Preston Sprenkle, MD, is an associate professor of urology at the Yale School of Medicine and chief of the Division of Urology at the Veterans Affairs (VA) Connecticut Healthcare System. An expert in the treatment of urologic cancers, Dr. Sprenkle has pioneered the use of the Artemis Device—a 3-dimensional imaging technology for diagnosing cancerous tumors in the prostate—as well as focal therapy in prostate cancer.
GU Oncology Now spoke with Dr. Sprenkle on his inspiration to practice urologic oncology, his role in the widespread use of the Artemis Device and focal therapy, and the efforts he oversees to make prostate cancer educational materials available to his patients outside of the hospital.
Why did you become a urologic cancer specialist? What was your inspiration?
Dr. Sprenkle: Urologic oncology initially interested me because of the many really challenging surgeries it involves.
From a career standpoint, working in oncologic surgery provides significant benefit to most patients in terms of controlling their cancer. For example, in kidney cancer, a surgery to remove the kidney tumor can be curative. In the vast majority of people, that is the only treatment they’ll ever need.
Other surgeries for bladder cancer significantly improve survival. Interestingly, there’s also a fair bit of reconstruction. When talking about bladder cancer treatments and removing the bladder, there are surgical techniques used to create a new bladder out of intestine. The process of reshaping something into a new function to help recover or maintain urinary function is creative and rewarding.
Also, I chose oncology because there is no shortage of research happening in this discipline to advance the field. There’s a tremendous number of new medications, interventions, and technologies being introduced and evaluated to improve patient outcomes. It is an exciting, always-changing area. I was also interested in staying in academia and being able to teach while doing research and being clinically active. There were a lot of opportunities within urologic oncology, and even subspecialties within urologic oncology, if desired.
By practicing urologic oncology, I was able to combine my interests in surgery, research, and the close personal relationships that you develop with patients as you manage them over a period of time. Urology is unique among many of the surgical specialties because you get to have a longitudinal relationship with many patients. In a lot of ways, we’re sort of a men’s health doctor; we’re able to develop longer-term relationships than some of the other surgical subspecialties, in which you’re really only called upon to address a particular issue. In those fields, once surgery is done, you do not necessarily see the patient again. In urology, it’s different, and I like that.
What is your official title, and how did you land where you are today?
Dr. Sprenkle: While my primary title at Yale is an associate professor of urology, I do wear several other hats and handle administrative functions within those roles. I am the chief of the section of urology at the VA Connecticut Healthcare System. I manage all of the other urologists and urology services at our VA hospital system. I am the director of our urologic oncology clinical fellowship. After someone finishes their residency, they can decide to do more training in urology. I manage and direct that fellowship. We also have a research fellowship, so I manage and direct that as well.
Furthermore, I am a vice-chair of the National Comprehensive Cancer Network Guidelines for Prostate Cancer Early Detection Panel. I had served on that committee for a few years before being selected as a vice-chair.
While not an official title, I direct Yale’s image-guided prostate cancer diagnosis and ablative treatment programs.
There are some other committees within the VA system, but these are administrative and leadership opportunities that have developed over time within my urology practice. All of this is done, of course, alongside being an active and busy clinician.
What is your most meaningful or impactful contribution to the field to date, and what do you have ongoing?
Dr. Sprenkle: A theme that bears out in my different interests and programs is my passion for helping men, or to really nail it down, accurately and effectively diagnosing and managing prostate cancer with the least impact on a man’s quality of life. It seems like a simple statement, but all of my work touches on that.
My work started with the Artemis Device. Initially, we were trying to evaluate how to make a prostate biopsy more accurate, which we did by obtaining magnetic resonance imaging (MRI) to identify areas in the prostate suspicious for prostate cancer and then utilizing the Artemis software-fusion device to perform targeted biopsies of the suspicious areas. This combined “fusion” biopsy increased the detection of clinically significant cancers and gave us more confidence that a negative biopsy truly indicated the absence of prostate cancer, allowing for both more personalized and more accurate risk-stratified management. Now, after several years of experience and collecting data, some men with appropriately low clinical risk and a negative MRI can avoid prostate biopsy all together.
