outcomes with PARP inhibitor ther-
apy, as seen in clinical trials with rucaparib[55] and 
olaparib[56]. In addition, the use of PARP inhibitors is 
under evaluation as monotherapy or in combination 
with other therapies, such as ADT, in earlier disease 
settings (reviewed in [57]). BRCA2 mutation status may 
also have implications for patients with early-stage 
PCa, given the increased molecular risk of aggressive 
disease[58]. However, it is still unknown how BRCA2 
and other germline mutation status may influence 
management during active surveillance.

Germline testing in patients with PCa also pro-
vides insights on hereditary cancer syndromes. In the 
case, the BRCA2 mutation identified in the patient is 
also associated with an increased risk for hereditary 
breast and ovarian cancer (HBOC) syndrome, as well 



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as additional cancer risks[54]. This is an important 
consideration not only for PCa survivors but also their 
families. The patient in the case qualifies for BRCA2 
cascade testing, which involves germline testing for 
a particular mutation in all direct relatives, such as 
children and siblings. Given the patient’s Ashkenazi 
Jewish ancestry, cascade testing could also be offered 
to other family members. In addition, the pathogenic 
BRCA2 mutation uncovered through germline testing 
would lead to specific screening recommendations for 
PCa, melanoma, breast, ovarian, and pancreatic can-
cers for the patient and his relatives. It is important to 
highlight that genetic counselling is critical both prior 
to and post germline testing to inform patients about 
the purpose of the test, the potential for uncovering 
hereditary cancer syndromes or additional cancer risks, 
as well as how test results may influence cancer screen-
ing and management for patients and their families[54].

The next presentation was by Dr. Maria J. Ribal 
(Spain), who discussed the impact of COVID-19 in 
urologic oncology. With nearly 153 million peo-
ple affected by the pandemic worldwide, this is an 
unprecedented situation in modern times that has 
had profound effects on different aspects of uro-on-
cological care. Dr. Ribal first focused on the impact 
on optimization of resources. At the beginning of 
the pandemic, all hospital resources were shifted to 
care for patients infected with SARS-CoV-2. This situ-
ation pushed physicians to best prioritize healthcare 
resources, which led to the publication of guidelines 
specific for rapid response in the COVID-19 era. With 
that in mind, the European Association of Urology 
(EAU) published guideline recommendations in April 
2020 in an effort to guide management decisions and 
patient prioritization during the pandemic[59]. While 
the clinical evidence to build these guidelines was not 
high level, the analysis of data collected during the 
past 1.5 years will provide important insights on the 
real impact of not only delayed therapy, but, more 
importantly, delayed diagnosis. 

Recently, the impact of delayed treatment was 
systematically reviewed in a series of retrospective 
studies[60]. The results demonstrated an association 
between cancer treatment delays and increased mor-
tality that may have important implications following 

the COVID-19 pandemic. To this end, an attractive 
strategy may be the establishment of COVID-19–free 
surgical pathways, in which major perioperative facil-
ities are not shared with patients with COVID-19[61]. 
Another challenge is determining the appropriate 
timing of surgery following SARS-CoV-2 infection. In 
a recent prospective study, reduced mortality risk was 
found in patients who had a least a 7-week delay for 
surgery following the infection[62]. Further delays may 
be beneficial if COVID-19 symptoms persist for over 
7 weeks. 

In addition to the utilization of resources, another 
important aspect is the impact of COVID-19 on 
patients with cancer who were undergoing active 
treatment. This is a controversial topic, as Dr. Ribal 
highlighted. While early reports suggested that cancer 
patients with COVID-19 undergoing treatment were 
at an increased risk of mortality, another prospective 
study demonstrated that the risk was not greater 
compared to non-infected patients[63]. Dr. Ribal 
emphasized that best way to address this question is 
by acquiring data from clinical registries. Some exam-
ples include the COVID-19 and Cancer Consortium 
Registry (CCC19)[64], the ASCO Survey on COVID-19 in 
Oncology (ASCO) Registry[65], and the ESMO-CoCare 
Registry[66]. 

