KM: Welcome to Vienna, welcome to the evening of the prostate cancer debate 2015. It is my pleasure to be here and to wrap up the most important findings, I would say, together with my colleagues here. To my left Maria de Santis, a medical oncologist from Vienna; Heather Payne, clinical oncologist from the United Kingdom, I got this right, and Frédéric Lecouvet, a radiologist from Brussels, Belgium, is that still true?
FL: Yes.
KM: Our discussion today revolved around new options for treatment of mCRPC and also management and many other small aspects. Probably we could start with new options now we probably have reached a plateau in introducing new drugs into the treatment of mCRPC. Today, January 2015, Maria, let’s start with that. What is… in general, what is our sequence in treating an mCRPC patient in asymptomatic, mildly symptomatic CRPC? What is your thinking?
MDS: I think the good thing nowadays is that we have several options in hand and that we can choose between oral treatment and chemotherapy and, in addition, also we have radium-223 in hand which is a nuclear medical agent. Oral treatments with abiraterone and enzalutamide, so we have positive trials for both drugs; chemotherapy, good old standard, and radium-223. It is not the easiest task to choose the right or wrong…
KM: The best.
MDS: Or the best option, of course. There are several possibilities to choose. We have symptomatic and asymptomatic patients and for symptomatic patients with more pain, heavy pain, then chemotherapy might be the first choice still. For other patients, mildly or asymptomatic, abiraterone or enzalutamide are the treatments of choice. In bone only disease there might also be a role for radium-223 in the first line. So right now we have the luxury of being able to offer and to discuss different treatment options with our patients.
KM: Heather, in the UK the situation is a little different because not everything that is available is also reimbursed.
HP: Yes, I think we’ve had a wonderful time in the UK with the cancer drugs fund for many years and we’ve presently been able to give enzalutamide and abiraterone. We can now give one drug or the other which concentrates the mind very much on the best drug for a particular circumstance. Cabazitaxel is no longer going to be available on the cancer drugs fund which is going to present some challenges as second line chemotherapy. I know in my own centre combination treatment with ECarboF, with three chemotherapy drugs, was used with great success and perhaps we will go back to using combination platinum based drugs as second line treatment in the UK and we will continue to fight the fight to use cabazitaxel in the future.
KM: If you make the step to what we just discussed is, yes, there are new options, it’s not very clear the exact or best sequence of the new options we have. Then when we start using whatever new drug we have in first line for mCRPC, the question comes up do we need baseline imaging. If so… that’s a strong argument, yes, to have baseline imaging to follow the patient, if so, Frédéric, that’s for you. Today, what’s the best way to assess the patient with metastatic castration resistant prostate cancer with the thinking in mind that you may have follow-up imaging and then assess progression response and this and that?
FL: I think that we’ve seen that things are definitely evolving in terms of modality of choice to detect the bone metastasis especially. There is rising evidence that newer imaging modalities, and I’m thinking to MRI and choline PET are doing better than what was available before, I mean bone scan. So there are huge improvements or changes in terms of early detection of bone metastases, that’s the first point. These images will probably help and maybe change the definition of the time point where the patient goes from M0 to M1. That’s the first step, lesion detection, we do better with these modalities. And the second role of these modalities is to assess the efficacy of the treatment once started. As you said, a baseline examination is necessary. If lesions are present we’ve seen that these modalities will help not only to demonstrate progression of the disease but also the positive response of some patients, really helping the physician and give him confidence in the treatment he chose or pushing him to shift to another drug by showing reliable progression.
KM: Heather, what Frédéric just suggested is also to look at response which is probably not routine today in daily practice for urologists and oncologists. What we’re used to is using imaging once you have rising PSA. What’s the practice in your environment? Are people starting treatment and then after a fixed time period they’re doing imaging or is it still triggered by PSA?
HP: I think it’s hugely variable. People who are used to monitoring patients in clinical trials often get into the habit of doing scans because that’s what you do with your patients in studies but I think the majority will do imaging either with new symptoms or with a rising PSA or alkaline phosphatase or other biochemical markers which would suggest progression. There is an argument that if a patient is well, asymptomatic and comes in and their PSA is stable that why are you looking for trouble?
KM: Why would you bother him with radiographic progression?
HP: But obviously the thing one has to be very mindful of is the patient with a stable PSA who is symptomatically becoming more unwell and so that you don’t miss any de-differentiation into small cell or neuroendocrine tumour.