Over time, we have begun exploring these questions: How do we improve our risk stratification using MRI-targeted biopsies and integrating genomic testing? How do we integrate that to give a man the most accurate risk stratification so that if he doesn’t need treatment, he can avoid it for as long as possible?
Today, I am heavily involved in, and excited about, subtotal therapies. Other names for this are focal therapies and ablation therapies. In short, these are ways of treating prostate cancer with some form of destructive energy (heat, cold, or electricity) that effectively controls the cancer while minimizing the quality-of-life side effects. The goal is to have as little negative impact on the patient’s sexual function, urinary function, and bowel function as possible while obtaining good oncologic control.
There are many new technologies within the ablation space that are trying to effectively treat prostate cancer while minimizing those side effects. Some of these are being examined in the early stages of clinical trials and have excellent potential to make an impact in the next 3 to 5 years. One technology that we are currently utilizing in clinical trials is transurethral ultrasound ablation (TULSA). This technology uses high-intensity focused ultrasound from a transurethral applicator to heat and destroy the prostate tissue while a computer monitors temperature in real time to adjust treatment using MRI thermometry. The early clinical experience demonstrates effective cancer control and excellent preservation of urinary continence and sexual function. We are currently enrolling men in the CAPTAIN randomized clinical trial comparing radical prostatectomy with TULSA ablation.
Can you tell me about your approach to interacting with and educating patients on their diagnoses and management options?
Dr. Sprenkle: When I speak with patients, I do so from the perspective of being their teacher. I’m there to educate them on all their options and help them figure out which is right for them. I’m certainly not the only urologist or urologic oncologist who does this, but I often get feedback that my approach is very helpful. Not every doctor has the time to do this, and not every doctor necessarily understands all the different options. Those are the sad truths.
I am blessed to have the skills and expertise to do ablations and surgeries, and I even work closely with radiation oncologists to do procedures with them. Though certainly not unique, I have a perspective that allows me to tell patients about all of their management options with first-hand knowledge and detail. I would estimate that most urologists or urologic oncologists do not; they tend to be more specialized or have expertise in a given treatment type.
Thus, a lot of information is not easily accessible for patients. To address this, I’m involved in a project that creates patient-facing educational materials about management choices and treatment options for prostate cancer. We’re hoping to promote the materials on the Yale website and make them available to everyone.
What will these patient-facing materials look like when they are complete? Will they be digital brochures or pamphlets?
Dr. Sprenkle: They will likely be digital-only. We recently posted a of couple of videos to our website about some of the ablation therapies and unique ways of approaching them. Most of this work will take the form of short videos—quick discussions about prostate cancer and the risks, focal ablation therapies, and whole prostate ablation therapies.
The main purpose of the materials is to talk through some of these options so patients can be relatively prepared before they walk through our doors. To be frank, it makes my life easier if patients have reviewed these materials before their initial visit. It can save me 45 minutes of laying out all the options, and they can have some idea already of what might be the appropriate strategy for them and ask more directed questions.
How are you directing patients to these materials? What other outreach do you have with patients before their initial visit?
Dr. Sprenkle: We interact with patients through our online portal before they are seen. We will often send them questionnaires and intake paperwork to fill out ahead of time. For patients who are appropriately identified, we provide them with a link they can use to learn about how to prepare for their visit, as well as some educational materials.
This practice is part of a larger effort to help people be good stewards of their health and to understand the questions they are facing. We are taught during fellowship that as soon as the word “cancer” is mentioned for the first time, most people only remember one additional thing you say. Being able to go back and listen to the information again is extremely helpful. We also find that it helps patients understand there are options beyond surgery and that surgery isn’t right for every patient. After hearing a diagnosis of prostate cancer, the reaction from many patients and spouses is “let’s get it out.” Surgery could be a great option for many people, but a lot of men don’t need surgery or any immediate treatment at all. They can defer treatment for potentially 10 to 15 years. Or maybe they are better suited for radiation treatment or ablation therapies.
Education and understanding, especially when it comes to cancer, is an iterative process. It is not completed during one visit. You cannot expect patients to understand everything right away. Even physicians who receive a medical diagnosis go to see a doctor and get educational materials. At the end of the day, the resources we’ve begun promoting and continue to create, along with our patient outreach before the initial visit, aim to make patients more comfortable with their options and their own decision-making.