The current challenge is evaluating the impact of 
COVID-19 vaccination on cancer. Several societies 
and organizations, such as the European Society of 
Medical Oncology (ESMO)[67], the American Society 
of Clinical Oncology (ASCO)[68], and the National 
Comprehensive Cancer Network (NCCN)[69], have 
provided statements encouraging the vaccination of 
patients with cancer, as long as components of the 
vaccine do not interfere with active treatments. The 
benefit of COVID-19 vaccination may be even greater 
for patients who undergo surgery, as suggested by a 
modelling study. Since vaccine numbers are limited, 
prioritizing patients undergoing surgery may not only 
support safe re-initiation of elective surgical services, 
but also reduce the incidence of postoperative pul-
monary complications and the associated healthcare 
costs[70]. 

The social-distancing restrictions imposed by 
COVID-19 had impor tant repercussions for the 



B2B: PROSTATE CANCER SUMMARY

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development of telemedicine. This novel modality of 
health care will likely remain a mainstay of health sys-
tems and will require adequate training for physicians 
and patients alike in order to fully explore the benefits 
of this tool[71]. However, each patient with cancer is 
different and many may still require in person interac-
tions with their healthcare providers[72]. Going for-
ward, the benefits of in-person interactions should be 
balanced with the continuing need for telemedicine. 

COVID-19 also imposed barriers to medical 
research, including patient recruitment for clinical trials 
and access to hospital facilities to conduct investi-
gations. For several ongoing trials in genitourinary 
cancers, the need for repeated in-person visits has 
precluded accrual. Research-related personnel and 
resources have also been relocated to COVID-related 
care and research[73]. The pandemic has also posed 
a burden on the mental and emotional well-being of 
physicians[74]. Medical departments should be aware 
of this challenge and develop initiatives to prevent 
burnout among their healthcare teams.

The pandemic will have a long-lasting impact on 
healthcare systems, particularly because of delayed 
diagnoses. In a recent population-based modelling 
study in the United Kingdom, delayed diagnosis due 
to COVID-19 was shown to result in increased 5-year 
mortality rates for breast, colorectal, and esophageal 
cancers[75]. In uro-oncology, the reduction in surgeries 
seen since the beginning of the pandemic will also put 
medical units under continuous stress to be able to 
absorb the growing demand[76]. Dr. Ribal encourages 
the medical community to collaborate during these 
challenging times and to learn from this experience to 
improve patient outcomes in years to come.

In the Q&A period, Dr. Ribal provided her perspec-
tive on how clinicians and researchers may overcome 
the obstacles in PCa research and care experienced 
during the pandemic. While these have been chal-
lenging times, Dr. Ribal highlighted all the achieve-
ments of the past year, including the development of 
several vaccines, and the importance of worldwide 
collaboration.

Next, Dr. Giovanni Lughezzani (Italy) discussed 
recent developments in high-resolution ultrasound 

(US), focusing on an update on the 29MHz micro-US. 
Dr. Lughezzani started by providing an overview of 
the PCa diagnostic pathway evolution. Conventional 
US-based imaging is a cheap, largely available, and 
easy approach that is only used for systematic biop-
sies and rarely provides any information regarding 
the presence of PCa. Multiparametric magnetic res-
onance imaging (mpMRI) represents an important 
improvement from conventional US for PCa diagnosis. 
However, the use of mpMRI-based imaging may be 
limited by its cost and availability, as well as the need 
for an expert radiologist to obtain the images and 
assist in targeted biopsies. High-resolution micro-US 
has the potential to bridge the gap between conven-
tional US and mpMRI. Micro-US allows immediate vis-
ualization and real-time targeting of prostatic lesions 
without radiologic assistance, in addition to limiting 
the use of mpMRI to essential cases only. 

