Dr. Todd Morgan
Appearances
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. Do you ever, do you use it? Do you say, I think we've carried you or it seems, sure seems like we've carried you?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So all high risk and most, but not all unfavorable intermediate risk. Okay, no issues with coverage, that's all kind of... No, yeah, it seems like we're doing just fine there. So it's certainly replaced CT and bone scan for all these patients. You know, an unfavorable intermediate risk can be reasonably heterogeneous, right?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
You have one core at 4 plus 3 and a PSA at 5, or you have higher volume, higher PSA. I tend not to get it on all unfavorable intermediate risk.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And I think radiation oncologists have a little bit of an earlier trigger to get a PSMA PET, which makes good sense. It's going to maybe impact their treatment plan. And so let's say there's a 3% chance of a positive finding in some of these settings. But maybe that 3% is worth it in the setting of a patient undergoing radiation.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
In the setting of a patient who's planning on undergoing surgery, it's hard to justify, I think. There's a lot of scans for not a lot of gain.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So they come back and they have a PSA, you know, recur within a year, PSA is 0.2, and you get that PET. And at that point, they've got one positive external iliac lymph node. Okay, well, you know what to do.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Should we have not done surgery if, you know, if they actually did have that, if you could see that? Certainly, it really gets into this important controversial area where we have no data, which is for those patients with small volume pelvic nodal disease visible only on a PSMA PET, are they appropriate surgical candidates? And I would argue that they
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Understanding with all these conversations and likely need for salvage treatment, that's a small volume disease with the nodes in the region where we perform a node dissection. I think it's totally, totally very, you know, add whatever other word you want to put there that's appropriate to do to offer surgery.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
We get it at six weeks. I know some people get it at three months, sometime in there. I don't think it really matters when you get that post-op PSA. You need to wait a certain amount of time, right, for the PSA to be able to decrease to an undetectable level. Our pathway is a six-week PSA. That's how it's been everywhere that I've trained. What do you guys do?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Typically standard sensitive, except for those patients at really high risk of recurrence, where maybe we want to keep a little bit closer eye on it. But I don't love ultrasensitive because of all the anxiety that it causes for the typical patient where it's going from 0.02 to 0.03. How would anybody understand that to be anything other than it's something that's worrisome?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Whereas we know that that's fine. So I really like that less than 0.1. But there are some patients where, yeah, they're at really high risk of recurrence. And I'd like to have a sense of the trend. And yeah, if I see it's 0.06, 0.08, we know probably it's coming and we can start to lay the groundwork for potential salvage treatment.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Looks great. I think we're fine. We're keeping an eye on this.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
No, I don't go there for that because it just, yeah.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, I'm worried, especially in a high-risk patient. And even, I mean, once we start getting above 0.05 with a trend, and that's a Godland statement, by the way, is if we're using ultrasensitive PSA, we need to confirm a rising ultrasensitive PSA. that we're not treating somebody because their PSA is 0.05 a couple of times in a row. Let's make sure that it's meaningful.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But yeah, once I see 0.1, it's notable. Again, it depends on patient's baseline risk. And so that's really an important fact to keep in mind. This is a study that we published using the CAPTURE database probably 10 years ago now, showing that your disease risk informs the meaning of a post-op PSA.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So the high-risk patient with a PSA of 0.1 is a whole lot more likely to have further progression than a low-risk patient with a PSA of 0.1. And so, you know, that's kind of intuitive, but we just exhaustively, I think, showed that using the CAPTURE database.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I think that's it. It's two things. It's one, sometimes there are some benign glands that we leave behind, right? You're right. If we have a patient who's got more favorable risk disease, especially they're young and we're doing everything possible to preserve potency, we are cutting it close. And so could we leave some glands, benign glands behind? Yeah.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Could we leave some lower risk prostate cancer cells behind too? Yeah. Yeah, even in margin negative patients. I mean, you've looked at those slides. Thankfully, it's a negative margin with like two cells between the cancer cell and in the margin. And so, yeah, I mean, those recurrences in that setting are lower risk. And that informs how we manage those patients, right?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
These patients, if they ultimately do continue to have a PSA rise and they get radiation, they can get away with just radiation to the pelvis. Whereas the high-risk patients, again, they need more. They need radiation right to the prostate bed, probably nodal radiation, ADT. And so they're really different entities.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Hey, Aditya. So awesome to be here. Thank you. Thank you. Thank you.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, well, so first I just want to speak to what you mentioned, which is like, I think we all take it personally. Actually deeply soul crushed when we see that, especially, I mean, sometimes we're kind of expecting it in really high risk patients, but patients with lower risk disease where we see that it's really, it hurts. And I remember in the last year or so speaking at a conference,
