Eggener Urges Pragmatic Approach to Prostate Cancer Innovations

Scott Eggener, MD

Bruce and Beth White Family

Professor of Surgery

Vice Chair

Section of Urology

Director

High Risk and Advanced Prostate Cancer Clinic

University of Chicago Medicine

Chicago, IL

UROLOGISTS SHOULD BE open to innovative technologies and methodologies without getting swept up in the hype of new things, Scott Eggener, MD, told attendees at the 2024 Large Urology Group Practice Association (LUGPA) Annual Meeting in Chicago, Illinois.

“You have to be balanced in what to embrace vs what not. It is easy to be wowed by new things. I think it’s part of our operating system, and it’s also…easy to be hijacked by things that may not be so important for patients. And I think it’s important to temper some of the enthusiasm sometimes,” Eggener, the Bruce and Beth White Family Professor of Surgery at the University of Chicago in Illinois, said.

Eggener gave a talk at the LUGPA annual meeting titled “Leveraging Cutting-Edge Technologies to Enhance Prostate Cancer Treatments.” He began by discussing screening.

“There are a lot of tests out there that absolutely, positively outperform traditional PSA [prostate-specific antigen] [tests]. The good news is some of them are easily accessible and cheap,” Eggener said. The tests, he explained, do well at identifying men with PSA grade group 2 or higher. However, Eggener said that he doesn’t order these tests frequently.

“I tend to use PSA free, PSA, PSA density [tests], things like that. There are absolutely times I order these, but it’s certainly not a reflexive test. But there is absolute value in these tests. I do think it’s also important for us to remember all the cheap, free things that are at our disposal to make smart decisions with screening,” Eggener said.

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Eggener made the point that not every patient needs PSA screening. “We’ve got a bit of an epidemic of sick older men getting PSA [tests],” he commented. He urged attendees to be familiar with current screening guidelines.

Eggener also stressed the importance of repeating a PSA test with an elevated PSA level result. “I’m not sure of any situation with screening treatment or posttreatment where you change the plan based on 1 new change in PSA. Always repeat it,” he said.

Obtaining a baseline PSA level for a man, Eggener said, “is gold. PSA velocity, on the other hand, is not very helpful.”

“I think [the] free PSA [test]—if we could monetize it, commercialize it, sell it—is better than [the] total PSA [test] if you look at the raw data. If someone asked me, ‘Would I rather know my total PSA or my free PSA [level]?’ I’d rather know my free PSA [level], so every single person I screen, I get a free PSA [level] on,” Eggener said.

Eggener then shifted his talk to imaging, where he spoke highly of MRI. “MRI has taken over. MRI is a win. There is value, but they’re good, sometimes great, and rarely perfect,” Eggener said. He also touched on technology such as artificial intelligence that can enhance MRI as well as prostate-specific membrane antigen (PSMA)-PET imaging. PSMA-PET, he said, is a “clear winner” vs MRI.

“It would be wonderful if PSMA-PET was cheaper, easier, quicker. I’d love to order it [for] all my patients, from surveillance on up. I don’t, because at least at our place, I’m told it’s a $7000 test, and I try to be at least cost conscious with it. I hope there’s a time where we order it more regularly,” Eggener said.

In terms of prognosis and staging, Eggener commented, “We’ve got a lot of genomic tests out there. I don’t have any ties to any of them. I would tell you that I think the single best one, based on extensive validation [and] really good science, is Decipher. I do think it has value in certain clinical situations [such as deciding] between surveillance and treatment when you’re looking for something to tip the needle a little bit.”

However, Eggener added that he feels the test is overordered. “I see a ton of patients where I say to myself, ‘Why did they get this?’ No matter what the Decipher [score] shows, you’re not going to change a darn thing in your counseling or your management for that patient,” he said.

Eggener also discussed advancements in prostate cancer treatment, particularly the potential of theranostic approaches. “This is an exploding space with new isotopes for theranostics,” he noted, referencing isotopes such as actinium and scandium that offer more targeted treatment options with potentially fewer adverse events.

Regarding focal therapy, “there are a lot of visceral opinions on focal therapy and a lot of blowback. I have absolute confidence there’s going to be a subset of patients [for whom] focal therapy is a very reasonable option,” Eggener said.

Eggener also touched on radiation therapy, including proton therapy and hypofractionation. “Proton therapy is exactly the same as regular radiation therapy for prostate cancer. It’s not any better, it’s not any safer, there are not fewer adverse effects,” Eggener said. Regarding hypofractionation, he reminded the audience of its place in the clinical guidelines as a viable option. “If…your patients are getting 6 to 8 weeks of radiation therapy, there’s only 1 benefit of those 6 to 8 weeks…and it’s not to the patient,” Eggener said.

He concluded his talk by urging attendees to “seek newer and better ways.” Regarding innovations, Eggener said attendees should “try to be sensible about things.”