You are here
Treatment Options of Advanced Castration-Resistant Prostate Cancer - Alberto Bossi and Paolo Gontero at PC Debate, Baveno, April 2016
Dr Alberto Bossi, Genito-Urinary Oncology –
Prostrate Brachytherapy, Gustave Roussy Hospital, Villejuif Cedex, France
Professor Paolo Gontero, Urologist,
Universita degli Studi, Turin, Italy and San Giovanni Battista Hospital (Molinette), Turin, Italy
Prostate Cancer Debates, Baveno, April 2016
The management of high-risk and metastatic castration-resistant prostate cancer patients is discussed by Dr Boss, Villejuif Cedex, France, and Professor Gontero, Turin, Italy. For advanced patients local treatment strategies should also be considered. They may increase the overall survival and improve the quality of life of these patients. Further randomized clinical trials and a multidisciplinary approach are required.
Alberto Bossi: Good morning, everybody. We are discussing here in Baveno, together with a bunch of colleagues coming from both sides of the water, about the treatment options for high-risk and metastatic castration-resistant prostate cancer. I am Alberto Bossi, a radiotherapist and oncologist working at the Gustave Roussy Institute in Villejuif, France.
Paolo Gontero: I am Paolo Gontero, a urologist, working in Molinette Hospital in Torino, Italy. Alberto Bossi and I have had the chance to concentrate a great deal, as part of our main job, on the treatment of high-risk prostate cancer. We are now in a setting that is slightly different and we are discussing the role of new treatment options for metastatic castration-resistant prostate cancer. This is certainly a field that has recently been enriched with the advent of dramatic new treatment strategies that aim to improve the hormone treatment of this disease. Alberto, if you want to give your thoughts about this?
Benefit of local treatment
Bossi: There is an aspect which, for sure, you would also like to stress today, which is the idea that we tend to forget that a local treatment, also for advanced patients, is still useful. By that, I mean that there are patients who are diagnosed with metastatic disease, and I also mean that there are patients who have never received a local treatment in their history. We feel – and, of course, this is a personal bias, since I am a radiation oncologist – that there may be a role for a local treatment for these patients.
Gontero: You are pointing out an absolutely key point, which may become even more relevant in the future. The typical patient in this setting is one who has a primary metastatic prostate cancer which is, by definition in the guidelines, a patient who is not fit for any local treatment. However, we are now talking about the new treatment strategies which have actually been shown to prolong the overall survival of these patients. This means that these patients may be more likely to experience also the local side effects of this primary tumour. When we talk about these new treatment strategies, we have an eye on the quality of life of the patient, so we are talking about treatments that are effective while at the same time having a very good tolerability profile as compared to standard chemotherapy. We are discussing the sequence of this treatment.
At the same time, we should not forget our own experience in daily clinical practice. We see these patients dying of dramatic complications, because of the recurrence of this local treatment. These patients will die anyway from their disease and, when the disease is giving side effects because of local progression, this is really going to be dramatic. We are talking about patients who end up living with bilateral nephrostomies, which are tubes coming out from the kidneys.
The question is, in the light of the new life expectancy of these patients, it may make sense also to address and to reconsider the rationale to address local treatment. I don’t know what you think about that.
PEACE1 and other trials
Bossi: That is totally correct – I do agree with you. There are two main possibilities, again: we use rays, or we use surgery. Treating the disease locally may be a new frontier for both of us here today – surgeons and radiation oncologists. Our experience, which has been published out there, both of a series of patients who have been treated locally by surgery – and we are certainly aware of Axel Heidenreich’s publication on these patients. There is a series of patients who have been traditionally treated by radiation therapy in the prostate and it is probably also interesting to remind our audience that there are randomised clinical trials going on.
At Goustave Roussy, we have launched the PEACE1 trial, together with Karim Fizazi’s team, in which we are looking also at the value of radical radiotherapy in this subset of patients: metastatic patients, presenting with metastatic disease, which may be treated locally by radiotherapy to what we consider a standard dose of 74 gray. I am sure that, in the surgical ward, you also have trials which are ongoing, and publications that are looking at this specific topic.
Gontero: As far as I am aware, I recall an American trial in patients with primary limited bone metastatic disease, who are hormone-sensitive. This means that they achieve a very good response to hormone therapy and they actually have a temporary clearance of their metastases to their bone scan. These patients can actually undergo the removal of their primary treatment.
You also mentioned that there is a recent, retrospective study, addressing the tolerability of radical prostatectomy for patients who have metastatic prostate cancer. The expectation of such treatment is probably in two ways, as we have previously discussed: it is potentially to reduce the local side effects, but also we need to identify the way we can measure the activity of such a treatment. This means that, somehow, we confer an additional survival advantage by removing the primary tumour and potentially also a better response to multiple sequential treatments.
Bossi: Indeed. Probably the final message could be that, in respect of those patients, don’t forget that local treatment may be a good way to go. It may enhance the survival of those patients, and it may certainly impact on their quality of life. Probably, in this setting, randomised clinical trials are certainly needed if you want to answer these questions. Again, I think that good co-operation between surgeons and radiation oncologists is a key issue for success, even in this respect. I don’t know what your feeling is on that.
Gontero: Absolutely. Ultimately, this is a plea for a multi-disciplinary approach to this disease. It is important that the oncologist is aware that primary metastatic prostate cancer is not only an oncological disease that has to be taken care of by the oncologist, but it is a disease which deserves a multidisciplinary approach with a urologist and with radiotherapy. As much as, the other way around, we are fully aware that we have to bring the oncologists into the setting of treatment of, for instance, high-risk prostate cancer, when we plan primary treatment at the start.
Bossi: Correct. Thank you very much.