Novel micro-US operates at 29 MHz, a much higher 
frequency compared to conventional systems. This 
leads to a substantial improvement in resolution to 
visualize both the axial and lateral axes of the pros-
tate. The micro-US technology allows the adoption 
of transperineal or transrectal biopsy strategies, and 
an MRI fusion approach can also be incorporated to 
allow better targeting of lesions[77]. Lesions identified 
by micro-US are characterized using the Prostate Risk 
Identification Protocol using Micro-US (PRI-MUS). This 
protocol classifies lesions in real time, using a scale 
from 1 to 5, ranging from benign to features typically 
associated with higher risk of PCa[78]. PRI-MUS has 
been validated by several studies, which have also 
shown that the protocol can be easily learned by urol-
ogists with previous experience with conventional US.

What are the potential applications of micro-US 
in the clinical practice? In addition to faster diagno-
sis and no need for contrast injection, micro-US may 
potentially help to avoid biopsies in the presence of 
PRI-MUS 1 to 2 lesions. Compared to conventional US, 
real-time micro-US resulted in an increased detection 
rate of approximately 12% in an early experience at 
the Cleveland Clinic[79]. In a prospective study of 320 
patients, similar detection rates for clinically significant 
PCa were found between micro-US and mpMRI[80]. 
More recently, in a multicentre registry of 1,040 



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patients, the diagnostic performance of micro-US 
demonstrated comparable or higher sensitivity for 
clinically significant PCa compared to mpMRI[81]. 

Micro-US may offer good visualization of target 
lesions. In a study of 144 prostatic lesions, 9% of 
lesions identified by MRI but not by micro-US were 
negative for clinically significant PCa at biopsy. By 
contrast, 11.8% of lesions identified only by micro-US 
but not by MRI also had a positive PCa diagnosis at 
biopsy[82]. In addition, in a single-institution study of 
222 patients comparing different diagnostic strategies, 
micro-US–guided biopsy of MRI targets was superior 
to a robotic MRI fusion approach[83]. This suggests 
that a substantial proportion of MRI targets may be 
visible and amenable for biopsy with micro-US.

Micro-US may also complement MRI to improve 
the biopsy of target lesions. In a study of 194 patients 
who underwent transperineal biopsy with mpMRI- and 
micro-US–guided biopsy, micro-US identified 11% of 
additional lesions that were not detected by mpMRI. 
This suggests that micro-US may add significant 
information to current MRI approaches[84]. Similarly, 
in another study, the combination of micro-US and 
mpMRI was revealed as the best approach for the 
detection of clinically significant PCa[85].

Finally, micro-US also shows potential to provide 
local staging of PCa. In a feasibility study of 54 patients 
scheduled for robotic-assisted radical prostatectomy, 
five risk factors were evaluated to predict the presence 
of extraprostatic extension (EPE)[86]. This preliminary 
experience revealed a statistically significant associ-
ation between the presence and the number of risk 
factors and PCa EPE.

Based on the evidence currently available, Dr. 
Lughezzani proposed an alternative micro-US–based 
pathway for the initial work-up of patients with sus-
pected PCa. The micro-US findings can be used to 
guide subsequent decisions, which span from targeted 
biopsy in patients with positive findings to a tailored 
clinical follow-up in those with a negative micro-US 
result. In patients with an inconclusive micro-US image, 
a complementary mpMRI may be considered.

During the Q&A, Dr. Lughezzani discussed whether 
in the future some multiparametric features of mpMRI 

could be incorporated to improve the current micro-US 
technology. Micro-US is based on B mode images, 
which could potentially be improved with features 
such as Doppler and elastography. Dr. Lughezzani 
also detailed the learning curve with the micro-US 
technology. He explained that a urologist experienced 
with conventional US may need between 40 to 50 
cases to become comfortable with the technology. 
Dr. Lughezzani also highlighted that, in his personal 
experience, the learning curve is continuous and there 
is always opportunity for growth.

