Profiles in GU Oncology: Preston C. Sprenkle, MD

Preston C. Sprenkle, MD, is associate Professor, Urology, at the Yale School of Medicine in New Haven, CT. He also serves as Director of the Urology Research Fellowship and Urologic Oncology Clinical Fellowship Programs at Yale, as well as Chief of the Division of Urology at the associated VA Connecticut Healthcare System in West Haven, CT. “I’m a urologist who focuses on surgical oncology,” Dr Sprenkle explains. “I see patients clinically, then operate on them and manage them both medically and surgically.”

Dr Sprenkle’s clinical practice and research are focused on prostate cancer, although he also manages patients with kidney cancer, testicular cancer, and bladder cancer. He is well known for his interest in new imaging technologies to improve the diagnosis and treatment of prostate cancer and for pioneering focal ablation therapy, in which the prostate lesion is treated rather than the whole organ, avoiding treatment-related adverse effects such as urinary incontinence and erectile dysfunction associated with radical prostatectomy and toxicities from radiation therapy.

Although Dr Sprenkle decided to specialize in surgery quite early during medical school, that was not his original preference when he was considering his career options. Growing up in Seattle, WA, he was interested in medicine, influenced by his father who was an allergist/ immunologist, and he did his prerequisites for medical school. His major at Stanford University was evolutionary biology and ecology, however. “My general interests were in how we co-evolve with our environment and the environmental factors that influence human development and evolution,” he admits.

So after graduating from Stanford in 1998 with a BA in human biology, Dr Sprenkle did not immediately enter medical school. After reviewing a variety of possible career paths, he joined a health care management consulting firm in San Francisco. He recalls how his boss, health systems expert Molly Coye, MD, MPH, was influential in showing him how to integrate a medical education with solving problems by being involved in trying to improve the quality of people’s lives.

“I didn’t think I would ever leave California, but in 2004 I had the opportunity to go to Columbia University and it seemed like a great opportunity to jump coasts for a little while,” he says. He planned to return to the West Coast after four years, but he met his future wife in medical school, and they have been together in the Northeast ever since. (His wife practices as a gynecologist.)

Before he decided on his specialty, Dr Sprenkle was not inclined toward urology or surgery. “I thought that given my interest in the environment and travel, I would probably go into something like international health, so potentially tropical medicine or infectious diseases,” he says. (“I was very young,” he adds, laughing at the recollection.) “But we had a great semester-long anatomy lab, and once I got into that and started learning about the human body and more about surgery, it became very clear that surgery was what I wanted to do,” he recalls. “I thought that pelvic anatomy was especially intriguing, and obstetrics/gynecology and urology both seemed very challenging, the anatomy was complex, and the surgeries were difficult but rewarding. We were able to achieve a lot of benefit for patients with the surgical interventions.”

Beginnings in Urology

After medical school and opting for urology, Dr Sprenkle stayed at Columbia for his residency, where he had “great training” with many internationally recognized urologists, including Carl Olsson, MD, Chief Emeritus, Mitchell Benson, MD, then Chief of Urology at New York Presbyterian Hospital Columbia Campus, and James McKiernan, MD, who is the current Chief of Urology at Columbia. “Dr McKiernan is still a fantastic mentor and role model,” Dr Sprenkle enthuses. “He was very supportive in helping me understand which subspecialties and what areas of urology I wanted to be in.”

During his fellowship in urologic oncology at Memorial Sloan Kettering Cancer Center, Dr Sprenkle did bench research for a year. “It was a great experience, because I worked in the lab of James P. Allison, PhD, then director of the Ludwig Center for Cancer Immunotherapy,” Dr Sprenkle recalls. Dr Allison subsequently moved to The University of Texas MD Anderson Cancer Center in Houston, where he shared the 2018 Nobel Prize in Physiology or Medicine “for the discovery of cancer therapy by inhibition of negative immune regulation.”

“When I was working in his lab, I was investigating immunological markers to identify prostate and other cancers and their response to immunologic manipulation.” Dr Sprenkle recalls fondly the awe-inspiring discussions of his lab partners during the lab meetings and the continued relevance of the work for current practice. Following his year in the lab, Dr. Sprenkle was fortunate to train under many of the current thought leaders in urologic oncology, whose instruction and approach to oncology continue to guide much of his practice.

Dr Sprenkle has been at Yale School of Medicine since 2012. A typical week now consists of two days spent at Yale, and 3 days a week at the VA hospital. “My time is probably 90% clinical, with patients in clinic and in the operating room,” he explains. He uses about one day every other week for research and administrative work, which includes working with residents and fellows to ask and answer clinical research questions in urology, acting as Oncology co-chair of the Cancer Liaison Committee of the VA Connecticut Healthcare System, and as vice-chair of the National Comprehensive Cancer Network (NCCN) Panel that issues its clinical practice guideline on early detection of prostate cancer (most recently version 1.2022, issued February 16).¹

Discussing Prostate Cancer Guidelines

“The panel tries very hard to bring forward published evidence to support any changes in the guideline or recommendations,” he remarks. “One that we recently shepherded through was the use of multiparametric magnetic resonance imaging (mpMRI) prior to biopsy, which is now considered standard of care where available,” he notes. The panel has not yet reached consensus about screening, he admits. “I’m not going to mince any words there; I think it’s appropriate, but not for everyone,” he states. “Having a single test for any man over the age of 40 can really help stratify who should be followed more closely versus who doesn’t need that.”

