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Nov 24, 2020

Dr. Jeanny Aragon-Ching, a medical oncologist and clinical program director of genitourinary (GU) cancers at the Inova Schar Cancer Institute, shares her concerns over the decline in the screening, diagnosis, and treatment of prostate and other GU cancers amid the COVID-19 pandemic, and highlights promising clinical trials underway to advance the fields of prostate, bladder, and kidney cancers.


ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. Joining me today is Dr. Jeanny Aragon-Ching, a medical oncologist who serves as the clinical program director of Genitourinary Cancers at the Inova Schar Cancer Institute in Virginia. She joins me to discuss the worrying decline in screenings for prostate cancer due to the COVID-19 pandemic.

Dr. Aragon-Ching also highlights clinical trials underway to advance the treatment of prostate, bladder, and kidney cancers. Dr. Aragon-Ching reports no conflicts of interest relating to the issues discussed in this podcast. And full disclosure relating to old episodes of the Daily News podcast are available on our transcripts at Dr. Aragon-Ching, it's great to have you on the podcast today.

Dr. Jeanny Aragon-Ching: Thank you so much, Geraldine, for having me here.

ASCO Daily News: Well, screening for prostate cancer is vitally important. What are your concerns about the long-term impact of delayed screenings, diagnosis, and treatment in this setting?

Dr. Jeanny Aragon-Ching: Yes. So generally there have been already reports actually of observed decline in the common screening and diagnostic procedures and practices reflecting the impact of the COVID-19 pandemic on cancer prevention and early detection, signaling possible downstream effects on the timing and staging of future cancer diagnosis. Now, the issue is there has been no major guidelines or guidance regarding recommendations for screening during the pandemic.

Now, one closely aligned guidance, if you will, from the NCCN, actually it's more for management, it suggests that patients with known low risk or certainly very low-risk prostate cancer may actually defer staging active surveillance or even testing for treatment until conditions are deemed safe. Therefore, determination of who really needs to be absolutely screened and certainly diagnosed, I think, is key.

So especially since the subject of screening in prostate cancer has always actually been controversial even while the U.S. Preventive Services Task Force set forth the D recommendation, which is recommendation against PSA screening except for those target ages, let's say, between 55 and 69 years of age, they had a C recommendation, which involves individualized decision-making. And that means for us, we always have to have that dialogue with the patients in order to weigh the pros and cons of screening, especially during these times.

So therefore, I mean, there's really no current standards that are set forth. A lot of it I think would be tailored to each individualized person and patient as well as physicians in practice during these times of pandemic.

ASCO Daily News: Right. Well, COVID-19 will continue to be a threat for some time. So, how is the oncology care community to fill the gap in diagnostic services? Should cancer screenings, biopsies, and surgeries press on? If you see a patient that really needs treatment now, you, I assume, will proceed, correct?

Dr. Jeanny Aragon-Ching: Correct. Yeah. Now, I do think the gaps in diagnostic services is really actually being remedied by performing other alternative services, if you will. So, for instance, remote telehealth services have gotten and gained ground since the COVID-19pandemic. And my general recommendation is, and the thinking really is minimal harm is really expected with delays in care certainly for certain types of risk of prostate cancer, or even bladder cancer or kidney cancers. If one were to delay the treatment for, let's say, 3 months, especially when we weigh the risk of mortality or morbidity from being exposed to COVID-19, I think those are the critical issues.

Now, I would say that diagnosis and treatment for patients with GU cancers really require prioritization, adjustments for, let's say, screening biopsies, as well as individualized tailored approach to the diagnosis and treatment. The oncologic community, the GU community as a whole I think quickly filled that gap, as I mentioned earlier, by restricting non-urgent, in-person clinic visits, as well as adopting more remote telehealth visits to continue care that the physicians provide.

So in terms of prioritization of the goals, patients, let's say, who need to undergo immediate diagnostic procedures and biopsies to make a diagnosis would be a priority. So especially for those who are deemed to have high-risk disease, for those who are likely to have high-grade disease, let's say, muscle-invasive bladder cancer, or let's say, big tumors that are seen on abdominal imaging for a renal cell cancer because we don't typically biopsy, let's say, renal masses to diagnose renal cell carcinoma. And as a general rule of thumb, procedures and treatments that are curative in intent would be considered high priority, whereas benefits of care from treatments certainly has to be weighed against a potential risk for infections and morbidity from COVID-19.

Identifying the risks are important as well. So, for instance, treatment may be safely deferred for patients with low risk or certainly even intermediate-risk patients, whereas surgery may be delayed in most high-risk patients or alternative treatments, let's say, a neoadjuvant hormone therapy, coupled with external beam radiation, may be a treatment of choice with regard to the pandemic, and then may be a feasible alternative. So there's a lot of changes that are being set forth.

