CURE staff

How artificial intelligence is being used to augment the work of experts treating patients with prostate cancer.

For patients with prostate cancer, artificial intelligence (AI) appears to be en route to becoming a key part of the cancer journey, as experts who spoke to CURE explain.

“Right now, AI is definitely being folded into different levels of the entire journey for patients,” says Dr. Soroush Rais-Bahrami of Wake Forest University School of Medicine in Winston-Salem, North Carolina.

AI caught attention at the annual meeting of the American Urological Association, held in April in Las Vegas, where data were presented from a UCLA-led study showing that AI-generated cancer mapping was able to accurately predict seminal vesicle invasion (SVI), or the spread of cancer cells from the prostate gland into a patient’s seminal vesicles. 

“AI-generated cancer mapping accurately predicted SVI, despite never being specifically trained for this task. AI dramatically improved upon the SVI predictions of MRI, with the potential to support early diagnosis and treatment of invasive [prostate cancer],” wrote researchers, including Dr. Wayne Brisbane, an assistant professor of urology at UCLA Health, in study findings published in the Journal of Urology.

As Dr. Nitin K. Yerram, director of urologic oncology at Hackensack University Medical Center in New Jersey, explains, the technology’s potential utility in prostate cancer care and management is ever-evolving.

“This role, it’s relatively new over the [past] few years, and it just keeps changing every day,” Yerram says.

“But there [are] two main places that I think AI is used more on a day-to-day basis: one of them is more a diagnosis, and the other one is treatment stratification.”

Regarding diagnosis, Yerram says AI is now sometimes used to read an MRI of a patient’s prostate in order to understand whether there are potentially suspicious areas of the organ.

“That’s going to be prime time in the next few years,” he says, “but what it’s currently being used in right now is, when you do a biopsy — and these slides are sent to a pathologist — [AI] is augmenting the pathologist and helping them determine the areas that need further investigation. ... So it’s really making the pathologist more accurate as well as probably more efficient.”

Concerning treatment stratification, Yerram explains that when a man is diagnosed with prostate cancer, he is placed into a category of low, interme-diate or high risk. “Based on those categories, we’re able to either offer them surveillance for low-risk patients — because that cancer is really slow-growing and probably not going to be a major issue in their lifetime — or, for high risk, we’re saying, ‘Hey, we need maybe surgery or radiation, or maybe both.’

“... Now we’re actually using [AI], and ... they’re able to now look at that slide and understand very minute patterns over a course of many slides, or all the tissue that pathologists probably can’t really perceive but a machine learning algorithm never forgets, [and it] can really understand and see those patterns and can help decipher a little bit more of what is high risk, what is low risk, maybe what’s intermediate risk.”

Such work, Yerram explains, is currently being done by the team at Artera via its ArteraAI Prostate Test, for example.

“We’re able to send the patient’s tissue to this company, and they’re able to scan the whole slide and be able to give us an output saying, ‘Hey, this patient is probably low risk,’ or maybe it’s high risk, or maybe it’s intermediate risk. So, we’re able to further identify patients and stratify them better to help make treatment decisions.”

In the realm of treatment, Yerram says machine learning algorithms are playing a role, for example, by making robotic surgery more efficient and less harmful for patients in order to effectively treat cancer and improve functional outcomes after surgery.

“You know, not everyone needs surgery,” Yerram adds. “We have different options, including ultrasound ablation ... and AI is able to help us determine, when you have a whole prostate and you want to just treat one certain area, how we can use [AI] to find that area, give a good treatment margin [and] help us determine what the most effective treatment course [is]. It’s helping the physicians augment that treatment pattern, and I think we’re going to be able to see leaps and bounds of improvement in this area for the years to come.”

However, questions and issues remain, as researchers note.

“The long-term success of AI in prostate cancer depends on our ability to solve multiple challenges spanning ethical, legal, regulatory and technical realms,” wrote Dr. Irbaz Bin Riaz, of the Mayo Clinic in Phoenix, and colleagues in the 2024 American Society of Clinical Oncology Educational Book. “Critical issues include protection of the privacy of the patients’ data, liability management between the [mistakes and biases] that can come with the AI systems, and the interpretability and adaptability deficit of the AI systems with respect to current clinical workflows.

