USANZ 2017 Conference Summary Part 3

USANZ 2017 Conference Summary Part 3

Talking Urology conducted a series of live recordings at USANZ 2017 conference in Canberra.

Part 3 of the USANZ 2017 Conference Summary sees Melbourne-based urologist Dr Joseph Ischia discussing a range of topics with the following thought leaders in the field of urology:

A/Prof Shankar Shiva, Dr Laurence Klotz, A/Prof Nathan Lawrentschuk, Dr Marlon Perera, Richard Grills, Kath Schubach, Sandra Warden, David Gray, Cara Webb

Talking Urology is supported by Ipsen.

Talking Urology podcast transcript

USANZ 2017 Conference Summary Part 3

Joseph Ischia: Welcome back to talking urology. I’m Joseph Ischia and some are saying, thankfully final installment of the conference highlights from USANZ 2017 Conference in Canberra. Let’s get straight into it. We’ve got what my mum described as the highlight of the conference which was my talk on the role of early systemic treatment in oligometastatic disease. It was a point counterpoint session with Shankar Siva, a radiation oncologist from Peter Mac in Melbourne, who was given the near impossible task of arguing against me but did quite a good job of making the case for metastasis directed therapy in this setting.

I looked at this from the perspective of I know we can delay ADT if we give metastasis directed therapy and I know that either by surgery or radiation, we get very good local control certainly at the doses that are appropriate for radiation which you could go to a pretty high dose, but we’re looking over 99% control and certainly with surgery we see very few infield recurrences. But the argument that I made was we can do that and you do delay ADT but inevitably most of these people will have an out of field recurrence. My discussion focused around are we doing these patients a disservice by not treating them early while their disease volume is low? It’s because we know that disease volume is important. It is a surrogate marker for how it’s going to respond to androgen deprivation whether that be looking at the early ADT treatments. We’ve got several meta-analyses looking at relatively old data that it’s arguable whether there’s benefit in overall survival but certainly benefits in complications and disease progression. We’ve even got the Messing trial. While it was underpowered, you don’t need a large trial to show a large effect. Men lived longer. In fact 84% chance of being alive, greater chance of being alive at any time point if they’d had early ADT rather than delay. So this has really formed the basis of my argument, is that we can do metastasis-directed therapy, but are we missing an opportunity to cure micrometastatic disease some might say, but at least knock it on the head. I think one of the key things to realise is that there is no evidence in this oligometastatic disease comparing metastasis-directed therapy to early ADT, and in light of that, we are desperately in need of a trial in this space because we spend a lot of our MDM discussing this exact topic.

And it was remiss of me not to mention our very own TOAD, timing of androgen-deprivation trial, which again showed a benefit for early ADT but Shankar was not shaken by my eloquent argument and delivered this withering rebuke.

Shankar Siva: Yes, I mean thanks for debating with me. Yes I found it was really quite stimulating debate. From my perspective, I suppose I was doing the case for metastasis-directed therapy and in a lot of ways, our arguments are synergistic in a sense because we do recognise a lot of patients will actually recur. The majority of patients will recur and majority of them will recur within two years. But from my perspective, going through with androgen deprivation and early systemic therapy is a medical rollercoaster. Once you start on this and the patient is pretty much committed to this for the remainder of their lifespan and switching between different agents. But I think the role of metastasis directed therapy is the potential to treat and add an extra line of therapy and potentially have a localised therapy that can be used in conjunction with the systemic therapy at a later time point. And so far, you’re right, it’s about patient selection and it’s low volume, oligometastatic disease is the key. The evidence that we have and my interpretation of the data so far is that the use to systemic therapy is most beneficial for high-volume disease and in the biochemical recurrence setting, we still have a level 1 evidence to support the use of the early initiation of immediate androgen deprivation. So we’re talking about a patient population that may potentially benefit locally directed therapies whether that be surgical from a lymph node dissection, stereotactic radiotherapy or pelvis radiotherapy whichever approach. The question is about balancing the toxicities of each approach and selecting the appropriate treatment approach for those patients. You’re right though, these kinds of opinions are largely non-evidence based. We have run a couple of clinical trials so far particularly in Melbourne and these are due to report relatively soon. And one of the studies I was involved with which was POPSTAR will hopefully have some results in only a handful of months’ time.

