Treatment dilemmas in managing locally advanced prostate cancer (PCa) is one of the most problematic cases in PCa management, but thanks to new screening and diagnostic imaging tools specialists today are better equipped to meet some of these challenges head-on.
At the upcoming and second edition of the EAU Update on Prostate Cancer (PCa18) to be held in Milan on September 15 and 16, cancer experts are presenting a compact and comprehensive interactive course to inform specialists of the best practices and most optimal therapeutic options for patients with advanced disease.
In a session on local treatment for PCa, expert speaker and faculty member Prof. Dr. Axel Heidenreich (DE) will speak on salvage local treatment to highlight issues that pose a tough challenge to many doctors.
One of the key issues that Heidenreich, director of the Urology Clinic at the Universitätsklinikum in Cologne (DE), will examine is the aim of curative local therapy in organ confined and locally advanced PCa following primary radiation therapy.
“Too few patients are subjected to a second local therapy with curative intent because of the fear of too many that radical salvage prostatectomy is associated with many complications. However, more than 90% only receive palliative androgen deprivation therapy,” Heidenreich pointed out. “Another message is that this type of surgery should be done at reference centres only.”
With expertise and a high success rate for these type of operations making a crucial difference, due caution is not necessarily a handicap in certain cases. In other cases, however, a well-thought out treatment plan can mean appropriate intervention.
Heidenreich said in patients with oligometastatic disease, there are still options that physicians can carefully look into. “Oligometastatic disease exists and that even patients with low volume lymph node metastases will benefit from salvage surgery or salvage radiation therapy,” he said.
Point-by-point case discussions
Participants to PCa18 can also look forward to a comprehensive update on key developments and the role of best practices in decision-making. In salvage local treatment, Heidenreich said the emergence of sophisticated imaging such as PSMA-PET/CT has made a clear impact on how doctors select the patients suited for local treatment.
“The key developments took place in the selection process of patients: every patient should undergo a multi-parametric MRI of the prostate and a PSMA-PET/CT scan in order to identify the extent of locally relapsing disease and to rule out lymph node or even systemic metastases,” he explained.
Furthermore, Heidenreich said that in patients with biochemical relapse following radical prostatectomy, “… PSMA-PET/CT is a key development with the possibility to identifying patients with oligometastatic lymph node disease amenable to local surgery/radiation.”
This option is crucial since it underscores the vital role that modern imaging plays in identifying the most suitable patients, enabling doctors to intervene at an opportune time.
Asked what in his view are the biggest challenges for urologists, and the role of focused educational meetings such as PCa18 in dealing with these challenges, Heidenreich said:
“ Some of the biggest challenges are in the areas of low-risk disease such as ideal patient selection, ideal treatment which can either be active surveillance, active or focal therapy. Another area of discussion is biochemical relapse after local therapy, such as the role of salvage surgery; and finally, the issue of metastatic hormone-naive PCa, what options to choose— ADT versus ADT plus abiraterone versus ADT plus docetaxel,” he added.
He also reiterated that often many urologists and prostate cancer experts struggle in the management of the primary tumour. “Treatment of the primary in the setting of locally advanced PCA, metastatic hormone-naive and castration PCA is often overlooked, as it is the case with the multimodality management of oligometastatic disease.”
As a compact, in-depth update meeting with many opportunities for participants to directly confer with experts and learn new insights in managing difficult cases, Heidenreich said a dedicated update meeting such as PCa18 has added value in bringing together experts for a critical assessment.
“One of the gains from this meeting is that we can learn more about the benefits of multimodality treatment and interdisciplinary approaches, enabling specialists to consider options that can provide a more optimal treatment,” he said.