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Highlights from the WUOF meeting, Glasgow, 2014, by Henk van der Poel

12th October 2014

Minimizing morbidity and maximizing survival in the treatment of urologic cancer.

Henk van der Poel gives his summary from the meeting of the key highlights in different stages of prostate cancer.

 

Focal therapy

Philip Dahm, Mark Emberton, Henk van der Poel

Focal therapy studies sofar lack level 1 evidence. Most studies done sofar are in IDEAL class groups I and II, i.e. registry or prospective single arm protocol. Recruitment of patients in these trials was found to be relatively smooth due to the appealing prospects of non-whole gland treatment. Although MRI has changed the imaging of prostate cancer, it is still missing smaller higher gleason grade lesions within the prostate. Moreover followup schemes after focal therapy are still in development and long term followup data are lacking. The panel therefore recommends to include all focal therapy treated patients into a clinical trial or the EAU provide ECLIPSE registry.

 

Metformin in prostate cancer management

Neil Fleschner, Canada

Neoadjuvant metformin prior to prostatectomy showed a decrease in Ki67 proliferation index and a reduction of p4eBP1 as a reflection of growth inhibition.  Metformin users from a national registry did not have a decreased risk of prostate cancer diagnosis but mortality of prostate cancer in metformin users was found to be reduced.  Metformin use is currently studied in a randomized study in men on active surveillance for low risk prostate cancer (MAST study). Combining metformin with statins was shown to reduce cell growth in preclinical models. A ligand trial has been designed to study the delay of PSA progression in men with PSA recurrence.

 

Biopsy diagnostics in prostate cancer

Hashim Ahmed, UK

Non-image guided prostate biopsies are the way of the past. Cognitive MRI-TRUS biopsies had comparable yields to template biopsies. MRI guidance should direct the biopsies to the center of the tumor.

 

MRI and prostate cancer

Arnaud Villers, France

Either 1.5T or 3T should be available. A prospective trial design the PRECISION study was presented comparing MRI-targeted biopsies and standard biopsies. Are repeat biopsies necessary in men with an initial negative biopsies set?

The PROFUS trial showed that MRI targeted biopsies with cognitive fusion was similar to MRI-TRUS fusion taken biopsies. In his view, men with an elevated PSA should go for MRI prior to biopsies, although this view does carry some consequences on capacity and costs.

Robotic surgery in urology in developing countries Shin Egawa His main disclosure: no use of robotics. His plea is to carefully consider costs and in the meantime try to resist the seemingly sweet fruit of progress.

Robots: the skeptical view for developing countries Arturo Mendoza Why buy a robot for a disease (prostate cancer) that is not so prevalent in developing countries. Recent data show that prostate cancer incidence is increasing in development countries.  However, in western counties many more older men may require surgery. In mexico with 112 million inhibatants we expect 86500 men with prostate cancer and 10.117 prostate cancer related deaths, whereas actually in mexico only 5000 men dye of prostate cancer yearly. The number of prostatectomies in Mexico is considerably lower than in the neighboring USA. Many robotic systems in mexico are not used. Dr. Mendoza doubts whether a surgical robot is beneficial in developing countries.

 

Robotics in the developed world

Peter Hammerer, Germany

The impact of robotic surgery in the US showed a decrease low volume centers. The percentage of centers using a robotic system increased also for low volume centers. In Canada only 23 systems are available. It is a market let development. Incorporation of new technology into medical practice is the challenge. Costs are prohibitive. EAU guidelines on minimal invasive surgery state that outcome is not improved by using the surgical robot. Quality assessment is required and the robotic system provides an important platform to train virtually.

 

Intermittent androgen deprivation

Betrand Tombal, Belgium

A rapid drop in the androgen ablation-free period is observed in men on intermittent androgen deprivation. Intermittent androgen ablation had no detrimental effects in non-metastasized disease, however, in men with metastases intermittent androgen ablation non-inferiority of intermittent treatment could not be excluded.  In three randomized trials intermittent androgen ablation was associated with a non-significant increase in prostate cancer related death. In particular in men with high gleason score cancer an imbalance in favor of continuous androgen ablation as compared to intermittent use. The studies on intermittent androgen ablation used conditional randomization where 18-36% did not receive a PSA response after initial ADT and therefore were not included in the comparative studies and therefore proposing intermittent therapy to all may give a different result. Finally, Tombal puts forward that a placebo effect in the intermittent arm of the studies may have overestimated the actual benefit. Intermittent androgen ablation should be seen as a “drug-holiday” only in those men that initially respond favorably to androgen ablation. The long term benefits of intermittent androgen ablation remain to be established.

 

PSA recurrence after prostatectomy

Hein van Poppel, Belgium

Risk adapted PSA recurrence definition (Mir 2014). Choline PET is viewed as more sensitive for detecting recurrences after prostatectomy compared to MRI. Since targeted radiotherapy is not considered in oligometastases, early imaging becomes clinically relevant. Salvage pelvic nodal dissection may, in some selected patients provide long term biochemical progression, but choline PET was shown to clearly underestimate the extent of nodal metastases in these patients. In a summary of all the published data on salvage nodal dissection van Poppel showed longer term PSA control, although some studies used androgen ablation that may have obscured biochemical recurrences.  Patients with a PSA <4 Gleason<8 and only pelvic nodes are the ideal candidates for salvage nodal dissection. In these, 5 year biochemical recurrence-free survival of around 30% can be expected.

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