Dr Sprenkle also believes that the current guideline cutoff age for screening, 75 years, is inappropriate. Realistically, men who were over 75 years in studies done 10 or 15 years ago were not as healthy as men who are over 75 today, who currently have an average life expectancy approaching 15 years, he points out. “I think one of the points we’ll be discussing at our next meeting will be whether we should get rid of age-cutoff altogether and really emphasize the concept of a 10-year life expectancy,” he predicts. That is what really matters, he says, because prostate cancer is very unlikely to lead to death or morbidity within 10 years after diagnosis.

Most prostate cancer guidelines, including those of NCCN and the American Urological Association (AUA), stress the importance of shared decision making, he notes. “I think it’s appropriate for prostate cancer screening and prostate-specific antigen (PSA) testing, because it’s very important that patients understand the risks and benefits before ‘getting on the PSA train,’” he says. Primary care providers could explain this, “but they don’t, because they don’t have the time or the detailed understanding of what’s going on,” and not even many urologists do it, he maintains. “One of the projects at Yale that I’m proud to be participating in is the development of care pathways and guidelines for primary care physicians about who should be having a PSA test and the type of language they should use with patients when discussing PSA testing,” he says. “I am interested in trying to make more patient-facing content for education about the complex decisions regarding PSA screening.”

Work in Prostate Ablation Therapy

His main current clinical interest, and topic for patient education, is prostate ablation therapy. It is a relatively new technology and not a lot of urologists are aware of the latest developments and the options available, he believes. “I am very interested in how we can utilize technology to improve the patient experience and maximize their quality of life while maintaining appropriate cancer care. Getting rid of all of the cancer is our goal, but that’s very hard to do, and even when we give it our best try with conventional treatments, we’re not always successful,” he says.

The appeal of many ablation technologies is that it is possible to treat the cancer area in a more precise manner: so with minimal damage to the nerves related to sexual function, preservation of the urethra and surrounding structures, and with minimal changes in urinary continence. “A drawback is that if you are not doing it as radical a treatment, you’re probably not going to have as good cancer control,” Dr Sprenkle admits. “But many men don’t need to have their cancer controlled so well. If it’s a small improvement in cancer control, with a big improvement in treatment-related side effects, we can repeat those treatments if the cancer recurs with a similar side effect profile,” he points out.

Ablative therapy is not for everyone, he stresses. “but for some patients, it is a great option and an increasing numbers of patients and physicians and urologists are embracing it.” The biggest impediment has been an acceptance of the importance of the quality of life and the balance between quality of life and cancer control, he notes. “For the longest time, we accepted that we had to do the big cancer control and that to compromise this was doing the patient a disservice. [Ablation therapy] is changing the playing field, because we can get 80% cancer control or higher and have minimal impact on quality of life.”

As evidence of patients’ attitudes to this, Dr Sprenkle cites the COMPARE (COMparing treatment options for ProstAte cancer) study (NCT01177865), which surveyed patients with localized prostate cancer in 34 urology departments in the UK, and found that patients at all risk levels were willing to trade cancer-specific survival for a better chance of retaining urinary continence and erectile function.² “That was an interesting study that really drives home the point that this is what patients want and that having these options is very important to them,” he says. “I spend most of my clinic days having long talks with patients about all their options, and I am trying to put some of the talking points and information on our web site, because I think the education component for patients is largely missing.”

Research in ablation therapy is a very exciting area to be involved in, he adds. New technologies are being evaluated at Yale, including, currently the TULSA (Transurethral Ultrasound Ablation) procedure (Profound Medical), which combines real-time MRI with robotically driven directional thermal ultrasound to deliver precise, customized ablation of whole-gland or partial prostate tissue. It is being compared with radical prostatectomy in the CAPTAIN trial (NCT05027477). Dr Sprenkle is looking forward to additional clinical trials with other new technologies starting in the next few years.

Linda Brookes, MSc is a freelance medical writer/editor based in New York and London.

References

1. Moses KA, chair, Sprenkle PC, vice chair; NCCN Prostate Cancer Early Detection Panel. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Prostate cancer early detection, version 1.2022 – February 16, 2022. National Comprehensive Cancer Network; 2022. Accessed August 25, 2022. https://www.nccn.org/guidelines/category_2
2. Watson V, McCartan N, Krucien N, et al. Evaluating the trade-offs men with localized prostate cancer make between the risks and benefits of treatments: The COMPARE study. J Urol. 2020;204:273-280.