“The effectiveness of the AI models depends highly on the quality and diversity of the training data; therefore, models often do not have their intended effect across different hospitals and healthcare systems settings because of data limitations. Additionally, there is concern about healthcare providers potentially over-relying on AI, which might diminish the value of human clinical judgment and intuition. The absence of standardized AI guidelines, coupled with high deployment costs and fears about job security and loss of professional autonomy, further complicates AI adoption in clinical practice.”

“Right now, [AI] has a complementary role, as far as it can make our jobs easier and [make] sure that things are not falling through the cracks,” says Richard Boyajian.

An advanced practice registered nurse and nurse practitioner in the Department of Radiation Oncology with the Dana-Farber Brigham Cancer Center in Boston, Boyajian founded the Virtual Prostate Cancer Clinic at Brigham and Women’s Hospital in 2016.

He is also a member of the CURE advisory board.

“The quicker you can present all the data succinctly to the provider, they’re able to make a decision based on these multiple points that should be considered,” Boyajian says. “If you don’t present all of it, it’s human nature to ... [say], ‘OK, I know we need to focus on [prostate-specific antigen]. We need to focus on what’s going on ...’ But there may be other things that are in play that AI can calculate to build the picture so we can put whatever’s going on into a context, if you will.”

Aside from skin cancer, prostate cancer is the most common cancer among men in the United States, with the American Cancer Society estimating that there will be approximately 313,780 new cases of prostate cancer in the United States in 2025. Incidence rates of the disease have increased by 3% per year since 2014, and approximately 1 in 8 men will be diagnosed with prostate cancer in their lifetime.

“With prostate cancer, we’re going to cure, what, 90% of these guys? They’re the biggest male population of cancer survivors in the world, in the country,” Boyajian says. “So, if you think of what’s going on now ... we’re being asked to
see more people than humanly possible in a certain time frame. It gets overwhelming because the human mind can’t process everything quick enough.”

Boyajian says he is now working with Cancer Insights on a National Cancer Institute grant to use their AI platform to understand what phase of care
a patient is in based on medical records data, with eventual plans to develop monitoring modules for each phase of care.

“It will make most of my colleagues’ lives infinitely easier, especially in the survivorship and follow-up community,” he says, “because we’re just drinking at a fire hose right now, where there [are] just so many patients.

“The other thing I worry about is [that] our human structures are breaking down. I’m not in love with AI, don’t get me wrong, but I’m seeing more and more that humans are fallible, and when you overwhelm the healthcare system — like it seems like it is now — there’s a lot of stuff falling through the cracks. And in other businesses, that might be acceptable, but falling through the cracks here means there’s a patient [who] hasn’t got an answer on something, stressing out of their mind, wondering, ‘What’s happening? Are they just letting me die?’ or things like that. That’s the communication issue and ... we need to find ways around it.”

When it comes to treating the prostate, Brisbane explained in a 2024 interview with CURE that precision is key.

“There are some very important factors that run in and around
the prostate,” Brisbane said. “One is the urethra, and the others are the neurovascular bundles, which are like telephone wires from the brain to [the] phallus, saying it’s time for an erection, and those are running right alongside the prostate. The bladder is right behind the prostate, and then there are the pelvic floor muscles, which are responsible for urinary continence and fecal continence, right at the apex of the prostate or the nose of the prostate.

“The prostate is kind of... high-stakes real estate, so where the tumor is relative to all those structures really indicates what kind of side effect profiles patients are going to experience when they’re getting treatment. So, knowing that with accuracy is very important to know [when asking], ‘Can we treat this cancer?’ or ‘How do we treat this cancer best while minimizing side effects?’”

Tumors, Brisbane explained, are shaped like crabs, in that they have a central body as well as “a lot of legs that go out beyond the portion [of the tumor] that is visible on imaging, and that’s true for all imaging modalities [such as] MRI, [prostate-specific membrane antigen] and these newer imaging modalities like microultrasound.”

As of late, Brisbane has been utilizing the cancer-mapping tool Unfold AI.

As explained by AI health care company Avenda Health, Unfold AI “combines patient-specific data from prostate imaging, biopsies and pathology into deep learning algorithms to create a unique and tailored cancer estimation map. Its 3D, AI-generated map visualizes the location of the cancer for physicians to use in treatment decision-making and interventional planning.” It was cleared for use by the Food and Drug Administration in late 2022, according to Avenda Health.

