AUA 2016: Dr. Peter Schlegel's Key Take-Aways
Having attended AUA2016 in San Diego earlier this month, Dr. Peter Schlegel reports on his key take-aways from the conference.
PI-LBA 03 Testosterone Therapy and Prostate Cancer Risk. S Loeb
A late-breaking abstract presentation by Stacy Loeb, MD, of NYU reported on the relationship between prostate cancer detection and use of testosterone therapy in a population-based study in Sweden. The authors reviewed over 38,000 cases of prostate cancer compared with over 192,000 matched control cases. Although the authors were not able to relate testosterone levels, they had precise prescribing information on all men in this system. The authors found that the risk of detection of favorable (low-grade) prostate was increased by 35% in men treated with testosterone, whereas the risk of aggressive prostate cancer was decreased by 50%.
Since testosterone therapy can increase PSA and is associated with detection of previously existing low-risk prostate cancers, the increased detection of favorable prostate cancers likely reflects previously existing tumors, not induction of prostate cancer by testosterone treatment. The lower risk of aggressive prostate cancer suggests a suppression of prostate cancer, if there is any effect at all.
Testosterone therapy continues to show no risk of induction of prostate cancer.
Complex Cases: Chronic Orchialgia. Presenter, DA Shoskes; Panelists, SJ Parekattil, PN Schlegel, DH Williams
This plenary panel discussion overviewed practical aspects of management of testicular/scrotal pain. Several key points were emphasized for this very common clinical condition:
- Scrotal pain is often the consequence of non-scrotal conditions, including chronic pelvic pain ("prostatitis/prostatadynia"), inguinal, spinal, and ureteral/retroperitoneal pathology. Consideration of these sources is important, with a focus on detection of pelvic trigger points on physical examination.
- Initial conservative management with treatment of specific identifiable conditions such as epididymitis is important.
- Varicoceles are common, but pain from varicoceles is less typical. Varicocelectomy should be limited to those men with larger varicoceles and typical pain (chronic, increasing with standing, relieved with lying down, dull in nature).
- Spermatic cord block (with xylocaine or bupivacaine) can be an effective test to help determine whether the source of pain is testicular/scrotal or from a more proximal source.
- Spermatic cord denervation is an effective intervention for chronic scrotal pain that is relieved by spermatic cord block. Vasectomy reversal may also help post–vasectomy pain patients with congestive epididymitis and pain localized to the epididymis.
PI-LBA 02 Reevaluating PSA testing rates in the PLCO trial. J Shoag
This abstract, presented by Jonathan Shoag, MD, from Weill Cornell in the late-breaking abstract session, provided unique insight into the PLCO trial. The abstract content was published in The New England Journal of Medicine as a letter on May 5, and extended data from this work will be published in the Journal of Clinical Oncology as well. The authors went back to raw data from the PLCO trial, obtained from the NCI.
For a screening trial to evaluate a test, there must be a substantial difference in testing of the "screening" arm vs the "control" arm. In PLCO, the control arm had "usual care" in the United States. Shoag et al showed that PSA testing in the control arm was actually more frequent than in the screening arm. In the setting of inadequate difference in the screening and control arms, the results of the PLCO trial are invalidated. This leaves only the ERSPC trial as a valid evaluation of PSA screening. The ERSPC trial demonstrated a clear benefit of PSA screening—decreasing the risk of death in men with prostate cancer.
These data suggest that the ERSPC trial data should be considered as the sole evaluation of PSA screening.
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