KM: And in terms of the modality, is bone scan still a… although Frédéric just mentioned probably we’re in a mind-shift here. Is it still widely used? I think yes.
HP: Yes it is.
KM: Maria?
MDS: Bone scan is widely used but on the other hand I think it’s important to remember that also CT scan, MRI and other imaging modalities can help us to, for example, find more disease than bone. So disease like visceral metastases and soft tissue disease and these might also be a reason to change treatment. So prostate cancer is not only about bone disease.
KM: I think if we will switch more routinely to MRI we’re definitely going to detect more visceral metastases, more lymph node metastases in the past than when we just used bone scans to assess the patient. So let’s try to get back to that question that also involves all of us about multidisciplinary teams. We had quite a lively discussion on that. Heather, coming back to you in the UK, there’s no choice.
HP: No.
KM: Because you have to.
HP: We have to.
KM: So how is that? Everybody is annoyed by that or everybody is happy by that? The patient, the doctors, what is the situation?
HP: We’ve been doing it for such a long time that it’s an accepted part of practice. I think it’s really nice, actually because it’s the kind of…
KM: You like it?
HP: I like it. You actually get to sit with your colleagues and you can bring forward patients that are difficult, that need various considerations. But I think the difficulty with MDTs is that we spend a lot of time discussing patients where there isn’t really a decision to make. The men with localised early disease, the output from the MDT would be ‘Needs discussion with all options,’ so they will go off and have an active surveillance, prostatectomy, radiotherapy talk. The MDT is very good for finalising the radiology and the pathology and ratifying that but it isn’t, perhaps, the best use of time. Personally I think the biggest challenge is with advanced patients and I don’t think that necessarily needs to be the same MDT as the one that looks at patients with new diagnosis. But when men relapse they don’t necessarily come back to the MDT and I think that’s important so that they don’t miss out on opportunities, for example chemotherapy, by talking to an oncologist, or miss out on going into clinical trials.
KM: Frédéric, if I talk to my pathology colleagues and my radiotherapist, they’re a little bit fed up because they spend all their time in MDTs, what about the radiologists? You could spend all your time in MDTs, you know, what is the situation?
FL: Yes. It really takes time but I think it’s really useful and really improves the care to the patient by bringing everybody’s advice around the same table and bringing some continuity, evident continuity, in the care.
KM: Is that clinical reality in Belgium?
FL: Yes, that’s clinical reality. That’s rewarding – you have a question, you provide an answer, you have the follow-up. I’m enthusiastic about this kind of work.
KM: Oh good, that’s good. Maria?
MDS: Well I’m enjoying to have an MDT in my hospital. I enjoy to have the opportunity to meet my colleagues, and including radiologists, to discuss the patient. I think it is an added value, it definitely is added value. The problem is that caregivers have not planned to increase resources for the MDTs and this is the missing link here. So actually MDTs are required but we do not have more human resources and not more financial resources to support our added time and what we have to invest into those meetings which are very valuable for all sides, for the patient and for us.
KM: Is that reimbursed in the UK? I mean, do they… as there’s no alternative in the UK, that’s what I understand, so…
HP: Yes, it’s put into our job plan. So it’s put into the job plan to do an MDT.
KM: Yes, so the effort you’re taking, the resources you’re spending for MDTs, is that reflected in what you get?
HP: A lot of MDTs, especially as they get longer, we just start earlier in the morning to try and fit it in to the daily workload, which probably isn’t the right way to do it because you just keep extending the end of the day. But we do have a dedicated MDT co-ordinator who is employed to get all the films together or to get everything IEPed across and to put the notes together and will type up a letter to the GP afterwards. Patients love it though and I think that’s right. I would be very comforted to think my case was going to be discussed by a team of people, so I think that’s really good.
KM: It gives them a good feeling?
HP: Yes, the confidence.
KM: That’s right. But as Maria is saying, and that’s probably also the situation in Germany, it’s not adequately reimbursed still. Politically it’s now correct, everybody intuitively feels it’s good for everybody, it’s good for the patient, it’s better for the doctors and this and that, but as the same is true for counselling patients, if you talk to patients for an hour it’s poorly reimbursed, that’s the problem. It’s better reimbursed if he gets an MRI. No, that’s not… No offence against… but that’s probably still the missing link to get a better care for the patient, that this is adequately reimbursed. So thanks everybody. Thanks to the panel for that lively discussion and I look forward to seeing you at the next prostate cancer debate. Thank you.
