The role of novel imaging and the treatment options for metastatic hormone-sensitive prostate cancer (mHSPC) were some of the topics explored today during Plenary session 5: Treatment for metastatic hormone-sensitive prostate cancer. The session was led and moderated live by internationally-known experts Prof. Alberto Briganti (IT), Prof. Dr. Karim Fizazi (FR), Prof. Silke Gillessen Sommer (CH), and Prof. Arnauld Villers (FR).
Prof. Declan Murphy (AU) launched the session with this scenario: Your friend, the English singer and songwriter Dua Lipa has invited you and your partner for dinner at her new address. How are you going to find your way? Through animation, he used the A-Z Atlas and Guide to London and Google Maps as the analogy to conventional scans and novel imaging, respectively. Then he asked, “Are you going to rely on conventional navigation to make decisions about your route? Or should you embrace novel navigation which offers more accuracy with less equivocation, plus the convenience of a smart device?”
In his State-of-the-art lecture “De novo versus recurrent metastatic mHSPC: What is the role of modern imaging?”, he emphasised that the accuracy of prostate-specific membrane antigen (PSMA) positron emission tomography and computed tomography (PET/CT) is superior than conventional imaging in the de novo setting.
Citing the 2017 proPSMA study that he co-authored, Prof. Murphy said that the trial reported PSMA PET/CT correctly staged 92% of the patients, while conventional imaging such as CT and bone scan (BS) only had a 65% accuracy. He stated, “The management impact was profound with PSMA PET/CT leading to management change in more than a quarter of the patients. Conventional scans had more equivocal findings (23%) than PSMA PET/CT scans (7%). Radiation dose was less than half in PSMA PET/CET compared to CT and BS. Additionally, the PSMA PET/CT has the convenience of a quick one-stop scan.”
According to Prof. Murphy, the United States Food and Drug Administration (FDA) recently approved the first and second PSMA-targeted PET-imaging drug for men with prostate cancer (PCa) in both primary and recurrent settings. He also cited systematic reviews which reported that PSMA PET/CT can identify PCa even at very low PSA levels. Therefore, the current EAU Guidelines support PSMA PET/CT for biochemical recurrence at a level of 0.2 ng/mL and above.
The caveat is that novel imaging is a disruptive technology which comes with uncertainties and poses new research questions. Nevertheless, Prof. Murphy encouraged EAU21 participants to embrace novel imaging and better accuracy, and make better decisions to improve patient outcomes. He concluded, “Sure, let’s do more trials along the way but the direction of travel is now very clear. Novel imaging using PSMA PET/CT is here to stay.”
On recurrent mHSPCa
Plenary session 5 also examined the treatment options for recurrent mHSPCa in a segment comprised of three presentations on systemic treatments, radiation therapy and surgery, then concluded with a case discussion on a patient with oligometastatic disease.
In his lecture entitled “Systemic treatments: When and how?”, Prof. Christopher Sweeney (US) said that there is evidence to support the hypothesis that men with mHSPCa have a wide array of prognoses, which can be easily defined by clinical variables. “The next steps are to refine definitions, and to incorporate PSMA PET imaging. I do believe that these variables impact the efficacy of different treatment strategies. We need to collate all data as part of the Systemic Treatment Options for Cancer of the Prostate (STOPCAP) individual patient data. There are broad, distinct, and underlying biological profiles which we need to find by harmonizing analyses from all mHSPC trials,” said Prof. Sweeney.
Assoc. Prof. Pierre Blanchard (FR) presented the following lecture “The role of imaging-guided treatments: Radiotherapy” wherein he said “There is low level of evidence for metastases-directed therapy (MDT) in oligometastatic recurrent PCa setting, although MDT is widely used. Randomised trials and inclusion of patients in those trials are important to demonstrate the magnitude of the benefits. It is clearly an avenue for large-scale, prospective meta-analyses.”
According to Prof. Dr. Tobias Maurer (DE), salvage lymph node dissection (LND) and MDT are still outside the current Guidelines recommendations. During his presentation “The role of imaging-guided treatments: Surgery”, he said “We should only consider MDT on an individual basis. PSMA PET is the most accurate imaging modality currently available and plays a major role. In my opinion, based on molecular imaging results, we now have several treatment options for patients with biochemical recurrence. Aside from local salvage options or watchful waiting, and in case of systemic progression treatment, salvage LND or salvage radiotherapy or even combination treatment might represent a valid therapeutic option.”
Access and/or review all Plenary Session 5 presentations and case discussions in full. Visit and explore the On Demand feature on the EAU21 Virtual Platform.