Detecting high-risk prostate cancer remains a tough challenge for clinicians, but with advances in imaging and the recent results of large multi-centre studies on prostate cancer detection physicians are now better equipped to identify aggressive disease and an optimal treatment plan.
“With the recently published data from the PROMIS and PRECISION trial it is clear that multiparametric MRI (mpMRI)-guided biopsies are superior to systematic biopsies. First, when using mpMRI as a stratification tool pre-biopsy, about one in four men will avoid unnecessary biopsies,” said Prof. Wouter Everaerts (BE), speaker and faculty member at the upcoming second EAU Update on Prostate Cancer (PCa18) to be held in Milan on September 15 and 16.
Everaerts will speak on the opening day of the meeting during the session on ‘Updates in Diagnosis and Staging’, tackling the issue of prostate biopsy options. Doctors often faced the dilemma which biopsy tools to use, whether systematic biopsy or targeted, or both, to avoid complications from invasive procedures.
“MRI-targeted biopsies detect more clinically significant prostate cancer, while reducing the over-detection of insignificant prostate cancer. Finally, fusion biopsies mean less complications than systemic biopsies,” explained Everaerts who specialise in uro-oncology and robotic surgery at UZ Leuven in Belgium.
There is, however, a caveat in combined biopsies, according to Everaerts, as he noted that the benefits from newer techniques must be carefully balanced with concerns regarding over-detection.
“Adding systemic biopsies to MRI-targeted biopsies can increase the detection rate of clinically significant cancers; however, the added value of combined biopsies is not very pronounced, and strongly depends on the definition of clinically significant cancer and comes at the cost of increased (over)detection of insignificant tumors,” he pointed out. “Thus, targeted biopsies, similar to all other solid organ cancers, is for me the preferential initial approach in men with a suspicion of prostate cancer. Systemic biopsies should be reserved for patients with contra-indications for MRI and/or those with red flags despite a previous negative targeted biopsies.
Pitfalls of random biopsies
With recent outcomes from large studies such as the PRECISION trial and incremental progress in genomic markers, Everaerts noted such developments further reinforce the message that doctors should exercise due caution with regards blind and random biopsies.
“The most important message from the different trials, using either pre-biopsy MRI or genomic markers is that we should avoid going straight to blind random biopsies in asymptomatic men with an elevated PSA. Both MRI and genomic tests can improve our risk-stratification and avoid unnecessary biopsies in a subset of these patients,” he said.
Moreover, according to Everaerts, pre-biopsy MRI has now become standard of care to guide subsequent biopsies.
“Concerning treatment strategies, these tests can help us to better risk stratify patients that are suitable for active surveillance. EAU guidelines strongly recommend the use of MRI before confirmatory biopsies in patients on active surveillance and the PRECISION trial enforces this recommendation,” he said.
Among the issues confronting attending physicians and specialist is how to improve their skills in classifying patients into various risk groups. During the PCa18 meeting in Milan, Everaerts said participants will get a comprehensive update on the current standard and future development of diagnostic tools to risk-stratify patients with localised and metastatic prostate cancer and how to implement these in treatment decisions.
Everaerts: “The biggest challenge for urologists remains to better stratify prostate cancer patients and selecting the best therapeutic approach for the individual patient.”
He also noted that an aspect of urology that is underappreciated is the actual process of shared decision-making and patient counselling. “These issues are important particularly with regards patients’ individual concerns and preferences. How to discuss uncertainties about oncological benefit and potential side effects and their impact on quality of life are equally relevant matters,” said Everaerts.
Highly interactive programme
Faculty members will directly interact with participants in small breakout session groups to facilitate a point-by-point discussion and exchange of views, making the PCa18 Update series a unique educational event.
“PCa18 is a time-effective way to get comprehensive update in recent prostate cancer developments. The multidisciplinary approach, with case-based discussions will facilitate the implementation of these new scientific insights into our daily practice,” said Everaerts.
Core topics in the agenda will include update on local treatment, management of systemic disease, best practices in surgery, and assessment of insights from results of new research. Pre- and post-testing of all participants will also be conducted to enable both participants and organisers to identify areas for further learning.
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