PCa: Debates, PROMIS and heredity at fifth plenary session

On the fourth day of EAU17, delegates could once again spend a whole morning on a key urological topic. Following earlier plenary sessions on andrology, bladder cancer and BPE, Plenary Session 5 extensively covered the screening, early detection and optimal treatment of localized prostate cancer.

The session featured five separate debates and closed with Dr. Pat Walsh’s (USA) state-of-the-art lecture and a ‘late breaking news’ presentation by Prof. Claus Roehrborn (USA) on the impact of dutasteride/tamsulosin combination therapy on sexual function.

PROMIS-ing results?

One of the key debates was between Mr. Hashim Ahmed (GB) and Dr. Jochen Walz (FR), on the results of the PROMIS study. The study was designed to assess the ability of multi-parametric prostate MRI prior to first biopsy in order to: identify men who can safely avoid unnecessary biopsy; reduce over-diagnosis of clinically insignificant cancer; and improve the detection of clinically significant cancer.

Mr. Ahmed presented the details of the study, including some limitations of multi-parametric MRI and especially the factor of costs. He nevertheless concluded with strong recommendations for the use of MP-MRI prior to biopsy:

“MP-MRI can identify at least one quarter of men presenting with an elevated PSA who might safely avoid prostate biopsies. It can also reduce the over-diagnosis of clinically insignificant prostate cancer, and still identify over 90% of men with clinically significant prostate cancers. An MP-MRI strategy is clinically effective as well as cost-effective, and should now be the new standard of care before a first biopsy.”

Tasked with providing some criticism to the recently published results of the PROMIS study, Walz focused on the definitions used in the study, as well as the quality control checks for MRI scanners.

Walz extensively quoted Ahmed’s article in his presentation, pointing out some drawbacks and arriving at the following conclusions: “PROMIS works as advertised if: you do not expect to find every millimeter of significant disease; if you accept that results depend on your definition of clinical significance; and if you quality assure ever scanner, optimize the sequences iteratively, quality control scans and have robust training for radiologists.”

Heredity and PCa: a thirty-year journey

One person who thoroughly enjoyed the PROMIS debate and EAU17 in general was Dr. Pat Walsh. “Mr. Ahmed seemed to say the paper in the Lancet was great, but Walz’s analysis was excellent, pointing out several holes in their conclusions. He was very objective, there was nothing personal about it.”

Walsh was awarded an Honorary EAU Membership on Friday evening, during the opening ceremony. Surprisingly, this also marked Walsh’s first visit to an Annual Congress.  “So far it’s been a very good meeting. This morning was an excellent example of really great talks with analysis and true experts being able to have detailed discussions.”

“To be honest, I don’t attend many meetings or congresses any more. Some people travel so much that when they come back to the lab they say “What did I discover while I was gone?” I like to help my patients and make discoveries, I can’t do that on an airplane. I’ve operated on 4569 patients, my hands need to be in Baltimore. Meetings are great and there are a lot of interesting themes at the congress, but I suppose I’m just not a meeting guy.”

Walsh gave a state-of-the-art lecture on heredity and prostate cancer, and was introduced with great respect and affection by Prof. Manfred Wirth (DE), who recalled Walsh’s groundbreaking demonstration of nerve-sparing radical prostatectomy at the 1982 AUA Congress. Walsh’s complete presentation at Plenary Session 5 can be read in article form here.

Asked about the future of his research, Walsh was honest and hopeful. “We don’t know. I’ve been in field for 30 years and it’s been difficult, finding these genes. We’re going to have to see where the field goes. There has to be an answer there. I’m expecting we’re going to make a breakthrough.”