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.
Transcript
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 ASCO.org/podcasts. 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 genetics...so 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
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Disclosures: Dr. Jeanny Aragon-Ching
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