Next, Dr. Rafael Sánchez-Salas (France) led a case-
based panel on focal therapy advances and appli-
cations in 2021. The discussion had input from Dr. 
Caroline Moore (United Kingdom), Dr. Art Rastinehad 
(United States), Dr. Linda Kerkmeijer (the Netherlands), 
and Dr. Hashim Ahmed (United Kingdom). Focal ther-
apy offers the opportunity for achieving cancer control 
while preserving function in PCa patients. Some bene-
fits associated with focal therapy include lower rates of 
incontinence requiring pads and frequent maintenance 
of natural erections without medication, following a 
day surgery procedure with short catheterization time. 
By contrast, patients undergoing focal therapy may 
need a second focal procedure (1 in 5 men) or radical 
treatment (1 in 15 men) after 5 years and require more 
stringent monitoring.

The first case was a 52-year-old male with hyper-
tensive cardiac myopathy who presented with a PSA 
level of 6.9 ng/mL and a GS 3+4 upon biopsy. The 
patient underwent three treatment blocks of left 
focal high-intensity focused US (HIFU) treatment, with 
excellent Uchida changes. In his 12-month follow-up, 
the patient showed no signs of disease by imaging, 
a PSA decrease to 1.9 ng/mL, no urinary symptoms, 
and natural erections. In a retrospective analysis of 
1,032 patients treated with HIFU, 63.4% had GS 3+4, 
20% required a second focal treatment in 5 years, and 
3.7% required radical treatment after 5 years[87]. When 
looking at predictors of need for retreatment, higher 
GS was associated with greater risk. In the study, a 
trend for reduced retreatment rates was observed 
over time in response to improved patient selection, 
imaging, and operator experience.



B2B: PROSTATE CANCER SUMMARY

39

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Patient selection is essential for treatment deci-
sion-making with focal therapy. This approach is cur-
rently recommended for patients with PSA levels <20 
ng/mL, GS up to 7, life expectancy greater than 10 
years, and any prostate volume[88]. A biopsy after 1 
year is critical for evaluating treatment outcomes. In 
the second case, a 70-year-old male presented with 
GS 3+4 on transperineal MRI-US fusion biopsy 3 years 
after initial investigations for PCa. The patient was 
treated with gold nanoshell-localized photothermal 
ablation as part of a clinical pilot device study[89]. After 
infusion, the nanoshells penetrate the tumour, allowing 
tumour-specific ablation through heat following stim-
ulation with infrared light at a specific wavelength. An 
MRI performed 48 hours post-ablation revealed no 
signs of disease in the targeted area. In a single-arm, 
multicentre, phase 1/2 trial of 44 patients, treatment 
with gold nanoshells resulted in 48% PSA decrease 
and 71.1% negative lesions at 12 months[90]. With 
improved patient selection, imaging, and treatment 
technologies, focal therapy may become the preferred 
management approach for intermediate-to-high-risk 
PCa in the future.

While focal therapies offer an attractive option to 
PCa management, it is important to also consider the 
limitations. PCa is a multifocal disease with several 
lesions that are not all detected, even with high-resolu-
tion mpMRI[91]. Focal therapies are also heterogenous, 
both in target volume definition as well as technique, 
which limits comparisons[92]. In addition, the lack of 
prospective clinical trials comparing focal therapies 
to radical treatment limits inferences with respect to 
differences in toxicity and risk of recurrence. Currently, 
the EAU-EANM-ESTRO-ESUR-SIOG guidelines for 
local PCa treatment recommend that focal therapies 
are only offered in the context of a clinical trial[93].

