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Final Thoughts on Evolving Treatment of Prostate Cancer

Panelists: Dan George, MD, Duke Cancer Center; Joe M. O'Sullivan, MD, FRCPI, FFRRSCI, FRCR, Queens University Belfast; Charles Ryan, MD, Masonic Cancer Center; Christopher Sweeney, MBBS, Dana-Farber Cancer Institute; Bertrand Tombal, MD, PhD, Cliniques Universitaires Saint-Luc
Published: Tuesday, Dec 24, 2019



Transcript: 

Dan George, MD: This has been an extremely informative session. I want to thank my colleagues here who have all participated in this. Before we end this discussion, I’d just like to get final thoughts from each of the panelists. Joe, maybe we can start with you.

Joe M. O’Sullivan, MD, FRCPI, FFRRSCI, FRCR: I think it’s an exciting era. We’re right across the spectrum in prostate cancer. We’ve seen data in hormone-sensitive disease and castrate-resistant disease. I think we’re seeing the beginning of the genomic era, which is really exciting. I think for patients, there is a massive amount of choice. But first, for clinicians making decisions for patients, it’s even more important for us to try to make the right decision based on what’s important to the patient, what their priorities are, and their state of health.

Dan George, MD: Excellent. Chuck?        

Charles Ryan, MD: The 2 words that come to mind as I’m listening to my colleagues are clarify and classify. I think we have data now clarifying a variety of unanswered questions, gray areas in our disease. The CARD study, for example, is really definitive in terms of just saying that, for the most part, for the population, the second AR [androgen receptor]–targeted drug is probably not the best option. Classify is to classify your patient, whether it’s genomic classification in looking for a PARP inhibitor use as they become available. That’s now becoming something that you can’t not know about. You have to know about genomic sequencing; otherwise it’s a disservice to your patient. I would also classify applied to the nonmetastatic state—the low-versus-high-volume hormone-sensitive space. We’re beginning to see the disease enter into new different classes. It’s not just about metastasis, yes or no, hormone resistance, yes or no. It’s high volume, low volume, BRCA2, BRCA1, etc. It’s getting more complex, and it makes it more interesting. What’s great is that we now can speak with a little more clarity to our patients about the therapy options that they have.

Dan George, MD: Fantastic. Chris?

Christopher Sweeney, MBBS: I 100% agree with all of that. The 1 notion I’d like to add is future horizon scanning. I’m hoping we can get to a point with all this new knowledge of getting to a point of doing testosterone suppression. This would be AR inhibition with a potent AR inhibitor, plus a new targeted therapy without background testosterone suppression and to have something like…for HIV. We may have an AR inhibitor, an plus PI3 kinase inhibitors...and have a triplet Of therapies that really does much better than we do now.

Dan George, MD: Bertrand?

Bertrand Tombal, MD, PhD: I think if I look at the next year, we first of all have a huge education challenge. As mentioned by Chris, the strategy we’ve been following so far was if you can’t convince, confuse. We have no convincing evidence, so we should stress de-confusing people. We’re going to have to increase 2 types of formation. The first, as you understand from Chris’s explanation on newly diagnosed metastatic disease, we need to announce the ability of community physicians understanding what the paper means and how to read the paper. I think that is very important to help them in that. The second 1, we have a huge challenge in Germany with imaging that, I would say that most of the urologists in Europe I know very well, who treat patients in a very high-level quality, the same for the medical oncologist. They have no idea about the difference between ATM, biallelic, DNA-repair losses. We are facing a huge education challenge, and we should actually give as much energy to this even before we plan the next generation of trials.

Dan George, MD: I agree with you, and I would just add 1 more to Chuck’s, just because he brought the Cs, clarify and classify.

Charles Ryan, MD: I was looking for a third anyway.

Dan George, MD: Personalized, so we could do PCC. So it’s prostate cancer…

Christopher Sweeney, MBBS: CCC. Choice.

Dan George, MD: Yeah. Classify, clarify, choice. But I like personalized because it brings up all of what we’ve heard about from the differences in these therapies and the therapies’ options, to the patients, what the patients prefer, what the patients bring to the table from fitness and everything, to the genomics and how we personalize the genomics into therapy and think about profiling each patient, because each patient’s profile could be different. It’s important to encompass all that into a treatment plan. You know AI is going to struggle with that. I think we’re still going to be employed for quite some time figuring all these things out. But it’s a challenge and opportunity in our field, and I really appreciate everyone’s insights into this exciting time post-ESMO [European Society for Medical Oncology] 2019.