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And I think I was addressing like, you know, why does not every patient in that scenario get referred to a radiation oncologist? Because if you look nationally, they don't. And I kind of hazarded a guess of like, there's a little bit is urologists, we actually, that feeling of like, oh my God, we kind of like are embarrassed.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
and somehow we dropped the ball, even if the margins are negative and things are okay, but also the margins are positive, but we did something bad and we're just gonna push it off a little bit. I think most people can kind of, hopefully, maybe hopefully not, but I think most people can relate to that.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And Mac Roach, who's an amazing radiation oncologist, gets up and says, yeah, you guys, like you surgeons, you just have it all wrong. But the thought is, wow, we've gotten 98% of your cancer. We did this. And we made a huge dent in this disease. And our colleagues from Radiation Oncology are going to help, hopefully, with the last couple percent.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And I have really thought that was such a good comment. And we need to internalize that. And that was memorable for me. And I really have tried to internalize that. I actually use that terminology more now. That's mindset. Second is, you know, we see these patients and that, right, we're going to, your PSA is elevated. Yeah, that does suggest there's some cancer cells probably there.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, you know, a given PSA can be inaccurate for lots of reasons. We're going to check it again. And, you know, yes, I know there's like there feels like there's got to be urgency to do something. But believe it or not, prostate cancer is still relatively slow, slow growing. We look at all the disease features for that person's cancer, just like you mentioned, what do you factor in?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Of course, age overall. health and comorbidities brought, like hopefully if they're a surgical patient, they've got a life expectancy greater than 10 years and all that. And then the cancer features, right? What stage, grade, pre-op PSA, did you have a PSMA PET pre-op or not? And what did it show? So those things are really important. What is their PSA at the time of recurrence?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
0.2 is a whole lot better than 2.0. And then the timing that like the, what is the distance between the surgery and that time of recurrence? And so that six-week mark, that persistently elevated PSA is a much worse prognostic feature than somebody who has a recurrence five years after surgery, which does happen.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Those patients that have a really late recurrence are at much lower risk of progression. So all those things are important considerations. There is a table in the guideline that lists those key considerations that I just mentioned. I think PSA doubling time is in there too. Genomics can be in there for folks who find genomics to be helpful in their practice. That's kind of the initial framework.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And then we've got to think about, okay, this is a patient who is likely going to need radiation. We're going to confirm their PSA. And then we've got to think about timing because, yeah, radiation does have side effects. And one of the important acts that we think about is kind of as good as a patient's continence gets before radiation is as good as it's going to get.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
We really want to hold off time. on salvage radiation until ideally the patient has regained continence and it had a chance to fully heal. And hopefully that really reduces the risk of significant urinary complications. Yeah, there are some adverse effects of post-op pelvic radiation. It can cause urinary frequency. It can cause bowel irritation and cause stricture.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Oh, wait, wait. So tell me about that. I missed it. Where is it published?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But if you look at the data, they're probably not as bad as we think in our heads as urologists that There's a pretty robust set of data, including from University of Chicago, who's looked at there's a series of patients undergoing salvage radiation. And a lot of the side effects are relatively short-term, and late effects are pretty mild. So I think we think about all those things.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And then so on top of all that, these days, we're going to get a PSMA PET at some point. And maybe we're going to get it at the six-week mark. We're going to confirm the PSA and then get it probably typically, but we're certainly going to get a PSMA PET sometime in the vicinity of when we confirm that PSA recurrence.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So that's a great comment. It's something that was not on my radar prior to the guideline process. And it was Brian Chapin who said just what you said. He said, oh, I find MRI really useful in this setting. And we looked at the data and we had, you know, discussed it with our radiology colleague on the guidelines.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And at the end of the day, that is included as a, forget the exact language, but you may consider an MRI as well in this setting. And so I've been, I've started using it in some patients and it is interesting. Certainly, MRI can pick up some local recurrences that just get washed out by the tracer in the bladder, in the urine.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Well, that's where hormones really saves the day, I think. Because these patients who have high-risk disease, who have earlier recurrence, shorter doubling time, they're going to need ADT with their RT. And so that really can provide a bridge. And we absolutely use that. Just very broadly, we usually say, okay, we're going to think about radiation around the six-month mark. Yeah, some patients...
