Dr. Ashley Ross

Melanie Cole:
Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole, and I invite you to join us as we discuss the Society of Urologic Oncology annual meeting highlights. Joining me is Dr. Ashley Ross. He’s an associate professor of Urology at Northwestern Medicine. Dr. Ross, thank you so much for joining us today. So tell us about the prostate cancer highlights from the 2021 annual meeting of the Society of Urologic Oncology. What stood out to you? What was it like?

Dr. Ashley Ross:
Well, it was a great meeting this year! One of the major areas of focus was “how we approached the diagnosis of prostate cancer”, and specifically it was discussing how we do prostate biopsies, some of the issues around there, and some of the stepwise evolutions we’ve seen. At the meeting, Dr. Edward Schaeffer, who’s the chair of urology at Northwestern, talked a little bit about the landscape of bacteria in the colon and how it affects prostate biopsies. In the past, prostate biopsies were most commonly performed with transrectal ultrasound guidance and needles that traversed the rectum into the prostate. And Dr. Shaeffer pointed out that there’s been an increase in Fluoroquinolone resistant (inaudible). These are bacteria that are normally colonizing our guts, and there’s been an increase in their frequency of being resistant to Ciprofloxacin and other Fluoroquinolones, which are antibiotics we commonly give for these transrectal ultrasound guided prostate biopsies. So he pointed that out, and then as the session continued, we talked about the advances made in doing transperineal prostate biopsies, which are now commonly performed in the clinic at Northwestern and at many other institutions. These biopsies go through the skin as opposed to the rectum, and as they do that, they have much less infectious risk and they do not require the use of antibiotics. Now, currently at Northwestern, Dr. Schaeffer and other physicians from around the United States, like Dr. Hu at Cornell, are conducting a comparative effect in this trial that looks at this type of biopsy, this ‘through the skin, transperinel biopsy’ and compares it to the traditional ‘transrectal biopsy’ to really flush out diagnostic yield. Is the patient comfort the same? And what do we see in terms of infectious risks? This was a highlight of the meeting: these sessions around how we do prostate biopsies. And I think that it’s a harbinger of what we are going to see an evolution towards, which is the clinic-based transperineal, transect ultrasound-guided prostate biopsy, which as I noted is one of the more common ways that we do the prostate biopsy at Northwestern. So that was a big focus. And then another focus of the meeting was talking about “management of lower risk prostate cancer patients with clinically localized disease”. Dr. Catalona helped push forward a debate about the management of these low risk patients and our understanding of active surveillance. “Active surveillance” is the observation of prostate cancer, which is thought to be of lower risk with the deferment of treatment until disease appears to be substantial enough to require it. This is because the treatments we have for prostate cancer often have some morbidity, whether it be in the sexual domains or urinary domains. In this debate, he highlighted, there’s a heterogeneous group of men that have low risk disease, and that we have to do personalized approaches towards determining who is a good candidate for surveillance and who may want to seek upfront treatment. So it was an excellent session and I was happy to see a lot of my colleagues on the stage, furthering knowledge in prostate cancer.

Melanie Cole:
Thank you for sharing that answer. So Dr. Ross, now I’d like you to tell us some of the key takeaways from your presentations as well as your Northwestern colleagues, Dr. Schaeffer, who you mentioned and Dr. Catalona were among the featured speakers at this conference. So tell us some of the key takeaways from your presentation too.