Now with regard to radiation, there's also some concern, for instance, for lymphopenia, for those who undergo radiation. So actually identifying the patients who really would benefit from upfront treatment is key. So for patients with bladder cancer, let's say, who have muscle-invasive bladder cancer, they undergo surgery. We call it TURBT. And they undergo intravesical treatment.

So a lot of it highly depends on the goal of the therapy. Is it curative in intent? Certainly if they undergo neoadjuvant chemotherapy, that adds to the layer of complexity for these patients because they are now being exposed to chemotherapy. But on the other hand, it is an important treatment with the goal of curative intent.

And there's also something to be said about the varying institutional procedures. For instance, each institution has in place their own safeguards to screen, let's say, or treat patients with COVID-19. So in our institution, for instance, doing rapid COVID-19 tests to assess prior to performing these procedures, anesthesia or procedures that are high-risk for aerosolizing like respiratory secretions, would be of paramount importance. So I think there's a lot of institutional guidance also that comes into play in this day and age of COVID-19 in the treatment of our patients who have a diagnosis of GU cancers.

ASCO Daily News: Absolutely. What can you tell us about new developments in diagnostics in the prostate cancer space which have truly advanced the field, resulting in fewer unnecessary biopsies and hopefully making men a little less reluctant to actually take care of their prostate health?

Dr. Jeanny Aragon-Ching: Yes, that's a great question. And emerging data suggests that targeting using a combined MRI and an ultrasound fusion approach may perhaps increase the detection of significant high-risk prostate cancer, which, after all, is really the clinically significant and meaningful cancers that we need to treat, and therefore lead to perhaps lower detection of the lower risk prostate cancer that may not need to be treated.

Now, it's important to recognize also that a negative MRI does not necessarily exclude the possibility of cancer. And therefore, biomarkers have been in place to be also helpful to perhaps avoid a biopsy in someone, let's say, who has a negative result.

Now, there are numerous tests or biomarkers out there available. I always have said that a lot of times it is dealer's choice. It's highly dependent on what physicians are comfortable using, [and] what the availability is within their own institutions. And what the payers or insurance would pay for or cover. But there are several promising ones out there that help further predict if a patient has a high-risk of having a diagnosis of clinically significant prostate cancer.

So, for instance, there was a urine base marker, it's called IntelliScore, so it looks at three different genes that would be able to discriminate a higher grade group of cancer versus a lower grade group. And that would help physicians and providers to help further define who needs to be biopsied, especially in this day and age, again, of COVID-19, so that they would be able to predict the likelihood of higher risk prostate cancer that ultimately needs to be treated.

And that's not the only one out there that's currently available. There's other things like blood work or blood tests, like 4Kscore, which combines different parameters like free PSA, total PSA, intact PSA, that will help further predict high-grade prostate cancer. And the bottom line is all of these tests would help the physicians, the urologist hopefully to decide who they need to biopsy and prioritize versus those who can safely wait based on just an elevated PSA alone.

ASCO Daily News: Well, African American men are at a significantly greater risk of getting prostate cancer. Can you talk about the health disparities that exist in this setting? And do you think the field is doing enough to address this?

Dr. Jeanny Aragon-Ching: Mm-hmm. Yeah, so prostate cancer disparities actually constitutes one of the most complex issues in cancer today. So it is known that African American men unfortunately do have disproportionately higher incidence of prostate cancer, easily about 60% to 70% higher compared to Caucasian men counterparts. And they also have a higher 2-fold increased risk of prostate cancer death. So these are very relevant in the practice of prostate cancer in the field.

African American men are also more likely to be diagnosed at a younger age. They tend to have more advanced and aggressive disease. And African genetic ancestry is really unfortunately not a modifiable risk factor, so when we talk about there are potential reasons why this is so, why African American men may have a higher incidence or mortality. One potential explanation could be genetics. So it has been found that several genetic variants may be a little bit more common in African-American men.

So, for instance, like 8q24 mutation in a tumor suppressor gene, there's differences in microRNA regulation, and they tend to, unfortunately, present with more aggressive tumors. And certain gene mutations also can lead to poor outcomes, let's say, P53 mutations, CDK M18, which is more commonly seen in African American men.

Now, I would say that there are also possible issues with screening. So you may all recall that when US Preventive Services Task Force, which is felt to be the most influential in making recommendations for a PSA screening, gave a D recommendation in their most recent iteration of PSA screening, and that is that PSA screening is not recommended for the average person, especially for the older individuals, there was no real recommendation for men of African descent, or African American men.