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
have a really quick recovery. We feel comfortable with radiation at three or four months. But in principle, we're kind of thinking the six month mark is the right timing for most patients. But we can start ADT at three months. We can start it at four months. We can start it at two months. If we were at this patient, if they have a PSA of
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
one or two, and they're really at higher risk of recurrence. So that helps. Because then we get started ADT, that lowers anxiety quite a bit. PSA goes down to zero. And I think that buys time to give safe radiation that balances the oncological benefit with toxicity.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So it's really sort of the radiation field. Is it just prostate bed or prostate bed plus nodes? And then I guess even prostate bed plus nodes plus or minus metastasis directed therapy if there are a couple other sites of disease seen on PSMA PET. So that's really, that's the radiation piece. And then there's ADT and there's timing of or length of ADT.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Cure is a term that we just like all of us oncologists just really have a hard time saying because pretty much everybody with a history of cancer, of any kind of cancer, has some risk of that cancer coming back. And that risk may be really, really, really low so that we kind of in lay terms use words like cure, but
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Time that we give ADT, minimum of four to six months for patients who are getting ADT, but 18 to 24 months recommended for patients with high-risk features who are undergoing RT. And then on top of that, there's ongoing research into intensification. And so meaning intensified hormone therapy, like adding enzalutamide or apalutamide.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so that data is still basically immature in TBD, but clinical trials evaluating whether that might also be beneficial. And then there's the timing of when do we actually start initiating these steps.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
You're thinking like Decipher or Terra or something else?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Presented some data at the AUA this year on using Arteria classifier. I think not everybody, probably not everybody knows what it is. Although just I think today, yesterday, it was named in Time Magazine as the medical invention of the year. So that's kind of huge props to that team led by Andrea Esteva and Felix Fang.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
That's awesome. That's a great idea for a study. Really, really good. I can't wait to see it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
What it is is basically digital pathology-driven AI multimodal learning to input patients' clinical features and the images from their histology can be biopsy, can be prostatectomy, and then output, just like the cipher, prognostic information like risk of metastasis. So Otero's model uses the digital pathology images along with the clinical information.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And of course, folks who listen to you, in addition to getting their information, maybe elsewhere too, I don't know, but mostly here know all about Decipher and that it's a gene expression classifier that can be used also, tons of data to support that it's prognostic. And possibly even can help with decisions around RT versus RT and ADT in the newly diagnosed setting.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So these are both classifiers or models that can be used in the post-operative setting. It's still relatively early days for those, but lots of reason to think that they could be used to help, especially around these decisions around intensification, use of ADT or not. And then we did have a little bit of data that we presented using our Tera
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Suggesting that maybe it could, in addition to being prognostic in this setting, maybe it can help inform who benefits from hormone therapy and who doesn't.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, yeah, exactly. We can hope. We can hope.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
The principle is that earlier is better. And, you know, it's hard. It's like, it's really hard to get at specific cut points. 0.5, PSA 0.5 is probably the best big picture cut point, but still earlier is probably better. And there's some data from Derek Tilkey and her team at the Martini Clinic
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
published in JCO that suggested, now it's retrospective data, but suggested, ah, you know, 0.5 is good, but 0.25 maybe is even better. And it's really hard to tease this out because when you're looking at these questions retrospectively, you're saying, okay, patients who get radiation
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
earlier seem to do better, but also patients with lower PSAs may have a slower doubling time and they may actually just be lower risk patients. And that makes it a little more challenging as always to tease out cause and effect. But guidelines, we feel very, very confident in that 0.5 threshold. We want to give salvage treatment. We want to initiate it before PSA 0.5.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And look, if you have that patient who's got a high risk disease and their PSA is 0.1 and you know it's going up and they've healed up and all that, There's no reason to delay. And in fact, the patient is going to be better off if we don't delay. And so one thing that we just fall short of as urologists is getting those patients to radiation oncology quickly.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Really, we tend to rely on a little bit more technical things, which sound awkward, like no evidence of disease. And basically, if we're getting two years, three years, four years out, and no evidence of recurrence, no evidence of disease, we're feeling really, really good, really optimistic.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And it really does make a big difference.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So I I've done maybe about 10 of these. Have you done some?