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Physician Resource

How UVA Urology Built a Destination Center for Prostate Cancer Care

At a Glance

At UVA, your prostate cancer patients can tap leading experts who offer:

  • MRI-guided biopsies, along with a transperineal approach providing a close-to-0 infection rate
  • Nerve-sparing robotic prostatectomy to preserve sexual function
  • Retzius-sparing robotic prostatectomy to minimize urinary leakage, compared to conventional robotic approach
  • Rectum-sparing radiation therapy and other techniques proven to improve outcomes
  • PSMA PET imaging for recurrent and metastatic prostate cancer
  • Pivotal clinical trials investigating everything from a non-invasive way to potentially restore spontaneous erections post-treatment to a novel immunotherapy for metastatic prostate cancer

When Robert Dreicer, MD, MS, FACP, FASCO, became UVA Cancer Center’s deputy director in 2015, he brought with him 30 years of experience in the field of urologic oncology. Since then, UVA has tripled the size of the urologic surgical oncology faculty. Not yet done growing, UVA is recruiting 2 more urologic medical oncologists to bring the total to 4 by next academic year.

“UVA has become a destination place for prostate care. Like the major urologic oncology centers, we have a highly functional interdisciplinary program that’s built around a large clinical research program,” says Dreicer, part of the leadership team that helped UVA reach Comprehensive Cancer Center status.  

He adds, “Because of our close interactions, we schedule patients to see multiple GU oncology specialists on the same day. And at any given time, we have 8 to 12 clinical trials running for prostate cancer.”

Dreicer pinpoints people as the driving factor behind this growth; People, he says, who “bring exceptional patient care and clinical research interests. We now have a chair of the Department of Urology who is a nationally known urologic surgeon and a high-volume prostate cancer surgeon. She joins a number of talented surgical oncologists who work in the department.”

Leading Urologic Surgeon Takes Helm

Kirsten Greene, MD, MAS, FACS, became chair of UVA Urology in October 2019. A UVA alumna, Greene is excited to return to Charlottesville after 20 years as one of UCSF’s highest-volume robotic-assisted urologic surgeons.

She notes that Dreicer is, himself, a stalwart in the field. “Dr. Dreicer is such a big name in urologic medical oncology. It’s wonderful for our patients that he brings every important clinical trial to UVA,” Greene says. One of these trials is notable in that only a handful of sites are participating, offering a novel immunotherapy as part of a two-part, phase 1 study for patients with metastatic, castration-resistant prostate cancer.

Approaches That Prioritize Patients

Our team members have experience not only with the conventional robotic approach, but also with the Retzius-sparing radical prostatectomy that leaves most of the natural bladder and urethral support intact and approaches the prostate from below the bladder. “For patients, this means a much faster return of continence,” Greene says.

Sumit Isharwal, MD, also brings this experience. He joined UVA 3 years ago after completing at Johns Hopkins University a postdoctoral research fellowship in urology with a focus on prostate cancer and a fellowship in urologic oncology at Memorial Sloan Kettering Cancer Center. His research interests include precision medicine in urologic cancers and improving clinical outcomes in patients with urologic cancers.

“Our volumes are increasing because we’ve made prostate cancer a priority. We strive to see patients in a week or so and always encourage them to meet with one of our radiation oncologists so they understand all of their options,” Isharwal says.

Isharwal is excited to offer transperineal biopsy as an alternative to transrectal biopsies, almost eliminating the risk of a post-biopsy infection.

Noah Schenkman, MD, has built a 20-year career around minimally invasive, robotic-assisted surgeries for prostate cancer, along with benign prostate conditions, kidney stones and kidney cancer.

Schenkman notes that we have proven ways to increase accuracy with MRI-guided transrectal biopsies. And unlike transperineal biopsies, these can be done with local anesthesia in the office. Schenkman also applauds our radiologists, who bring their expertise to the table.

Collaboration for Optimal Recovery

Before treatment, patients are encouraged to tap the expertise of David Rapp, MD, who developed and oversees a continence recovery program that data show significantly improves outcomes when implemented pre-treatment.

Patients can also consult with urologist Ryan Smith, MD, who had a trial investigating whether low-intensity shockwave therapy can promote blood vessel growth and tissue repair in men with post-treatment erectile dysfunction.

Pioneering Cutting-Edge Radiation Therapy

Rounding out the prostate cancer program is a radiation oncology team that has pioneered the field. UVA Health was one of the nation’s first few organizations to offer a combination treatment of prostate brachytherapy, hormone therapy, and external beam radiation that a landmark clinical trial revealed improves cure rates by as much as 20%, compared to treatment without brachytherapy.

Since 2013, UVA has been offering high-dose-rate brachytherapy with ultrasound-image guidance. “This has become the gold standard as the most precise form of high-dose radiation therapy available,” says UVA Cancer Center radiation oncologist Timothy Showalter, MD, who co-authored a major overhaul to the American College of Radiation guidelines for prostate brachytherapy and high-risk prostate cancer.

With a well-established brachytherapy program, UVA has seen an increased volume of patients in recent years. Showalter and colleagues offer an updated, more conformal version of the combination therapy. This 3-pronged approach includes:

  • HDR brachytherapy
  • Intensity-modulated radiation therapy
  • Use of a prostate-rectal spacer, which dramatically reduces the risk of radiation injury to the rectum

In addition to employing every technique that’s proven to improve outcomes, the UVA Health radiation oncology team offers national clinical trials. Participation in these trials requires UVA Health to be credentialed to perform at a higher bar. “It’s a real mark of our quality,” Showalter says.

Showalter has two clinical trials open for MRI-based brachytherapy: for patients who have a cancer recurrence after radiation therapy, and for high-risk patients who need brachytherapy for upfront treatment.

Proud to be part of the broader prostate cancer program, Showalter says, “We’re like the (Navy) SEAL team for prostate cancer care. We’re a small group with a lot of expertise. For every discipline, we have people who stay current on the latest treatment techniques and research. And even though our patients receive care from people who are known at the national level, we all work closely together and adjust our schedules to accommodate patients. We treat our patients like a family member,” Showalter adds.

Major Investment in the Future of Prostate Cancer Care

Always pushing the envelope, UVA is installing an MRI-based linear accelerator. “This is the latest and greatest type of technology, and UVA is making that investment,” Showalter says. With this technology, he explains, “Each day, we can visualize the patient’s tumor and make real-time adjustments to fine-tune the treatment plan.”

The UVA Health urology team is also tapping the forces of nuclear medicine by using the most advanced prostate-specific membrane antigen (PSMA) PET-CT scan to deliver treatment. “With our nuclear medicine colleagues, we can deliver radiation molecules through the bloodstream and only to prostate cancer. This is done by linking the radiation molecule to the PSMA molecule that is specific to prostate cancer,” Greene says.

Lale Kostakoglu Shields, MD, MPH, director of the UVA Division of Nuclear Medicine and Molecular Imaging, predicts that “prostate-targeted imaging and therapy will transition into clinical practice very soon, identifying those patients who have biochemical recurrence of disease, but present with undetectable tumors,” Shields adds. “All of these developments are very exciting and innovative in the quest of making metastatic prostate cancer a chronic disease rather than a fatal one.”

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