And they are really the ones who are underrepresented in these studies. So in one study, for instance, that looked at rigorous modeling, when they look at these trials, they suggested that PSA screening can actually yield greater mortality benefits for high-risk groups. And that includes men of African American descent.

So one other big issue with this is probably access or utilization of health care, which would be a key factor in racial or ethnic disparities. And we know that standard prostate biopsies are still really the gold standard for diagnosis. And whenever we talk about better tools for making diagnosis, and we mentioned earlier about MRIs, for instance, MRIs may be less utilized in patients with lower, let's say, socioeconomic status. So there are a lot of reasons why we are seeing these disparities in men with African American descent.

ASCO Daily News: So speaking of research, I'd love to ask you about your current research. You treat patients with bladder, kidney, prostate, and testicular cancers. Is there anything you'd like to highlight today?

Dr. Jeanny Aragon-Ching: Yes. So, for instance, we are looking carefully at prostate cancer. And we are very much in tuned with the fact that a lot of men with prostate cancer have genetic variants and genetic and hereditary mutations. So we are looking carefully at the differences between men who present with de novo metastatic disease, and that means at the very first presentation to the medical or health professionals, they already have metastatic disease, versus those who were treated with curative intent treatment and then later on down the line present, unfortunately, with metastatic disease because they were not cured.

We would like to further define what the differences is between these two population of patients because the former seems to, unfortunately, do worse. So those are the things that we are highlighting.

In bladder cancer, we are very closely following what the outcomes would be for patients who have muscle-invasive bladder cancer. For the longest time, we've known that neoadjuvant chemotherapy followed by cystectomy is one of the gold standards of care for treatment of these patients. So the additional role of immunotherapy in addition to neoadjuvant chemotherapy, that is a key improvement perhaps in the field, especially now that we know that avelumab maintenance has been shown to improve survival for a lot of metastatic bladder cancer patients.

And for kidney cancer, one of the key things that we would like to further highlight and improve upon the care is for patients who have high-risk, high-stage kidney cancers. So the standard of care remains to be surgery, but we know that a proportion of them would unfortunately recur with metastatic disease or have disease that comes back later on.

So the idea is, can we improve upon these odds by giving them adjuvant therapy? So we have an adjuvant immunotherapy trial that addresses the issue of delaying or preventing recurrence for these patients who have or are deemed to have high-risk disease (NCT03138512).

ASCO Daily News: And what is the name of that trial?

Dr. Jeanny Aragon-Ching: So this is actually CheckMate 914. This is the neoadjuvant immunotherapy nivolumab and ipilimumab versus a placebo. It's a placebo-controlled trial.

ASCO Daily News: Excellent. So Dr. Aragon-Ching, is there anything else on your mind that you'd like to address today before we wrap up the podcast?

Dr. Jeanny Aragon-Ching: Yeah. I really just think that the changes in practice brought on by the COVID-19 pandemic has us rethinking and reorganizing as an oncologic community the practice that we do. I believe that some are likely here to stay. So, for instance, the changes in the landscape and practices of treatment, we are really thinking about how long the duration of treatment are we providing.

Even clinical trials, since the start of the pandemic, of course, the key issue here is some trials have closed their doors on enrollment. And I think we're starting to pick up on those. Some have limited its enrollment. And I think once we get institutional practices streamlined, and people are in general a little bit more comfortable about exposures because they see that everything is safe, I think we'll be getting back to our routine.

But I don't think things are going to go back to the way they were. I think telehealth visits, for instance, are here to stay. We're creating a lot of guidance and guidelines on who are the patients who are best fit for these telehealth monitoring visits, or who are the patients who still need to come in person in order to get their care?

ASCO Daily News: Absolutely. Well, Dr. Aragon-Ching, thank you so much for sharing your valuable insight with us today on the ASCO Daily News Podcast.

Dr. Jeanny Aragon-Ching: Yeah. Thank you so much, too, Geraldine for having me and for sharing the insights with you all.

ASCO Daily News: And thank you to our listeners for joining us today. If you're enjoying the content on the podcast, please take a moment to rate and review us wherever you get your podcasts.


Disclosures: Dr. Jeanny Aragon-Ching

Paid Honoraria: Bristol-Myers Squibb, EMD Serono, and Astellas Scientific and Medical Affairs Inc.

Consulting or Advisory Role: Algeta/Bayer, Dendreon, AstraZeneca, Janssen Biotech, Sanofi, EMD Serono, AstraZeneca/MedImmune, Bayer, Merck, Seattle Genetics, and Pfizer

Speakers’ Bureau: Astellas Pharma, Janssen-Ortho, Bristol-Myers Squibb, and Astellas/Seattle Genetics

Travel Paid or Reimbursed: Dendreon, Algeta/Bayer, Bristol Myers Squibb, and EMD Serono

Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.