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah. There was about a three-year period where I was doing them. I mean, it's doable. There's some challenging ones. I mean, like Mayo and Jeff Carnes have published their experience. They have a vast experience with this. And so I talked to Jeff and learned from them. I also talked to Dan Lin at UW a number of times back when I was doing these because he also had a lot of experience with these.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And they're doable. Pretty, like, you know, you learn a lot. It's super interesting. At the time, we were mostly basing our information from patients who went elsewhere for, say, choline PET or maybe a little, like, Axmin 2 back when that was being used.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And, you know, you'd go and you'd do a full dissection, and of course you'd find that node that was positive and about seven other positive nodes. And sometimes the PSA went down to zero, and most of the time it didn't. And sometimes it was a really difficult case.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I mean, I've only tackled one that's very memorable of when the node was in that kind of perirectal fat and just trying to, you know, so we've learned based on PET imaging that maybe about 10% of lymph node metastases go that direction. Different nodal chain and like finding that little pea-sized thing in there was unpleasant. We got it out, but we're like, by the grace of God, we got it out.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Did the patient benefit from it? That's the question. Well, when you look at published series, really, it does not look like it. All of these patients recur. This was, you know, really, I think, nice study published in European Urology four or so years ago, I think. Bravi was the lead author. It just shows that all these patients recur.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, it's awesome. I mean, pretty amazingly early in my career, I think, thanks to some phenomenal mentors that I've had, I had the opportunity to participate in some different AUA and ASCO guideline panels and NCCN. And I, you know, surprised how much I enjoy that process, you know. It is meaningful.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so in the absence of better data, data was convinced that it wasn't making a difference based on data like that and stopped doing it. And in the guidelines, we do include it as something to have on the table in, you know, select circumstances. But I'm actually looking at the text here. It's right.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
However, these patients should be counseled regarding the uncertain oncologic benefit from surgery in this setting. And I'd say to put that mildly, conditional recommendation evidence level grade C. Yeah. I don't know many folks are still doing it.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I totally agree. Yeah. It was worth a try, I think. And again, people, I mean, there were people who did a lot of these and I'm sure did an amazing job and they published their data, which is awesome.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I don't think so. I mean, the most important thing that we can do is talk to our patients, help them understand what's going on, and get them to a radiation oncologist. Like, it's still something that we don't do enough of, and we just, we got to do it. There's really strong data now to support getting a PSMA PET in the setting. I think the coverage is not an issue.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Around here, it's happening throughout the state, and so I'm really encouraged by that. I suspect in California, it's the same. Radiation or salvage treatment informed by PET scans is well supported now. And that's the EMPIRE study, EMPIRE-1 study, where patients were randomized to either a PET-informed or non-PET-informed strategy. And the PET-informed strategy worked better.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
It's like the ultimate, in some ways, of implementation of all the different things that we think about and write about. It's just being part of these multidisciplinary teams, thinking about everybody's different expertise that they bring to the table and learning from them, and then trying to distill
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so that's a great study. And that really justifies the role of PSMA PET in this setting. And so, right, so we need to recognize these patients. We need to keep track of them because this is another like piece of tantalizing music data that I've seen unpublished and I haven't seen the real details yet. So I can only give like a small headline and hopefully Tudor Borza doesn't kill me.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But like a lot of patients are lost to follow up after prostatectomy. And so we, you know, we don't necessarily always have great mechanisms.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
for keeping track of patients and we have to in primary care docs are managing a million different things and putting this on PCPs is really challenging when the report from you know PSA test reports back less than four or three years normal and not every patient understands the nuances and not every primary care doc understands those nuances and it's totally understandable so we have to be able to just keep track of our patients to be able to entertain any of this guideline-based care.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Ah, bingo. Thank you. Yes. That's a, it's really, really important. And so that's, so that's like the, the clinical scenario, I think that people understandably struggle with, which is like patient has a PSA of 0.2 and then maybe it's 0.3 and then you get the PSMA PET and it's negative.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so some people might reasonably say, well, let's just hold off and let's, you know, we'll wait till the PET's positive. And then, well then, well, now we got metastatic disease that we're waiting for.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And, you know, until we have, Studies that have answered that question, like negative PSMA PET, we have tons of data to support the role of salvage radiation in this setting. PSMA PET's only a handful of years old. So we need to fall back on where we really do have level one evidence.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
