Plenary Session: Are we advancing in GU cancer staging?
Led by esteemed Chairs Prof. Morgan Rouprêt (FR) and Dr. Jochen Walz (FR), day one of EAU24 started with the Plenary Session “Controversies in GU cancer staging: Is it only imaging?”. Experts from various medical fields shared valuable insights and lively discussion on staging for prostate cancer (PCa), kidney cancer (RCC) and bladder cancer (BCa). This article highlights PCa disease characterisation, a debate on how to treat a PSMA M1a positive patient, PSMA PET standardisation, and the ‘Oncidium Initiative’ for radiotheranostics cancer care.
Molecular imaging, and biomarkers
“PSMA PET is the best imaging test available. There are challenges, but these can be addressed by training and more data”, stated Dr. Ken Herrmann (DE) in his lecture “Advantages and pitfalls of molecular imaging”. He address the following pitfalls: an increased frequency of unspecific bone uptake, inter-tracer differences in the rate of false positive lesions, current treatment recommendations are based on conventional imaging findings, and the efforts to translate PET/CT findings to clinical outcomes.
According to Dr. Herrmann, it is important to implement PSMA PET in all future clinical trials. Current trials include PRIMORDIUM and ARASTEP. The next step is the need for standardisation to secure the long-term success of PSMA PET, which is the aim of SPARC” (see more details below).
Dr. Brian Chapin (US) took a deep dive into the question ‘Can biomarkers provide added value’? He emphasised that sceptical optimism is appropriate until active trials are complete and stressed the importance to acknowledge the difference between prognostic vs predictive biomarkers.
Dr. Chapin: “Prospective trials with a generation of biobanks are necessary to validate current biomarkers, to test new biomarkers for prognostic risk stratification, and to prospectively assess predictive biomarkers with defined therapeutic benefit.”
Treatment planning: PSMA M1a positive disease
In his lecture “Treat as M0”, Prof. Henk Van Der Poel (NL) firstly defined M1a prostate cancer (PCa) disease as the presence of non-regional lymph nodes (LNs) above the bifurcation of the common iliac arteries without other metastases (TNM classification).
According to Prof. Van Der Poel, the current EAU guidelines strongly recommend offering a combined systemic + local therapy approach with ADT + non-curative prostate radiotherapy for patients with M1a disease, but he suggests that patients with PSMA-detected M1a disease should be considered differently as these recommendations are based on evidence from the pre-PSMA-PET/CT era.
Prof. Van Der Poel: “M1a PCa is an understudied and heterogenous disease that is getting more common (40%) and is increasingly being found at lower disease volumes with PSMA PET.” In his opinion, patients of the disease are not benefiting from more systemic therapy (PEACE-1) and are amenable to non-systemic treatment options such as RT (radiotherapy) and MDT (metastasis-directed therapies).
Contrary to the above viewpoints, the lecture from Prof. Christopher Sweeney (AU) showcased his advocacy for the “Treat as M1” approach and stated that patients with de novo PSMA-detected M1a should be treated as M1 with ADT + ARSI (androgen receptor pathway inhibitor).
He suggested the PSMA-PET-CT scan is more precise for initial staging, but a bridging study is required to define the cut-off points from a PSMA-PET-CT to determine which PSMA-PET M1a disease benefits from triplet therapy of AFT + ARSI with addition of radiation to the prostate or addition of docetaxel. “When cut-off points are determined we will know the best personalised treatment plan”.
PSMA PET analysis and reporting
In his lecture “SPARC: Standardised PSMA PET analysis and reporting consensus”, Prof. Anders Bjartell (SE) emphasised the importance of having clear and standardised communication between nuclear medicine and clinicians.
Prof. Bjartell: “The SPARC project (previously COPRA) intends to initiate the process to combine classifications and recommendations under one unifying umbrella to establish a living framework of PSMA PET reporting.”
Taking a multidisciplinary approach, the SPARC panel includes experts in nuclear medicine, oncology, radiology, urology, and research, making up five working groups. According to Prof. Bjartell, the project aims to deliver additional standardisation of PSMA reporting, consensus on reporting, evaluation of response to treatment and further understanding of PSMA expression vs therapy.
Access to radiotheranostics
Dr. Alice Viana (BE) shared details on the “Oncidium Initiative”, a foundation developed to support, promote, and accelerate the development and access of radiotheranostics for cancer care worldwide. With more than 600 centres already participating in this initiative, she encouraged the audience to join this initiative and its bold ambition of saving 356 lives within the next five years. There are multiple projects running including educational publications, the NOBLE registry, and RLT-CONNECT (building digital bridges for patients in financial need.)
To (re)watch the full presentations during this Plenary Session, please visit the EAU24 Resource Centre.