Brisbane and his colleagues have utilized Unfold AI to support the use of precision medicine (also known as focal therapy) to treat cancer with the TULSA procedure, or TULSA-PRO, which uses ultrasound to create high temperatures and destroy prostate tissue.

“The use of AI is certainly building and only becoming more augmented,” Rais-Bahrami says. “As we move forward, there’s definitely going to
be an important role for AI in a lot of the processes we use, and I would say ... the diagnostic and treatment decision-making journey for patients with prostate cancer, we have yet to see where it’s going to land, but I certainly see it developing [and] becoming more commonplace.”

Rais-Bahrami is the William H. Boyce Endowed Chair in Urology and Professor and chair in the Department of Urology at Wake Forest University School of Medicine. He is currently using the Unfold AI tumor mapping tool retrospectively to compare its accuracy to diagnosis without AI assistance.

“Specifically, with Unfold AI, it’s integrating the inputs from patient demographics, clinical parameters and patient imaging — so the primary imaging from prostate indication, pelvic MRI, multiparametric MRI input [and] the pathology output from biopsies that we get,” Rais-Bahrami says. “It’s giving us cancer estimation maps that have been very valuable in my practice to scale the degree of radical prostatectomy surgical planning, [as well as] planning for focal therapy patient candidates.”

Rais-Bahrami also explained that the use of AI can help level the playing field, so to speak, for patients and providers. “Understanding each clinical case and personalizing treatment algorithms, decision-making [and] patient counseling is going to be key, and that’s where the nuances of AI will most likely normalize some of the personalization that was largely based on clinician and provider expertise,” he says. “AI is taking huge data sets of input with deep learning and machine learning, whereas that would take an entire generation of learning, a senior practitioner and a senior urologist with hundreds or thousands of cases of experience and background.

“So certainly, it levels and normalizes the playing field. And early on,
it normalizes the experience that practitioners can provide to their patients in personalizing the care recommendations. And then even
for very seasoned and experienced practitioners [who] have had their own subset of patients over career-long practice, AI will also bring in infinitely more data points of experience than even one practitioner — even seasoned ones — will have seen.” 

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Articles

Artificial intelligence (AI) is increasingly integral to prostate cancer management, enhancing diagnosis and treatment stratification. AI's ability to predict seminal vesicle invasion and improve MRI accuracy was highlighted at the American Urological Association meeting. AI aids pathologists in identifying suspicious areas and assists in treatment decisions by categorizing patients' risk levels. Despite its potential, challenges such as data privacy, interpretability, and reliance on AI over human judgment persist. AI tools like Unfold AI are advancing precision medicine, offering personalized treatment plans and improving surgical outcomes.

Utilizing AI in Prostate Cancer Care and Management

From left: Katherine Mast Hagemann, B.S.N., RN, and Dr. Andrew Kuykendall

The current environment in oncology (and medicine in general) incentivizes hurried, impersonal care that prioritizes algorithmic over individualized decision-making. Efficiency is encouraged, and there seems to be little time to look a patients in the eye, hold their hands, and ask, “How are you doing?” It takes time to ask, and it invites an answer that could take much longer. All the while, documentation is delayed, emails flood in, administrative tasks build up and work days get prolonged.

Katherine Hagemann has refused to let any of those things stop her from asking that question. But more importantly, Katherine has refused to let any of those things stop her from listening to the answer.

Katherine has been my primary nurse in our specialized clinic where we focus almost entirely on patients with myeloproliferative neoplasms and systemic mastocytosis. These are patients with extremely rare chronic leukemias that result in abnormal blood cell counts, debilitating constitutional symptoms and poor quality of life. Patients travel significant distances to receive an accurate diagnosis, better understand their condition, obtain treatment recommendations and understand how this new reality impacts their old reality.

Katherine Mast Hagemann, B.S.N., RN, and Dr. Andrew Kuykendall

Although many oncologists (myself very much included) keep the focus on the disease — its diagnosis, treatment options, execution of treatment — Katherine has an exquisite instinct for understanding that there is a context to each patient’s diagnosis that is just as important to understand. In our clinic, we call them “emotional support visits” or ESVs for short. That’s when Katherine returns from a patient’s room before I’ve had the chance to see them . My face often reflects the confusion and frustration of someone who feels like they are running behind. She’ll look at me and say, “We had an ESV.” The implications of this statement have become clear. What I may initially see as lost or wasted time is, in fact, the exact opposite. The time she spends in an ESV will be cherished by the patient in a way that will ultimately pay dividends in the future. Regardless of what I talk about with that patient in the time that follows, they will leave the appointment knowing that they were heard because Katherine took the time to truly listen.

