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Expert Stresses New Technologies and Collaboration to Improve Outcomes in Genitourinary Cancers

Nichole Tucker
Published Online:3:24 PM, Tue September 10, 2019
Cristina Magi-Galluzzi, MD, PhD
Cristina Magi-Galluzzi, MD, PhD
During a presentation at the 2019 Physicians Education Resource (PER®) 3rd Annual International Congress on Oncology-Pathology, one expert explained that the role of a pathologist is just as important as that of an oncologist when diagnosing and treating patients with genitourinary cancers to provide the most complete information possible for the patient’s benefit.
 
Learning to work together and see the value that both pathologists and oncologists add to the process of diagnosis and treatment is an ongoing challenge. By perfecting this collaboration, however, physicians will have a better understanding of how pathology has changed to make more informed decisions for treating their patients. Another reason such collaboration is needed is because, in the past, patients with genitourinary cancers were over-treated because pathologic information about the aggressiveness of their cancer was not available.
 
Today, there are better tools for classifying and grading genitourinary cancers, and with these tools, pathologists can pass along more detailed information that helps oncologists provide solid diagnoses and offer appropriate treatments. The newest version of the Gleason scoring system for prostate cancer is one such example of advancements in genitourinary cancer technology.
 
In an interview with Targeted Oncology, Cristina Magi-Galluzzi, MD, PhD, director of the Division of Anatomic Pathology and a professor of pathology, University of Alabama at Birmingham School of Medicine, discussed the role of pathologists in the diagnosis and treatment decision for patients with prostate, bladder, and renal cancers. 

TARGETED ONCOLOGY: What are the key takeaways from your presentation? 

Magi-GalluzziPathology is not a black box. It's an integral part of the evaluation and treatment of the patient. We should not be considered less valuable than other physicians when making a diagnosis and deciding on treatment. We bring a lot of value to the table, so we need to have the same involvement as other physicians. 

TARGETED ONCOLOGY: How have your conversations with physicians changed with all of the advancements that have been developed just as we grow as a field. 

Magi-Galluzzi:I think we need to collaborate more and also understand that pathology has evolved over time. We can provide different types of information that we wouldn't have been able to provide 20 years ago. The clinician needs to be aware, for example, of all these new changes in the Gleason grading, classification, and staging that we have tweaked over time but now give a better prediction of outcome in the patient compared to what we were able to do in the past. It's important that we're aware as pathologists of what the clinicians see and what the patient’s clinical information is, but the clinicians also have to be aware of what the pathologists can bring based on the biopsy evaluation or the radical specimen.

TARGETED ONCOLOGY: What are some of the pathologic developments that have been seen in renal tumors? 

Magi-Galluzzi:In the past 10 years, we've gone from 4 renal tumors that were recognize in the 20 years to at least more than 30. There's a lot of development in renal cancer with the new entities that are discovered almost weekly. And, there are a lot of new tumors that have syndromic associations that are important to recognize, not only for the implication for the patients but also for their family members. 

TARGETED ONCOLOGY: Looking at bladder cancer, what are some of the pathologic features you're looking for to determine the right treatment for each patient?

Magi-Galluzzi:In addition to the invasion of the muscularis propria, the detrusor muscle, that will give the physician the green light for a cystectomy because the patient already has a high-stage tumor. There are some morphologic features. Some tumors are more aggressive than others. For example, if a patient has presence of plasmacytoid features or micropapillary architecture, those are tumors that are normally associated with worse outcomes. They also might have already spread through other organ systems at the time of diagnosis, and these may require neoadjuvant treatment or a more aggressive evaluation of the patient because they may already have metastatic disease.

TARGETED ONCOLOGY: As we understand more about the biology of prostate cancer, how have outcomes improved for patients? What are some of the enduring areas of unmet need?

Magi-Galluzzi:With prostate cancer in the past, I think we might have over-treated some of the patients. [This is because] PSA detects a typical pattern, then a patient gets a biopsy, and a diagnosis of cancer is made. [We have also] treated patients with low-grade tumors that may not have needed a radical prostatectomy. 

We're now trying to be more cautious, and that's why the new Gleason scoring scheme, grading system, and also the grade grouping will [prevent] aggressive treatment for patients with low-grade tumors and [allow] them to be involved in an active surveillance program. Instead, [we can] focus on the patients that have higher-grade disease and are at higher risk for recurrence, metastases, or death. This is one of the things that I think we need to focus on moving forward. Then, [we should focus on] trying not to over-treat patients.

Even as a pathologist, we are defining different criteria. [Some examples are] the presence of the cribriform, architectural, or intraductal glands. [These are] very aggressive features that are typically associated with aggressive disease, and those are the patients that we need to focus on instead of patients with low-grade tumors like Gleason score 3+3 = 6. Those are patients who will most likely die with the disease, not because of the disease.

TARGETED ONCOLOGY: What is the role of liquid biopsy in the diagnosis and management of these cancers?

Magi-Galluzzi: I think some of the challenges are related to the fact that there's a lot of variability in the type of techniques that can be used. Moving forward, the presence of next-generation sequencing and other new tools that are available will make things more likely to be implemented in clinical practice. But, we also need to do more studies to make sure that some of the preliminary data that have been presented can be validated in different cohorts, not just in small cohorts. 

The value is that, on the patient side, [liquid biopsies are not aggressive] because maybe some of the tests can be done in urine or saliva, or just in a blood test and so they don’t need to be biopsies. Particularly for patients with bladder cancer, [liquid biopsies] are important because they will also reduce the cost of [treatment]. There's a lot of expectation, and I think we are [heading in] the right direction. I don't think we're ready yet, just because we need to have a better validation of some of those tests.

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