So in the absence of this kind of high-level evidence, we really should get involved in clinical trials. And I think there is a new study being led from Piet Ost in the Belgium from Ghent University which is PEACE V, a study that’s been run through November and hopefully that’s an opportunity as us, clinicians in Australia and New Zealand to join in such a study.

Joseph: So keep an eye out for Shankar the POPSTAR and next time you’re in an MDT while discussing a man with oligometastatic disease and rad/onc starts discussing the peace sign, you’ll know what he’s talking about.

Next a head-to-head comparison dear to all our hearts. Some said it couldn’t be done. Some said it shouldn’t be done. But one man stands tall in the controversial arena of the retrospective analysis comparing the effectiveness of surgery to radiation for the management of localized prostate cancer I’d give you Laurie Klotz and he discusses his talk.

Dr Laurence Klotz: The title was surgery versus radiation, what is the evidence about comparative effectiveness? And so, there are in the literature 14 studies that compare the mortality outcome of surgery versus radiation using propensity analysis to adjust for relevant covariance. Because the obvious problem is that you take a group of radiation versus surgery patients, the surgery patients tend to be healthier, often tend to be younger. So, there are techniques to compensate for those variables is called propensity adjustment, and beyond those 14, there’s another five studies that use some other type of adjustment, one is called instrumental analysis to adjust for the covariance. And what is striking about these studies is that essentially they are 100% consistent in showing that the prostate cancer mortality is roughly two times higher in the patient treated with radiation than surgery. Now, why should that be? Because radiation is actually quite effective therapy for prostate cancer particularly modern radiation. So, there’s several reasons why that may be. One, of course, is that the data is all nonsense, that there is a systemic underlying bias involving every single one of these studies. In my opinion, that is not the most likely explanation. There are two others, one is that starting with surgery, just like testicular cancer, for example, where you get a surgical grading and staging, that drives subsequent management, with radiation, you don’t have that. I think it may be the benefit of surgical staging of the entire prostate, the lymph nodes, positive margins, role of adjuvant therapy in the long run may drive improved outcome in terms of mortality

The second is some very recent data that comes from Ros Eeles’ lab in the UK that compared the outcome of patients with BRCA mutations treated with surgery and radiation, and the striking observation is that the BRCA mutated patients, this is in other words germline BRCA mutation patients, did extremely poorly with radiation. It’s as if it was completely ineffective and this has not been identified before. And that could be an explanation, because since the BRCA mutation patients represent a very high-risk cohort much higher risk of dying of cancer, maybe they are accounting for some of the increased deaths in the radiation cohort and maybe this explains why if you look at mortalities and endpoint, again, most patients with prostate cancer are not dying of disease – if you look at mortality endpoint, you see more deaths in the radiation than the surgery. So, my message is radiation clearly has a role; it’s good treatment. But let’s move on from the rhetoric that the mortality outcomes from these are the same based on published data, it clearly is not the case.

Joseph: Laurie makes some very interesting points and food for thought especially regarding the BRCA mutation prostate cancers. But in the next MDT I can’t help but smile sheepishly as I pushed the file across the table to my radiation oncology colleague for the 75-year-old man with ischemic heart disease, COAD and a BMI of 45 of his Gleason 8 prostate cancer.

So, it was time to put the Conference convener, Nathan Lawrentschuk, behind the other side of the microphone and give us a brief wrap up of the program as he saw it.

Nathan, as the convener of this year’s meeting, what was some of your highlights or what do you see as some of the emerging themes to come out of the talks?

A/Prof Nathan Lawrentschuk: Look, it’s been a fantastic meeting and my hats off to Shomik Sengupta, my scientific convener, for really helping pull this all together. Look, apart from having wonderful international and national guests showcase the best of urology at present, I think there was some emerging themes to come out of this year’s meeting. In particular, the questioning of the role of MRI, its place prebiopsy and in active surveillance strategies, knowing your own local rates of positivity was very important. Again, PSMA, PET/CT being done increasingly for primary staging and re-staging has really taken off and again, we just don’t have the histopathology data to back a lot of that up, so still applies right for studies. I think moving into oligometastatic disease, again, it was good to have both the radiation oncology perspective and, of course, your own perspective on this. I think other things emerging, certainly we learn to be a bit smarter about perioperative management, perhaps using less fluids in larger cases and thinking about the length of DVT prophylaxis. I think in terms of other areas that we’ve looked at quite closely, we’ve seen emergence of new thoughts about Peyronie’s disease, whether the injectables and the aggressive surgery were required. The role of Botulinum toxin seems to be ever expanding. With stone surgery, the comeback of PCNL with the mini-perc has been interesting as well as the development of better and smaller instruments for ureteroscopy and, of course, the single-use ureteroscopes. We saw also the ever present and emerging role of cytoreductive nephrectomy coming about with the new tyrosine kinase inhibitors; and I suppose finally, from my perspective, to see the reiteration of the need to be more aggressive to have a success in bladder cancer. And, you know, personally for me on the back of the launch of bladdercancer.org.au and now new patient booklet, I think bladder cancer was brought to the front and center of this meeting and showing us again, we’re doing a pretty poor job with muscle invasive disease. But, you know, we have at least now got some good local patient resources available at bladdercancer.org.au. So, I’m really looking forward to Dan Moon and Declan Murphy in Melbourne come 2018.