Dr. Ashley Ross:
I think my presentation was about “how to operationalize a transperineal prostate biopsy in the clinic”. And in the past, a lot of people would think that transperineal prostate biopsies were longer procedures that required a large area of the perineum to be anesthetized and would be done with what’s called a “stepper and a grid” type apparatus. And because of that, it would be done in the operating room. It would be a more onerous procedure. My presentation basically discussed things that I had learned over the last year in operationalizing it in my clinic and other things that I’d learned from the literature. I basically put forth the idea that we can pretty easily do these procedures in clinic in about a 15 minute timeframe with a patient in the door, to out the door of the clinic being less than 30 minutes. And what I talked about was a tethered needle guide with someone we use in Northwestern as called Precision Point,(TM) which allows the operator, (myself) more flexibility to do the procedure in a more expeditious manner. And then additionally, we touched a little bit on, and it was shown in some other presentations, our better understanding or renewed understanding in the perineal anatomy and innovation to the prostate, such that we could make patients comfortable in this procedure without using anything except for 1% Lidocaine as analgesia. So my presentation was mostly about operationalizing perineal biopsies in the clinic. It really drew on a lot of things that I’ve learned at Northwestern. They had asked me to give the talk because about a year ago or so, before I joined Northwestern faculty, I was not performing this in the clinic. I was a little bit hesitant to do so because of the fears about barriers of implementation. Now, it is the most common way I perform biopsies in clinic. Because of that, the SUO asked me to present since I had now gone through this process. Can I help teach the audience: What was my learning curve? What were some of the barriers? How do we overcome it? What are the equipment and staff we need? And can we give any tips and tricks? In my mind, even though there’s a comparative effect in this trial, and we want to look for the answers from that, this approach that requires no antibiotic at all, which means that we’re doing excellent antibiotic stewardship and that in my hands, at least, and in the international reports, has had virtually no infectious complications, is likely to be, in the next few years, the main approach used by urologists across the United States. And it’s good to know that it can be done in an expeditious fashion in- clinic. And moreover, I think that it’s good to know that there’s a way forward that won’t contribute to this higher frequency of resistance bacteria. That it’s really an issue across spectrums of disease.

Melanie Cole:
How cool is that?

Dr. Ashley Ross:
It was a great opportunity and I got great feedback from some of my friends around the United States and from other attendees about the quality of that session, about us being able to disseminate knowledge that I gathered here and in full disclosure, the person who taught me sort of had operationalized this in my clinic was Dr. Schaeffer. And it was nice to move that knowledge forward. I took a lot of pride in it. The session itself was an important topic and Dr. Catalona’s session and others about personalizing medicine and prostate cancer, I think made the conference a very special one.

Melanie Cole:
So rewarding to be able to share what you’ve learned to really further the field. It’s an exciting time in your field! And before we get to the wrap up question, why don’t you expand on Dr. Catalona’s talk on “personalized medicine” because that’s really a big buzzword in the field now.

Dr. Ashley Ross:
Well, I think he was talking about, again, “surveillance for low risk prostate cancer” and there’s access for low risk. Prostate cancer is a very good option, maybe preferred for most men with low risk disease. He had actually acquired the largest series by collaborative efforts of patients on “active surveillance” across the United States. And he looked at the characteristics of those patients. And the reality is that the majority of the people that we survey, or have surveyed in the last 20 plus years of experience that we have gathered, have been on the ‘low end’ of the ‘low risk spectrum’. And it highlighted some points that for men that are on the ‘higher end’ of the ‘low risk spectrum’, (meaning they have more volume of disease in their prostate, they maybe have a stronger family history, or they may have genetic drivers) we have to often do careful decision making with them about, “should they do surveillance as a strategy or not?” How long do we expect them to be on surveillance before they will need treatment? And that can often determine whether or not it’s a viable approach. And so it was a good debate with him and Dr. Scott Eggener from University of Chicago and it highlighted these ongoing issues as we continue to understand who we need to put towards treatment and who we need to survey with prostate cancer. And the major thing of ‘personalized medicine’ is just getting away from the idea of ‘one size fits all’. Each person has different disease risks, and even with common clinical factors, without anything fancy, you can put people into different bins and help treat them in a very individualized way.

Melanie Cole:
Well, certainly the wave of the future in healthcare as a whole! Dr. Ross, as we wrap up, is there anything else, any other important information or learnings from this year’s SUO annual meeting that you want your colleagues who may not have been able to attend, to know about?

Dr. Ashley Ross:
I’ll wrap up kind of how I started and say that it was a great meeting. I think one of the things that was highlighted is this idea of “transparent biopsies”. And I think a lot of us have to look at how we do diagnosis of prostate cancer, how we use things like MRI, et cetera, that’s been around for a while, but there is going to be a sea change in my mind, in how we do one of the most routine procedures we do for our patients with elevated PSAs in the clinic. That’s why the organizers had dedicated a longer session to that. And why two talks from Northwestern came in that area. And I would tell my colleagues that weren’t able to attend, “take a strong look at some of the literature that’s already out there on transperineal prostate biopsies”. I’m sure there’ll be more discussion of this at future national meetings during this year, but I believe it is going to be the wave of the future. And we have to start thinking about how we adopt it across clinics in the United States.

Melanie Cole:
Thank you so much for that really comprehensive overview of the annual meeting of the SUO. Thank you again, Dr. Ross for joining us. To refer your patient or for more information, please visit our website at www.breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern medicine podcasts. I’m Melanie Cole.

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