all the science that's produced in some really high-level science and some of the, you know, retrospective work that we all do to, you know, make the best data out of, you know, out of problems where we don't have those RCTs. And so distilling that down to something that's meaningful in the clinic, it's a great process and it's really interesting and fun to be a part of that.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, I mean, we're getting better, right? The surgeries are getting better, without a doubt. It's a difficult surgery, but we're getting better at it. And we really finally understand this debate of adjuvant versus salvage radiation. And so we know what to do. And when I look at these guidelines, I mean, a lot of it is really well supported by high-level studies.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So we have a good handle on how to improve outcomes in the setting. And then, yeah, there's a ton of research to be done. All the questions that we can ask around PSMA PET and how we should change management based on PSMA PET, incredibly important. And then incorporating new therapies.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I mean, you know, androgen intensification is now a couple decades old, but we're still just understanding how to incorporate those medications into this setting. And then TBD about PARP inhibitors and other precision-based therapies. I mean, it's all out there for us to eventually do the studies and change management.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Any comments on that, Todd? No doubt. I mean, I think that's bearing out in various data sets. Thankfully, we're not treating Gleason 6 hardly anymore. Understanding better the role of surgery versus upfront radiation and virus disease is still an important question. But yeah, I mean, we're doing lots of surgeries on patients with high-risk cancers, understanding better.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
from the get-go in transparent conversations with patients that this is, it's multimodal care. And so that's what, that's what we're planning. We're planning surgery followed eventually by radiation or homeotherapy.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Hey, thank you so much for having me. I love being on this podcast. Love, love what you're doing. Love listening to it. So great to see you.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so when I got the opportunity, you know, AOA reached out and said, hey, we're planning on this project. This guideline, we think the time is right for this. And would you be interested in leaving it? That's, you know, you jump at that opportunity. It was that that was one of those that took me 30 seconds to respond to.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
It totally, yep. So there was a prior adjuvant radiation guideline from about 10 years ago. And that was a great guideline. And we can talk more about, you know, where the field was and where it's gone. But this was intended to be totally different, started from scratch.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And, you know, when you would ask kind of about the, just the process, it's funny because it's an AUA guideline, but really the urologists make up a minority of the members on this committee, and that's for a good reason. I mean, it's AUA plus Astro and SUO, but, you know, who has expertise in this space? Sure, we do as urologists, but also radiation oncologists.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so my co-chair was Ron Chen, who's just phenomenal, you know, just an amazing radiation oncologist and just such a clear thinker and so knowledgeable. And we had, you know, medical oncologists and patient advocate, nuclear medicine experts. So again, really, really multidisciplinary, and that's fundamental to this space because this is our space, but... is not only our space.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Radiation oncologists have such a huge leadership role in this space, medical oncologists, and all of those collaborations, radiologists are really important. And we really, as we went through the process, we really tried to listen to each other, learn from each other. And I think that that led to a guideline that I'm really proud of.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And often, even times after surgery, when the pathology looks really encouraging, we're feeling really optimistic. And by the way, good news, we have this test, PSA, which is... despite all of its flaws in the screening setting, is an unbelievable biomarker in the post-operative setting.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I'm sure that's laughable, but okay, fine. No chance of that. No chance of that.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
We started with a number of us really honing in on what are the key questions that we want to address, kind of the pie in the sky. And the AUA has a really great process, and it's unique to the AUA, different from, you know, NCCN, for example, where the AUA has a methodologist. And it's really intended to lock us in on the best evidence that supports the questions we're trying to answer.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so when the methodology review happens out of OHSU, when the methodology review happens, that we kind of end up with some of those questions that we want to address. We just don't have data for. And we have to be realistic about that and say, OK, well, there are some things we're going to have to put a pin in for, you know, future revision or update to the guideline.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
But we can't actually, with evidence, comment on that. So that actually happens really before we get started. We develop the questions. There's the methodology review. Then we start to get together as a group and start meeting. And then we divvy up basically subcommittees with questions.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
sets of questions, key areas that we say, okay, let's propose some initial guidelines to, you know, answering those questions based on the evidence that we're looking at. And so, you know, it's really iterative on that. So the committees meet, propose guidelines. We meet again as a group.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