Similar to other focal therapies, there have been 
promising results using focal radiotherapy approaches, 
such as focal brachytherapy and focal external-beam 
radiation therapy (EBRT)[94,95], although compara-
tive trials against radical treatments are still missing. 
Nevertheless, radical radiotherapy has seen much 
improvement in the past years, with advances in MRI-
guided radiotherapy and ultra-hypofractionation 
that lead to better targeting of the tumour[96,97]. An 

important consideration is whether there may be an 
alternative approach to whole-gland or focal radio-
therapy. The focal boost strategy was investigated 
in the randomized phase 3 FLAME trial, which com-
pared standard whole-gland EBRT to an additional 
focal boost to the prostatic lesion seen on mpMRI. 
Patients in the focal boost arm experienced signifi-
cantly greater biochemical disease-free survival (DFS) 
at 5 years (92% vs. 85%; HR=0.45 [95% CI 0.28–0.71; 
P<0.001), along with similar toxicity and health-related 
quality of life compared to standard EBRT[98]. In the 
phase 2 hypo-FLAME trial, a similar approach (but with 
a lower whole-gland dose) was taken to investigate the 
role of focal boost to hypofractionated stereotactic 
body radiotherapy (SBRT), which resulted in no severe 
acute toxicities 6 months after treatment[99]. Longer 
follow-up is needed to evaluate the long-term effects 
of this novel approach.

The last case was a male in his 70s with PSA level of 
6.4 ng/mL, Gleason 4+4, and metastatic lesion in the 
right superior public ramus as seen by MRI and subse-
quent bone scan and CT. The patient started treatment 
with ADT and enzalutamide, which resulted in minor 
tumour reduction. He was then enrolled in the phase 
2 ATLANTA trial, which is evaluating local treatments 
in men with newly diagnosed metastatic PCa[100]. In 
the trial, the patient was randomized to receive HIFU 
to the primary tumour and SBRT to treat the metastatic 
lesion. This ongoing trial will have a follow-up of at 
least 2 years and progression-free survival (PFS) as the 
primary endpoint.

During the Q&A, Dr. Moore discussed how tumour 
size may guide the decision between focal ablation 
and hemiablation. Based on clinical data of over 1,000 
patients, no differences were seen in cancer outcomes 
between the two approaches. She explained that her 
current practice is to treat focally, with a 5- to 9-mm 
margin depending on tumour characteristics. Then, Dr. 
Rastinehad discussed the use of novel US thermometry 
in focal therapy. This as a new imaging technique that 
improves real-time assessment of tumour ablation, 
although it is still in early stages of development. 
Next, Dr. Kerkmeijer provided her insights on patient 
selection for focal treatment of oligometastases. She 
believes that there is variation in imaging and disease 



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staging across countries that influence the classification 
of oligometastatic disease. This ultimately influences 
patient selection for focal treatment. As she pointed 
out, an international trial evaluating patient selection 
would be beneficial. Lastly, Dr. Ahmed summarized 
the key considerations for focal therapy. According to 
him, focal therapy is most advantageous for men with 
localized disease who require treatment. He cautioned 
that this approach is not an alternative to active surveil-
lance and that urologists should always be cognizant 
of the impact of overtreatment. 

The PCa session continued with a case-based panel 
on the adoption of systemic therapies by urologists. 
The discussion was led by Dr. Shusuke Akamatsu 
(Japan), with input from Dr. Alexandre de la Taille 
(France), Dr. Martin Gleave (Canada), and Dr. Neal 
Shore (United States). The first case was a 67-year-
old male with high-risk PCa who initially underwent 
radical prostatectomy and salvage radiation therapy. 
After starting ADT, the patient recurred and pre-
sented with castration resistance. Metastases were 
not observed by CT or bone scan and the patient had 
a PSA doubling time (PSADT) of 6 months. To guide 
next management decisions, it is important to first 
evaluate whether metastases are indeed not present. 
PSMA PET localizes cells expressing PSMA and has 
better specificity and sensitivity compared to con-
ventional imaging to detect metastasis. Recently, a 
study demonstrated that PSMA PET identified metas-
tasis in 55% of patients despite negative conventional 
imaging[101], leading to important changes in clinical 
management. Another important consideration is the 
PSADT. Patients with PSADT <10 months are at an 
increased risk of developing bone metastasis[102]. If 
PSMA PET is negative for metastases, the patient in the 
case is an ideal candidate for treatment with an ARPI, 
such as enzalutamide, apalutamide, or darolutamide. 
All three agents have shown benefit in prolonging 
metastasis-free survival in patients with nonmetastatic 
CRPC (nmCRPC), with tolerable toxicity[103-105]. 
Radiation therapy to the primary tumour is, for some 
authors, questionable[106], but no prospective data 
have yet been reported. If PSMA PET is positive, the 
number of metastatic lesions has important implica-
tions for treatment decision-making. In the presence of 

