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Considering the Role of ADT in Advanced Prostate Cancer

Panelists: Joe OSullivan, MD, FRCPI, FFRRCSI, FRCR, The Northern Ireland Cancer Centre, Belfast City Hospital; Johann de Bono, PhD, MB, ChB, Institute of Cancer Research, Royal Marsden Hospital; Chris Parker, MD, FRCR, MRCP, Institute of Cancer Research, Royal Marsden Hospital; Bertrand Tombal, MD, PhD, Cliniques Universitaires Saint-Luc
Published: Wednesday, Oct 25, 2017



Transcript: 

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: One of the potential benefits is delaying the onset of ADT in somebody who is recurring after radical therapy, isn’t that right? Perhaps if you’re able to see individual sites of recurrence—for example, on a lymph node. In your practice, Chris, would you chase a lymph node with stereotactic radiation, for example, to avoid starting ADT in somebody who is recurring post radical therapy?

Chris Parker, MD, FRCR, MRCP: Yes. Well, I don’t need new imaging to stop my using ADT after a biochemical failure after local treatment. I think there’s far too much use of early ADT after biochemical failure after radical treatment. But I do take your point, that the new imaging techniques do identify more patients with apparently oligometastatic disease that we didn’t pick up on in the past. Certainly, my bias is to treat radically where appropriate with radiotherapy, or even with surgery, for oligometastatic disease. I fully accept that there are reservations, as I haven’t got randomized trial evidence to support that. But that is my bias.

Bertrand Tombal, MD, PhD: One of the most famous papers I will ever have written is a paper about chasing Pokémon, which are actually “Pokémets,” which is actually what’s happening in Europe. It is an editorial we wrote with Chris Sweeney and Declan Murphy. In Europe, where we have had PET PSMA for several years, and we have had whole-body MRI, the European HTA (Health Technology Assessment)—something our colleagues in the United States don’t know yet, but will soon discover—came to us and said, “There is a rapid increase in the use of stereotactic radiation therapy that is driving a major increase in cost.” ESTRO and EORTC are now setting up a platform about this, because this is not limited to prostate cancer; it’s in lung, breast, GI, and prostate cancers. We want to understand what is driving the decision to treat and, at least at first, try to isolate patients who clearly don’t benefit. Because you still see a lot of these patients. You do a PET PSMA scan, you do stereotactic radiation therapy, and then 6 months down the line, they’ve got metastases everywhere. So, once again, we’re getting better, but we still have a long, long way to go.

Chris Parker, MD, FRCR, MRCP: I guess the counterargument would be that if you treat 10 patients like that and you cure 1 of them, it’s worth doing.

Bertrand Tombal, MD, PhD: Yes, that’s the typical decision, but we need to understand at least the 2 who clearly don’t benefit.

Johann de Bono, PhD, MB, ChB: There’s a lot of patient pressure to actually do this.

Bertrand Tombal, MD, PhD: Oh, yes.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Of course.

Johann de Bono, PhD, MB, ChB: We experience that. In fact, I’ve experienced that this last week. It’s quite difficult when the patient wants it to say “no,” actually. There are no data.

Bertrand Tombal, MD, PhD: Yes, but that’s when I would agree with Chris. I’ve been spending my life trying to better understand ADT, but that’s where, clearly, 1 shot of stereotactic radiation therapy, by far, is less toxic than 3 years of ADT.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Exactly.

Johann de Bono, PhD, MB, ChB: Agreed.

Bertrand Tombal, MD, PhD: There is absolutely no discussion, and you don’t need randomized trials to understand that.

Chris Parker, MD, FRCR, MRCP: If it was me and I had oligometastatic disease, I could have hormones alone and be certain of not being cured or I could have radical radiotherapy with a chance—even if it’s a small chance—of being cured. It’s still better than no chance.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: That’s certainly true in my practice as well.

Bertrand Tombal, MD, PhD: I’m still surprised how many men do accept ADT like this. They probably don’t realize what we do to them.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Or it’s too late.

Bertrand Tombal, MD, PhD: Usually they challenge you after 6 months, when it’s too late.

Transcript Edited for Clarity 

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Transcript: 

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: One of the potential benefits is delaying the onset of ADT in somebody who is recurring after radical therapy, isn’t that right? Perhaps if you’re able to see individual sites of recurrence—for example, on a lymph node. In your practice, Chris, would you chase a lymph node with stereotactic radiation, for example, to avoid starting ADT in somebody who is recurring post radical therapy?

Chris Parker, MD, FRCR, MRCP: Yes. Well, I don’t need new imaging to stop my using ADT after a biochemical failure after local treatment. I think there’s far too much use of early ADT after biochemical failure after radical treatment. But I do take your point, that the new imaging techniques do identify more patients with apparently oligometastatic disease that we didn’t pick up on in the past. Certainly, my bias is to treat radically where appropriate with radiotherapy, or even with surgery, for oligometastatic disease. I fully accept that there are reservations, as I haven’t got randomized trial evidence to support that. But that is my bias.

Bertrand Tombal, MD, PhD: One of the most famous papers I will ever have written is a paper about chasing Pokémon, which are actually “Pokémets,” which is actually what’s happening in Europe. It is an editorial we wrote with Chris Sweeney and Declan Murphy. In Europe, where we have had PET PSMA for several years, and we have had whole-body MRI, the European HTA (Health Technology Assessment)—something our colleagues in the United States don’t know yet, but will soon discover—came to us and said, “There is a rapid increase in the use of stereotactic radiation therapy that is driving a major increase in cost.” ESTRO and EORTC are now setting up a platform about this, because this is not limited to prostate cancer; it’s in lung, breast, GI, and prostate cancers. We want to understand what is driving the decision to treat and, at least at first, try to isolate patients who clearly don’t benefit. Because you still see a lot of these patients. You do a PET PSMA scan, you do stereotactic radiation therapy, and then 6 months down the line, they’ve got metastases everywhere. So, once again, we’re getting better, but we still have a long, long way to go.

Chris Parker, MD, FRCR, MRCP: I guess the counterargument would be that if you treat 10 patients like that and you cure 1 of them, it’s worth doing.

Bertrand Tombal, MD, PhD: Yes, that’s the typical decision, but we need to understand at least the 2 who clearly don’t benefit.

Johann de Bono, PhD, MB, ChB: There’s a lot of patient pressure to actually do this.

Bertrand Tombal, MD, PhD: Oh, yes.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Of course.

Johann de Bono, PhD, MB, ChB: We experience that. In fact, I’ve experienced that this last week. It’s quite difficult when the patient wants it to say “no,” actually. There are no data.

Bertrand Tombal, MD, PhD: Yes, but that’s when I would agree with Chris. I’ve been spending my life trying to better understand ADT, but that’s where, clearly, 1 shot of stereotactic radiation therapy, by far, is less toxic than 3 years of ADT.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Exactly.

Johann de Bono, PhD, MB, ChB: Agreed.

Bertrand Tombal, MD, PhD: There is absolutely no discussion, and you don’t need randomized trials to understand that.

Chris Parker, MD, FRCR, MRCP: If it was me and I had oligometastatic disease, I could have hormones alone and be certain of not being cured or I could have radical radiotherapy with a chance—even if it’s a small chance—of being cured. It’s still better than no chance.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: That’s certainly true in my practice as well.

Bertrand Tombal, MD, PhD: I’m still surprised how many men do accept ADT like this. They probably don’t realize what we do to them.

Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR: Or it’s too late.

Bertrand Tombal, MD, PhD: Usually they challenge you after 6 months, when it’s too late.

Transcript Edited for Clarity 
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