Joseph: Fantastic. It’s been an absolutely magnificent program. I know you’ve worked tirelessly, you and Shomik, and I congratulate you.

A/Prof Lawrentschuk: Thank you.

Joseph: Awards were given out. I didn’t win one so I can only assume they were not for excellence in podcast humor. At the gala dinner, two prestigious awards were given to members for outstanding service to USANZ over their careers. The Urological Society of Australia and New Zealand Medal was awarded to Dr David Malouf where particular note was made of his leadership in his role as president during the Christchurch earthquake. And Dr Andrew Brooks was awarded the fellow of the Society for his tireless contribution to urology with a chorus of he he’s echoing across the room when describing his inspirational mentorship to several generations of aspiring urologist. Congratulations David and Andrew.

Next, let’s talk to Marlon Perera who was the winner of the most prestigious research award for trainees, the Villa’s Marshall Prize, for his research from his PhD on the protective role of zinc in contrast induced neuropathy.

Joseph: I’m chatting to Marlon Perera who is a trainee currently in Queensland and is the winner of the Villa’s Marshall prize this year for his research presentation titled “The renoprotective role of zinc pre-conditioning against radiographic contrast media induced nephrotoxicity.” We’ve asked him just to give us a quick highlight of his talk.

Dr Marlon Perera: The question we asked was, how can we as urologists protect the kidneys against contrast nephropathy? It’s a growing problem obviously for urologists. So, we had the hypothesis that zinc reconditioning used intravenously could protect against contrast nephropathy. So, we trialed an in-vitro model, a cellular model, and essentially expose kidney cells to contrast media with prior zinc pre-conditioning and we found that zinc pre-conditioning resulted in improved cell survival and reduction in the generation of reactive oxygen species. So, the results are early but they are promising and I think translation of this work into small animal and human models are required.

Joseph: The winner of the Keith Kirkland prize for the best research done by a trainee not in full time research was Amila Siriwardana for his research on robot assisted salvage node dissection for oligometastatic nodal disease by Gallium PSMA PET/CT, a multi-center retrospective series. Congratulations to Amila and the team in Sydney.

Now, let’s chat to Richard Grills from Geelong who won the AbbVie Platinum trophy award for research innovation. Let’s hear from Richard.

Mr Richard Grills: Well, Joseph, we project where we looked at all of the flexible pyeloscopy cases done in Geelong over a two-and-a-half-year period. Fortunately, in Geelong we’ve gotten three hospitals and we’re able to capture all of the cases done at those three hospitals over a two and a half year period and we were looking at how often the scopes broke, how much it cost to fix them, and the durability. We found the scopes do break and they break or either need to be repaired or replaced about every 13 use.

Joseph: And what does the breakage rate equate to?

Richard: 282 dollars per case if you add that on, if you average the total cost of instrument repairs and replacements over that two and a half year period.

Joseph: And could they identify any causes of the breakages? What are the predictors, is it currency?

Richard: Unfortunately, you weren’t a registrar with us in Geelong during the study period, which might have altered the data a little bit, Joseph. No, interestingly, and in contrast to some other studies that have been done, we found that there were no actual predictors.

Joseph: So harsh. Lucky I didn’t tell him I put small holes in the tips of the index fingers in all the gloves in his examination room. So, there really was only one question left for me to ask.

And where are you going to put your AbbVie Platinum trophy, is it next to Carlton’s last trophy ‘coz that was a long time ago?

Richard: Well, it’ll go to the trophy cabinet at home, not a lot of room there, of course, Joseph. I’ll find a spot for it.