We keep hammering away until we have this, you know, set of 30 or so statements that we feel really comfortable with. And then we all do the writing. And so that's divvied up by everybody. And the AUA is a huge, huge help behind the scenes. You know, helping keep us on track, helping with writing, you know, parts of the methodology. And so it's a team game, big time.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
It was really hammered into us early on based on multiple different trials, including the Key Swag trial, that adjuvant radiation was really important for patients at high risk of local recurrence. You know, that was like, you find that on board exams, on early OCAD exams, I'm sure, patients with, you know, to repeat the PT3 disease or patients with positive margin, right?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
These are patients who were guidelines said strongly consider, I forget the exact statement, but really like these are patients that should see radiation oncology for consideration of adjuvant radiation, of course, meaning in the absence of any evidence of biochemical recurrence. And that was hammered into us for years based on, again, very, very reasonable, excellent, high-level data.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And yet, when you look at the utilization of adjuvant radiation for those patients over the years, and there are lots of different studies that have looked at that, including we've looked at this in MUSIC, the Michigan Urological Surgery Improvement Collaborative, and said, okay, of those patients,
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
who are recommended according to guidelines to strongly consider adjuvant radiation, how many actually get it? And the answer in every study is like 5% to 10%. So basically, nobody was actually getting adjuvant radiation. I'm sure more patients than that were seeing radiation oncology. Patients were opting against it. Docs were opting not to refer or docs were opting not to recommend.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
So we had this recommendation that really ultimately wasn't being followed. And Bring that forward to the present day where we have new key trials we've been talking about for years. When's Radical's going to report? When's Rave's going to report?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Asking the question that we all want to know, I've always wanted to know, which is, okay, like, we know adjuvant works better than, you know, waiting a million years to actually give the salvage radiation. We're never giving salvage radiation, but it's adjuvant radiation better than early salvage radiation for patients who are at high risk of recurrence. And
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And the answer is no, as far as we can tell. Now, you know, we can talk about, you know, maybe carve-outs for patients at really high risk of recurrence who maybe were undersampled in these studies. But really, you know, waiting until biochemical recurrence is totally appropriate, saves a ton of patients from unnecessary salvage treatment. And so that's where the field has moved, right?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, stylistically, I think it comes up a lot pre-op. It should come up a lot during that initial consultation, but certainly not every time. I think we talk about risk of recurrence, right? So we get to go through the whole discussion, surgery versus radiation for the patient who's thinking about surgery. We talk about all the usual quality of life risks, surgical expectations.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And then we do really try to address what I think is a common misunderstanding that Once the prostate is out, the patient is guaranteed to never recur. And patients, I think, are often surprised. What do you mean? I thought if the prostate's gone, how can I get it again? And why are you checking my PSA? Or why would you check my PSA after surgery?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And so it's much easier to address that beforehand than after the fact. Of course, not every single thing that we talk about at that initial visit is retained. That's impossible. But floating that is really helpful. I think I'd at least get to that point for every patient. Do I talk about, okay, now what happens if we hit that fork in the road?
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
I think I really make sure I address that with the higher risk patients, right? Patients with higher risk disease, where really that initial discussion is about
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
You know, we have option A, which is surgery with a distinct possibility, oftentimes greater than 50% possibility of undergoing additional treatment, likely to include radiation plus hormone therapy, or option B, which is radiation hormone therapy from the get-go.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And we talk about the pros and cons of each approach, but really ensuring that patients do understand that surgery is not a guaranteed one and done is important.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
Yeah, like never. And so patients, I'm sure you have this experience too, or say, well, so then will I be cured or am I cured? And I just, I always say, and I say, you know, cure is a term that we just like all of us oncologists just really have a hard time saying, because pretty much everybody with a history of cancer has, of any kind of cancer, has some risk of that cancer coming back.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And that risk may be really, really, really low so that we kind of in lay terms use words like cure, but Really, we tend to rely on a little bit more technical things, which sound awkward, like no evidence of disease. And basically, if we're getting two years, three years, four years out, and no evidence of recurrence, no evidence of disease, we're feeling really, really good, really optimistic.
BackTable Urology
Ep. 206 Biochemical Recurrence: Insights from AUA/ASTRO/SUO Guidelines with Dr. Todd Morgan
And often, even times after surgery, when the pathology looks really encouraging, we're feeling really optimistic. And by the way, good news, we have this test PSA, which is despite all of its flaws in the screening setting, is an unbelievable biomarker in the post-operative setting.