multiple metastases, ARPI (abiraterone, enzalutamide, 
or apalutamide) or docetaxel-based chemotherapy 
may be considered. By contrast, there is much debate 
regarding the management of oligometastatic CRPC. 
Current guidelines are based on conventional imag-
ing and recommend ARPI as standard of care[107]. 
Discussion of management decisions with the tumour 
board is advised. After the patient has started on a sys-
temic therapy, PSA levels should be monitored closely, 
and minor elevations may warrant subsequent imaging 
(either conventional imaging or PSMA PET) to assess 
for additional lesions.

The second case was a 59-year-old male with 
high-volume mCSPC with multiple bone metastases. 
The patient had no family history of prostate, breast, 
ovarian, or pancreatic cancer. He was initially treated 
with ADT + abiraterone but progressed to mCRPC 
after 5 months, with additional metastasis on conven-
tional imaging. At this stage, the management plan 
would include the participation of a medical oncologist 
to start the patient on docetaxel-based chemotherapy. 
Enrolment in a clinical trial may also be considered. 
However, some biomarker advances on the hori-
zon, such as the use of ctDNA, may help to identify 
genomic alterations to improve patient stratification 
and guide treatment sequencing decisions[108]. For 
instance, patients who progress while receiving ARPI 
may develop therapy-specific alterations in the AR 
that may alter their response to subsequent hormonal 
treatments[109]. These alterations may be mapped 
out with serial ctDNA to guide management changes 
during treatment resistance and progression. ctDNA 
may also help to identify other genomic alterations 
that have recently become therapeutic targets under 
investigation in PCa. This is the case of PI3K inhibi-
tion with ipatasertib, which demonstrated prolonged 
radiographic PFS when combined with abiraterone in 
patients with PTEN loss in the IPATential150 trial[34]. 
Other ongoing trials are aiming to refine optimal bio-
marker profiles to optimize benefit from dual AR/PI3K 
pathway inhibition. DNA repair alterations may also 
help inform therapy selection. These alterations may 
confer resistance to initial ADT and ARPI[2,110], but 
may underly good response to PARP inhibitors, as seen 
in the PROfound trial[111].



B2B: PROSTATE CANCER SUMMARY

41

B2B: Prostate Cancer Summary

The third case was a 74-year-old male with 
node-metastatic PCa who received whole-pelvic radia-
tion and adjuvant ADT for 2 years until recurrence with 
multiple bone metastases and local tumour extension. 
Subsequent treatment was composed first of ADT + 
enzalutamide, and then docetaxel, until the patient 
developed resistance, along with an additional bone 
metastasis and bulky primary disease. In this setting, 
treatment with cabazitaxel may offer benefit, which is 
particularly supported by the prolonged median OS 
observed in the CARD trial, following progression on 
docetaxel and an ARPI[112]. Future treatment options 
for patients in this disease setting may include novel 
radiopharmaceuticals. TheraP is a randomized phase 
2 trial examining the role of 177Lu PSMA-617 vs. caba-
zitaxel in patients with mCRPC who progressed after 
docetaxel therapy[113]. Another study is the phase 3 
Vision trial, which compared 177Lu PSMA-617 + stand-
ard of care to standard of care alone in patients with 
mCRPC and PSMA-positive metastasis[42]. Recently, 
it was reported that the trial had met both primary 
endpoints, with significant improvements in OS and 
radiographic PFS[41]. Other emerging therapies tar-
geting PSMA are currently under investigation.