Joseph: Fantastic. Thanks, Richard.

Richard: Thanks, Joseph.

Joseph: It must be a very small cabinet. Let’s also mention some of the other award winners. Congratulations also go to Handoo Rhee from Queensland. He was the winner of the BAUS trophy which goes to the best scientific podium presentation for his study “Metformin can reduce cardiovascular risk factors in men treated with androgen deprivation therapy.” Well done Handoo and his team in Brisbane. Jeremy Grummet was the winner of the Alban Gee Prize for the best poster by a full member of you sent for his poster “Robotic MRI ultrasound fusion transperoneal needle biopsy using the I.S. Robot Mona Lisa – technique, safety and accuracy.” And the winner of the Low-Arnold award in female and functional urology for the best podium or poster presentation went to Lewis Chan. Lewis has been one of the leading lights in research in this field. Well done Lewis. Canberra also saw the 22nd USANZ and Australia and New Zealand urological nurses meeting convened by Kath Schubach and Carla D’Amico with both national and international guest speakers covering a range of topics.

Let’s hear from Kath discuss her highlights of the program.

Kath Schubach: Thanks very much Joe for inviting me in. I think the highlights for our meeting this year were both Carla and myself we’re trying to highlight the advance practice in nurse-led clinics and also some leadership in nursing, so one of our keynote speaker was a nurse practitioner in sexual health and just looking at their scopes of practice in the advanced scopes of practice, but also a theme of leadership overall so that the novice to the advance practice nurse could take something away from it.

Joseph: What’s been one of the major changes? Is it the nurse cystoscopist? Is that they have an increasing role at the clinic?

Kath: I think it’s an overall learning. And also, I think the partnership and the collaboration with the urologists because we know from research that with collaboration of both the nurse practitioner and the urologists that our patients have better outcomes with that.

Joseph: How many nurses are nurse practitioners? I know a lot of extra study goes into it. How many do we have in Australia?

Kath: Quite a few. Coming up in urology. Of course, Helen Crowe leads the way as the first nurse practitioner in urology, but I think even the highlights of our presentations and the way how our program has grown, that it’s very – Sandra and I were talking about it, it’s about how we used to present case studies but now we’re actually presenting research and I think that’s really increasing our profile of professionalism of nursing.

Joseph: And the nurse practitioner role, I think it is one of the hot topics. How does that compare to, say, a urology CNC, clinical nurse consultants?

Kath: Well, I think we did discuss that and that was a theme that come out in our sessions and I think what it was, was it’s more about it’s not for everybody but there are lots of roles there. And if you’ve got a vision, whether it’s broad or narrow and a drive to pursue it, you can take any pathway. So, it doesn’t necessarily mean we all have to be nurse practitioners, but you can have fulfillment out of being a clinical nurse specialist and a consultant and many other roles within urology.

Joseph: Excellent. So, what was another one of the hot topics to come out of this year’s conference?

Kath: I think one thing that I think took a lot of people away was when my mention that “we’re not just a nurse.” And I think a lot of us describe ourselves as that and it’s about just how we’re going to articulate what we do as a nurse. One of the things that I took away from that was that she talked about personalized medicine and urology colleagues always talk about personalized medicine, but she said for us, to nurses, to look at nursing as a therapy. I just thought that that was really engaging and really something to think about.

Joseph: And I asked Cath, what does she expect to be the hot topics for future nursing meetings?

Kath: Well, again, I think it’s talking about nurses and what they’re going to pursue and how they’re going to pursue what we do as a profession and we’ll just take this further in Melbourne.

Joseph: That’s fantastic. Thank you very much Kath. It has been a pleasure chatting to you.

Kath: Thank you.

Joseph: Now, let’s hear from Sandra Warden a nurse practitioner from Redcliffe Hospital in Queensland and winner of the prestigious Diamond scholarship awarded by Boston Scientific. I ask Sandra to tell us a little more about the award and what she plans to do.

Sandra Warden: Yeah sure. It’s $5000 to go towards a professional development activity and what I’ve decided to do is to go to the BAUN conference in the U.K. and also to do a site visit to watch how other nurse practitioners perform their practice. There was a white paper in 2010 called Freeing the NHS or something like that, and since that time they’ve had a lot of health reforms and so they’ve been able to create a lot of change in terms of patient care and patient experience and access to care. And so, that’s what I really am going to have a look at to see how they’ve been able to do that.

