PCa18: Dilemmas in managing metastatic prostate cancer

15 September 2018

The optimal management for prostate cancer patients with systemic, progressive disease was discussed in one of the breakout sessions, with A. Merseburger (DE) and P. Cornford (GB) examining various issues in treating hormone-naïve metastatic cancer patients and some of the controversies encountered by many clinicians.

Using a case involving an elderly man (Gleason 8 (4+4), PSA 82 ng/ml, cT3 N1/bone scan), M1 (high volume), Merseburger explored treatment issues involving hormone-naïve metastatic disease. In the interactive voting, majority of the participants or 53% chose chemotherapy plus androgen deprivation therapy (ADT) as the primary treatment, favoring this strategy over other options such as antiandrogen alone, GnRH antagonist, antiandrogen + GnRH agonist (CAB), among others.

“This is truly a case of systemic therapy,” noted Merseburger as he referred to the EAU Guidelines which strongly recommends that in M1 asymptomatic patients, immediate systemic treatment should be offered to improve survival, defer progression to a symptomatic stage and prevent serious disease progression-related complications.

To the question which patients are most suitable for ADT, Merseburger said these include clinically localized disease, N1 PCa (standard of care), locally advanced and metastatic PCa.

“With regards metastatic hormone-senstitive prostate cancer (mHSPC), choose wisely, docetaxel or abiraterone,” said Merseburger. “But do remember that ADT is the backbone of all the aforementioned.”

He also urged participants to use the EAU Guidelines for evidence-based decisions and take into account upcoming changes in the coming year.

Cornford look into some of the controversies in treating mHSPC and examined issues in early treatment, low volume disease, the effect of imaging on diagnosis, assessing combination treatments.

In his concluding remarks he said: “There is no doubt that men presenting with metastatic disease benefit from combination therapy,” adding that there is no evidence that abiraterone is better than docetaxel (with choice likely to be driven by cost, patient preference and length of treatment).

He also said that there is insufficient evidence to support treatment for patients with high-risk M0 HSPC. “Furthermore, there is no data to suggest role for men progressing after local treatment,” according to Cornford.