Beyond this preternatural empathy and compassion, Katherine has a unique drive to understand the rare diseases we treat. Her ability to distill complex concepts and present them to patients in a way they can understand gives patients comfort and confidence as they navigate the unknown.

In the increasingly complex environment of cancer care, Katherine Hagemann is a unicorn. She combines an impressive understanding of rare diseases in a rapidly evolving field with a degree of compassion that is rarely seen. Her ability to keep the focus on the patient is a model to which we all should aspire. And, just like a unicorn, I often can’t believe she’s real. Katherine understands that the disease is just a component of the journey that patients with cancer must travel and, importantly, Katherine helps patients understand that it isn’t a journey they are taking alone.

In the current oncology landscape, efficiency often overshadows personalized care, but Katherine Hagemann exemplifies a compassionate approach by prioritizing patient interaction and understanding. Working in a specialized clinic for rare chronic leukemias, she emphasizes the importance of "emotional support visits" (ESVs), ensuring patients feel heard and supported. Her ability to simplify complex medical information fosters patient confidence. Katherine's unique blend of empathy and expertise in rare diseases serves as a model for patient-centered care, highlighting the importance of addressing both medical and emotional aspects of the patient journey.

Katherine has an exquisite instinct for understanding that there is a context to each patient’s diagnosis that is just as important to understand.

A Unicorn Among Us

New treatment combinations are transforming genitourinary cancer care: © stock.adobe.com.

When I was a urology resident in the early 2000s, the management of any advanced genitourinary cancer was challenged by a frustrating lack of available treatments that could prolong the lives of individuals with cancer. The chemotherapy we used for prostate cancer was associated with quality-of-life benefit, but no survival benefit. If bladder cancer did not respond to the initial rounds of chemotherapy, we usually transitioned to palliative care. And kidney cancer was managed with nonspecific immunotherapies that were either incredibly challenging to give or that were associated with limited improvements in survival. As the articles in this issue highlight, the rapid development of new treatments for localized and advanced genitourinary cancers is challenging our paradigms of care and readjusting our treatment algorithms on a regular basis.

We are moving from an era of monotherapies to better understanding how combinations of treatments with different mechanisms of action can work together to help patients have better survival and quality of life outcomes. Combining drugs that block the impact of androgens on prostate cancer cells with drugs that keep cancer cells from repairing their own DNA so that they cannot divide and make more cancer cells is associated with patients living longer with advanced prostate cancer. Combining traditional chemotherapies with drugs that block cancer cells escape mechanisms that allow them to evade our immune system was associated with better survival in bladder cancer that invades the outer muscle layer of the bladder.

New advancements can also mean learning how to optimize treatments. The IMvigor211 trial was the first demonstrating the benefit of immune checkpoint inhibitors in metastatic bladder cancer. Yet in these large trials, we usually learn the difference in outcome for the average patient in a trial. 

Some patients do better than average, and some do worse. Learning what additional factors can help patients have better health outcomes is a great motivator for secondary analyses of these trials, even ones published almost 10 years ago. In the case of the study highlighted in this issue, that means assessing the potential benefit of combining the immunotherapy with antihistamine medications. Sometimes, that means using biomarkers like the presence of circulating tumor DNA to better select patients for additional therapies. Either way, these secondary studies of large-scale trials help us as clinicians talk to patients when they ask us what they can do to optimize their health outcomes with these treatments.

Included in these studies are the individual experiences of hundreds of patients navigating their journeys with prostate cancer, bladder cancer, kidney cancer, testicular cancer and others. These are experiences that cannot be summed up in the aggregate data of these trials, because for these individuals, the trial has a sample size of one. 

Beyond understanding traditional outcomes for clinical trials like progression of the cancer, recurrence of the cancer or death from the cancer, more and more studies are examining the patient experience. Whether new therapies that make survival better, or additional adjuncts to treatment that make that treatment work better, underlying all of these studies is the impact on patient experience with their cancer.