Joseph Ischia: Are they doing things better than we are here in Australia or are there things that you’re hoping to achieve that they do?

Sandra Warden: Well, it’s not so much the specifics of what they do as much as expanding my mind to see how other people do things differently. So, it may not be that I bring back specific ideas but it’s about expanding my mind so that I can think better about what we need here.

Joseph Ischia: Clearly this is about developing leaders and, you know, whether it’s urologists or nurses, you need people that are mixing with the best in the world. It sounds like it’s a wonderful opportunity for you to do that, so congratulations.

Joseph Ischia: And when you come back –what are your obligations when you get back, do you need to give talks or a presentation anywhere?

Sandra Warden: Sure, so what I need to do is provide a report to ANZUNS and that’s a written report and a verbal report as well at next year’s meeting, and also I’d like to report back to my local area at QUNS and also to the hospital, of course, you know, bring back ideas and thoughts and things like that. And there might be things that they see us do that that they think is a great idea, you know. So, it’s all about exchanging ideas and just stimulating that thought process.

Joseph: Editorial note it was actually the 2010 health white paper “Equity and Excellence Liberating the NHS” which outlined the Government’s vision for the NHS.

Next, I’m chatting to David Gray, a nurse practitioner at the Australian Prostate Cancer Research Centre in Melbourne who has had three great successes in the past year with the birth of his first child, the prize for best paper for the USANZ program and the Bulldogs winning premiership. I dared not ask him to rank them in fear of upsetting his family. So instead I asked him to tell us about the subject of his paper.

David Gray: Thanks, Joe. So, it’s a six-month fellowship position that we offer at our center where nurses would leave their place of employment and come and work with us for six months and they set a series of objectives that they want to meet to further their nursing professionally. So, it could be in the way of learning more about sexual function issues going and watching the guys operating theater, you know, doing prostatectomy, spending time at the radiotherapy department as well, so things that they might not get the ability to do at their current place of work, but they come and do this observership with us and we enable them to do that.

Joseph: Is it only urology CNCs or are you getting like NUMS for urology wards in hospitals?

David: Generally, people with a clinical background and still with that patient contact. So, the grand plan is that when they come and work with us, once they finish their six months with us, then they go back to their place of employment and then introduce those learnings as well, so typically a lot of the nurses might have had experience with sexual function, for example, it’s not really talked about too much with the nurses, so when they go back then they’ll start setting up erectile dysfunction clinics, teaching the guys how to inject safely and what to do with adverse events as well.

Joseph: How many people have come through so far?

David: We’re up to our fourth nurse. We don’t discriminate. We’ve got a nurse that’s come through from Wellington in New Zealand and our current nurses from Perth.

Joseph: Fantastic. How do you apply for this position?

David: We advertise through the USANZ nursing group, so ideally those who would be suitable for it should be a member of our group, so we just do typically like a job application process for that.

Joseph: Fantastic Dave. Thank you very much.

David: Thanks Jo.

Joseph: I assume you do need a secondary education so Collingwood supporters need not apply. Alright, alright. I was only joking. There’s no need to break into my house.

Next, I’m chatting to Cara Webb whose disinterest in football is matched only by her passion for urology. Cara won best poster for her study titled “Study and evaluation of a nurse-led postoperative outpatient clinic.”

Cara Webb: So, we had a look at the wait list at our institution and the demand was pretty high on the wait list, so the urology unit looked at various strategies to address this situation and introducing a urology nurse-led clinic for postoperative reviews was implemented. We looked at five different surgical procedures that were appropriate for a review by nurses and we set up a weekly clinic at the beginning of 2015. With the introduction of nurse-led clinic and other measures, we able to show an overall decrease in our wait list without urgent referrals for new patients that were delayed passage, your recall date down by 95% and our review patients stand by 46%.

Joseph: Well, thank you Cara and congratulations. Well done.

Cara: Thank you.

Joseph: And that wraps up our Talking Urology Conference Highlights. I hope you enjoyed it and thank you to all the guests and speakers who were so generous with their time and expertise. Thanks to Ipsen for their wonderful support and I hope you can tune in for our second season of Talking Urology Landmark Paper Discussions coming soon. So, go to the website talkingurology.com.au, follow us on Twitter or forward complaints through Eddie McGuire to talkingurology.@gmail.com.

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