Day 2 of the B2B GU Cancers Triad Virtual Meeting 
concluded with Dr. Stacy Loeb (United States) pre-
senting the state of the art in digital health in urologic 
oncology. The use of social media is expanding glob-
ally, with 4.2 billion users worldwide as of January 
2021[114]. There has also been an expansion in the 
use of health apps, which is greatest in China, India, 
Indonesia, and United States, according to a recent 
report[115]. Not surprisingly, digital health may have 
an important role at different stages of the patient 
journey with urologic cancers, such as awareness and 
education, screening and diagnosis, treatment selec-
tion, treatment, and survivorship. At each of these 
stages, social media may have both a positive and a 
negative influence.

On the positive side, social media messaging may 
improve awareness and education, which may lead 
to increased cancer screening or lifestyle changes in 
response to known risk factors. At the diagnosis stage, 
health apps may help to guide the patient’s decision 
to undergo biopsy. An example is the Rotterdam 

Prostate Cancer Risk Calculator, a validated app that 
provides easy information about PCa risk based on the 
patient’s PSA level, prior imaging, biopsy, and other 
clinical data[116]. Another app, currently under devel-
opment in collaboration with Dr. Veda Giri, is the HELIX 
Webtool. This app assists with targeted family history 
collection and the decision-making about germline 
testing. It includes interactive features, as well as a 
series of educational modules on PCa genetics.

With regards to treatment selection, the Virtual 
Tumour Board sessions promoted by the National 
Cancer Grid in India represent an example of a practi-
cal platform where centres can come together to dis-
cuss oncological management and to promote stand-
ardized care to patients[117]. More recently, Twitter has 
become an essential platform to connect and engage 
the urological community worldwide. First introduced 
in 2018, the #UroSoMe hashtag has had a positive 
impact in helping the identification of urological con-
tent, as well as improving community engagement on 
the social media platform[118]. Social networks have 
also developed an expanded role for the dissemination 
of evidence-based medicine. Some examples come 
from the EAU, which has been using various social 
platforms, such as Twitter, Facebook, and LinkedIn, 
to disseminate clinical practice guidelines, thereby 
contributing to the adherence to evidence-based 
medicine[119,120]. With regards to delivery of care, the 
use of telemedicine has shown rapid growth among 
urologists and uro-oncologists, particularly during the 
COVID-19 pandemic, when telemedicine use increased 
from 16% to 46%[121]. Digital tools will also have an 
increasing importance for the future of uro-oncology. 
As shown in recent studies, trainees use video content 
on YouTube as their preferred tool to learn surgical 
techniques[122] and many have reported using apps 
to access practice guidelines[123]. 

Social media also has a positive role in survivorship. 
Patients and their families have started to make use 
of the GoFundMe platform to address the financial 
toxicity associated with cancer care. Facebook groups 
and online health communities may also be used by 
patients to obtain advice and support from others who 
may be going through a similar journey. Apps may 
be very useful during survivorship care, such as seen 



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in patients who underwent radical prostatectomy, to 
help in recovery and symptom improvement[124,125]. 
Digital networks and apps can also be used to help 
identify the unmet needs of patients, such as seen 
through WhatsApp-based surveys[126] and social 
media surveillance[127] during the pandemic. 

Despite the positive impact of social media and 
digital apps for physicians and patients, digital health 
may also lead to negative experiences. A particular 
concern is the spread of misinformative or inaccurate 
information through social networks. For instance, a 
study of the 10 most shared articles in uro-oncology 
on social media platforms revealed that one to seven 
out of those articles were misinformative or inaccu-
rate[128]. Perhaps even more concerning was the fact 
that those articles were also 28 times more likely to be 
shared than factual articles. Regarding the quality of 
bladder cancer and PCa content on YouTube, studies 
have shown that many videos contain misinformative 
and/or poor quality content[129,130]. Moreover, poor 
quality content had not only more views but also 
generally high engagement from viewers[130]. More 
recently, among the limited number of TikTok posts 
with objective PCa information, 41% was classified as 
misinformative[131].