The management of advanced genitourinary cancers has evolved significantly since the early 2000s, with new treatments improving survival and quality of life. The shift from monotherapies to combination therapies, such as androgen blockers with DNA repair inhibitors for prostate cancer, has shown promising results. Trials like IMvigor211 highlight the benefits of immune checkpoint inhibitors in bladder cancer, while secondary analyses explore factors like antihistamines and biomarkers to optimize outcomes. Patient experiences remain crucial, emphasizing the importance of personalized care and understanding beyond aggregate trial data.

New treatment combinations are transforming genitourinary cancer care, improving survival and quality of life while personalizing patient outcomes.

Rapid Developments to Enhance Patient Experience in GU Cancer

Antihistamines may be associated with survival improvement in patients with metastatic urothelial carcinoma receiving Tecentriq: © stock.adobe.com.

Antihistamines are associated with improvements in progression-free events and survival outcomes for patients with metastatic urothelial carcinoma (mUC) receiving Tecentriq (atezolizumab), research has shown.

Drawing on data from 896 patients from the phase 2 IMvigor210 trial and phase 3 IMvigor211 trial, researchers published their findings in Urologic Oncology: Seminars and Original Investigations. They found that at two years, the overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS) probabilities were 46%, 48% and 23%, respectively, among patients who received antihistamines, and 23%, 32% and 13% for those who did not.

After excluding patients who experienced immune-oncology-related side effects, researchers found a 22% reduction in the risk of cancer-specific death and a 29% reduction in the risk of death from any cause.

The median follow-up time for patients receiving antihistamines was 17.7 months and 7.7 months for patients who did not receive them.

“In this study we investigated the impact of antihistamines on oncological outcomes among patients with [metastatic urothelial carcinoma] treated with second-line [Tecentriq] in two randomized clinical trials. We found that patients [who] received antihistamines concomitant to [immune-oncology] had longer OS, CSS and PFS relative to individuals who did not receive antihistamine medications,” wrote Dr. Giuseppe Fallara and colleagues in the study.

Fallara is a urologist in the Department of Urology at the IRCCS European Institute of Oncology in Milan, Italy.

Among patients who received antihistamines, the median OS was 17.7 months versus 8.1 months for those who did not. Likewise, the median PFS times were 4.9 and 2.3 months, respectively, and the CSS times were 22.8 and 9.3 months, respectively.

Patients with locally advanced UC or mUC generally face poor prognoses, with a five-year OS rate of approximately 6%, the researchers stated.

However, they noted that previous data suggest that antihistamines may improve cancer outcomes, particularly when administered in conjunction with immunotherapy, by reversing T cell dysfunction.

Tecentriq, a type of immunotherapy known as an immune checkpoint inhibitor, binds to the protein PD-L1 on the surface of some cancer cells, which prevents cancer cells from suppressing the immune system, according to the National Cancer Institute.

Of the 896 patients whose data were utilized in the study, 155, or 17%, used antihistamines during the two trials in question. Researchers reported that overall, 645 patients died of cancer-related causes and 59 died of other causes. Seven hundred patients experienced disease progression while on treatment.

Fallara and his colleagues acknowledged that their study had several limitations, including that researchers did not have detailed data regarding the timing, duration, type of antihistamine and reasons for antihistamine use.

“In conclusion, using individual patient data from the IMvigor210 and 211 trials, we found that concomitant use of antihistamines was associated with prolonged progression-free, cancer-specific and overall survival in patients treated with [Tecentriq],” Fallara and colleagues wrote. “Our results showed a positive association between antihistamine use and oncologic outcomes in patients with mUC treated with [immunotherapy]. This effect deserves further prospective investigation, ideally with a randomized controlled trial of antihistamine versus no antihistamine use.”

Research indicates that antihistamines may enhance progression-free and survival outcomes in metastatic urothelial carcinoma (mUC) patients treated with Tecentriq (atezolizumab). Data from the IMvigor210 and IMvigor211 trials showed improved overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) in patients using antihistamines. The study found a significant reduction in cancer-specific and all-cause mortality risks among these patients. Despite limitations, the findings suggest a potential benefit of antihistamines in conjunction with immunotherapy, warranting further investigation.

Antihistamines may be associated with survival improvement in patients with metastatic urothelial carcinoma receiving Tecentriq.

CURE staff

Utilizing AI in Prostate Cancer Care and Management

A Unicorn Among Us

Rapid Developments to Enhance Patient Experience in GU Cancer

Additive Antihistamines May Improve Metastatic Bladder Cancer Outcomes

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