Thank you all for the contributions to the discussion. On behalf of the panel, I would like to thank you for joining us, and we hope you found the Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity

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Transcript: 

Dan George, MD: This has been an extremely informative session. I want to thank my colleagues here who have all participated in this. Before we end this discussion, I’d just like to get final thoughts from each of the panelists. Joe, maybe we can start with you.

Joe M. O’Sullivan, MD, FRCPI, FFRRSCI, FRCR: I think it’s an exciting era. We’re right across the spectrum in prostate cancer. We’ve seen data in hormone-sensitive disease and castrate-resistant disease. I think we’re seeing the beginning of the genomic era, which is really exciting. I think for patients, there is a massive amount of choice. But first, for clinicians making decisions for patients, it’s even more important for us to try to make the right decision based on what’s important to the patient, what their priorities are, and their state of health.

Dan George, MD: Excellent. Chuck?        

Charles Ryan, MD: The 2 words that come to mind as I’m listening to my colleagues are clarify and classify. I think we have data now clarifying a variety of unanswered questions, gray areas in our disease. The CARD study, for example, is really definitive in terms of just saying that, for the most part, for the population, the second AR [androgen receptor]–targeted drug is probably not the best option. Classify is to classify your patient, whether it’s genomic classification in looking for a PARP inhibitor use as they become available. That’s now becoming something that you can’t not know about. You have to know about genomic sequencing; otherwise it’s a disservice to your patient. I would also classify applied to the nonmetastatic state—the low-versus-high-volume hormone-sensitive space. We’re beginning to see the disease enter into new different classes. It’s not just about metastasis, yes or no, hormone resistance, yes or no. It’s high volume, low volume, BRCA2, BRCA1, etc. It’s getting more complex, and it makes it more interesting. What’s great is that we now can speak with a little more clarity to our patients about the therapy options that they have.

Dan George, MD: Fantastic. Chris?

Christopher Sweeney, MBBS: I 100% agree with all of that. The 1 notion I’d like to add is future horizon scanning. I’m hoping we can get to a point with all this new knowledge of getting to a point of doing testosterone suppression. This would be AR inhibition with a potent AR inhibitor, plus a new targeted therapy without background testosterone suppression and to have something like…for HIV. We may have an AR inhibitor, an plus PI3 kinase inhibitors...and have a triplet Of therapies that really does much better than we do now.

Dan George, MD: Bertrand?

Bertrand Tombal, MD, PhD: I think if I look at the next year, we first of all have a huge education challenge. As mentioned by Chris, the strategy we’ve been following so far was if you can’t convince, confuse. We have no convincing evidence, so we should stress de-confusing people. We’re going to have to increase 2 types of formation. The first, as you understand from Chris’s explanation on newly diagnosed metastatic disease, we need to announce the ability of community physicians understanding what the paper means and how to read the paper. I think that is very important to help them in that. The second 1, we have a huge challenge in Germany with imaging that, I would say that most of the urologists in Europe I know very well, who treat patients in a very high-level quality, the same for the medical oncologist. They have no idea about the difference between ATM, biallelic, DNA-repair losses. We are facing a huge education challenge, and we should actually give as much energy to this even before we plan the next generation of trials.

Dan George, MD: I agree with you, and I would just add 1 more to Chuck’s, just because he brought the Cs, clarify and classify.

Charles Ryan, MD: I was looking for a third anyway.

Dan George, MD: Personalized, so we could do PCC. So it’s prostate cancer…

Christopher Sweeney, MBBS: CCC. Choice.

Dan George, MD: Yeah. Classify, clarify, choice. But I like personalized because it brings up all of what we’ve heard about from the differences in these therapies and the therapies’ options, to the patients, what the patients prefer, what the patients bring to the table from fitness and everything, to the genomics and how we personalize the genomics into therapy and think about profiling each patient, because each patient’s profile could be different. It’s important to encompass all that into a treatment plan. You know AI is going to struggle with that. I think we’re still going to be employed for quite some time figuring all these things out. But it’s a challenge and opportunity in our field, and I really appreciate everyone’s insights into this exciting time post-ESMO [European Society for Medical Oncology] 2019.

Thank you all for the contributions to the discussion. On behalf of the panel, I would like to thank you for joining us, and we hope you found the Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity
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