Several advances to digital health are underway. 
Given its increasing role in uro-oncology, it is impor-
tant to consider the evolution of digital health while 
ensuring quality and equity. To this end, the DISCERN 

criteria provide a helpful guide to assist the production 
of consumer health information[132]. With regards to 
diagnosis, novel AI-based digital solutions are under 
development and validation. For instance, AI-based 
algorithms have been demonstrated to accurately 
assess core needle biopsies and may have important 
applications in pathology laboratory procedures[133]. 
Integration of big data may support improved risk 
stratification to guide treatment decision-making in 
PCa. An example is PIONEER, the European network 
of excellence for big data in PCa, which combines data 
from 32 partners across nine countries to improve 
management decisions and optimize PCa care[134]. 
Lastly, the role of telemedicine and remote surgery 
will likely expand in the future, with alternative health-
care delivery models and better data transmission 
systems[135,136].

During the Q&A, Dr. Loeb addressed how patients 
may respond to engagement among physicians on 
social media and which best practices should be con-
sidered. Dr. Loeb emphasized that physician partici-
pation is key to the dissemination of evidence-based 
data and dilution of the misinformation spread about 
urologic cancers on social media. For online commu-
nication, she stressed the importance of following pro-
fessional guidelines, out of which she highlighted three 
that are specific to urology: the EAU, the American 
Urological Association (AUA), and the British Journal 
of Urology International (BJUI).



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43

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Abbreviations Used in the Text
ADT androgen deprivation therapy
AE adverse event
AI artificial intelligence
AR androgen receptor
ARP androgen receptor pathway inhibitor
ASCO American Society of Clinical Oncology
AUA American Urological Association
BiTE bispecific T-cell engager
BJUI British Journal of Urology International
CCC19 COVID-19 and Cancer Consortium 
CI confidence interval
CRS cytokine release syndrome
CT computed tomography
ctDNA circulating tumour DNA
DDR  DNA damage response
DFS disease-free survival
EAU European Association of Urology
EBRT external-beam radiation therapy
EPE extraprostatic extension
ESMO European Society of Medical Oncology
FDA    U.S. Food and Drug Administration
GS Gleason score
HBOC hereditary breast and ovarian cancer
HIFU high-intensity focused ultrasound
HR hazard ratio
HRR homologous recombination repair
ICI immune checkpoint inhibitor

mCRPC    metastatic castration-resistant prostate 
cancer

mCSPC metastatic castration-sensitive prostate 
cancer

mpMRI Multiparametric magnetic resonance 
imaging

NCCN National Comprehensive Cancer Network
nmCRPC   nonmetastatic castration-resistant pros-

tate cancer
OS overall survival
PARP    poly(ADP-ribose) polymerase
PCa prostate cancer
PET positron emission tomography
PFS progression-free survival
PRI-MUS   Prostate Risk Identification Protocol using 

Micro-Ultrasound
PROTAC  proteolysis targeting chimera 
PSA prostate-specific antigen
PSADT prostate-specific antigen doubling time
PSMA prostate-specific membrane antigen
SBRT stereotactic body radiotherapy
SEER Surveillance, Epidemiology, and End 

Results
SNP single-nucleotide polymorphism
UPS ubiquitin proteasome system
US ultrasound
WHO World Health Organization



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46

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B2B: Prostate Cancer Summary

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PROCEEDINGS FROM THE SIU B2B URO-ONCOLOGY: GU CANCERS TRIAD • MAY 21–22, 2021 – SIUJ VOLUME 2, SUPPLEMENT 1, JULY 2021

B2B: Prostate Cancer Summary

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