Thinking outside the current staging categories

Prof. Wolfgang Fendler wins the 2021 EAU Prostate Cancer Research Award

By Juul Seesing

The findings of his and his co-authors’ study have the potential to drastically impact the disease burden categorisation of non-metastatic castration-resistant prostate cancer (nmCRPC) patients. “The diagnostic landscape of prostate cancer has undergone rapid change with the introduction of next-generation molecular imaging,” Prof. Wolfgang Fendler (Essen, DE) says. “Prostate-specific membrane antigen positron emission tomography (PSMA PET) spearheaded this development by demonstrating high-level evidence for superior accuracy in the settings of primary staging and biochemical recurrence. As a next step, we assessed the diagnostic accuracy of PSMA PET in patients with high-risk castration-resistant prostate cancer, non-metastatic by conventional imaging.”

The results won Prof. Fendler the 2021 EAU Prostate Cancer Research Award for the paper “Prostate-Specific Membrane Antigen Ligand Positron Emission Tomography in Men with Nonmetastatic Castration-Resistant Prostate Cancer”, originally published in Clinical Cancer Research in September 2019. The award is given annually for the best paper published on clinical or experimental studies in the field of prostate cancer.

Using PSMA PET, Prof. Fendler and his colleagues found metastatic disease in more than 50% of the 200 patients who participated in the study, again, while all these patients had been considered non-metastatic by conventional imaging. “Our findings have been confirmed in several subsequent studies. In the meantime, we have gathered more and more information on diagnostics, imaging, and how to describe different stages. The next step is to bring this to a level of clinical relevance; how can we use the higher accuracy of PSMA PET to guide treatments for prostate cancer to improve the patient outcomes?”

Nuclear medicine
Prof. Fendler won the EAU Prostate Cancer Research Award as a physician researcher working in the field of nuclear medicine, which made him feel even more honoured. “The award was given for a project focussed on nuclear medical imaging. Although this is highly relevant for prostate cancer and urology in general, I still see it as something very special to be acknowledged in this way, also because it comes from an association that has had a motivating influence on my career. Seeing the very stringent, high-quality clinical work by the EAU to change the clinical practice for improved outcomes of prostate cancer patients was a great motivation for all of us. The value of PSMA PET imaging for treatment guidance should now be tested in future studies, eventually influencing the EAU Guidelines, thus changing the practice and, indeed, improving the outcomes for patients.”

No common labels anymore
Prof. Fendler describes himself as an “active researcher, always actively pursuing hypotheses.” “I don’t necessarily observe. I create ideas in new fields as we did with this project. I like to take new steps. Instead of having very practice-oriented questions, I like to ask new questions that haven’t been asked before and may be a bit provocative. With our findings of this study, for instance, we basically changed the name of the patient cohort we looked at. The fact that this so-called ‘non-metastatic’ cohort shifted to a higher, metastatic stage completely changes how to view and talk about these patients.”

Prof. Fendler comes across as determined; for instance, when asked about his career choices, he answers without a hint of doubt: “The field of nuclear medicine has always had my interest because of the technology and great methods for imaging and treatments with radionuclides that are available for many cancer entities.” Also when asked for a word of advice for fellow researchers, the words come to him easily:

“One of our motivations behind this publication was to think outside the established categories, to think outside the current boxes we all have designed. There’s always a different way of looking at patients. Only because current disease stages have been divided into several categories doesn’t mean this will still be helpful in the future. It will be helpful to not put patients in a common label like nmCRPC anymore but to really look at them individually. New technologies such as PSMA PET provide us with the possibility to have that much information about a patient to really individualise care by designing a treatment that will most likely fit that specific patient. In the end, this might improve the outcomes for patients and the survival rates.”