Novel Approaches in Prostate Cancer Treatment - Episode 4

Active Surveillance and Prognostic Value of Prostate Biopsy


Dan George, MD: Bertrand, any thoughts on active surveillance? How is that in Europe?

Bertrand Tombal, MD, PhD: No, active surveillance actually has become, I would say, the standard of care of high-risk localized disease. The missing link was getting confidence in the prognostic value of your biopsy. This is because the problem is that everybody speaks about prostate biopsy and doesn’t understand there is a huge quality-control issue around biopsy. It’s very interesting to see that both continents have solved the quality insurance differently. In the US it is by incorporating genetic tests, MDx and Oncotype DX. We don’t have these in Europe yet because we have a value-based system, and the company failed to make the value-based estimation.

In Europe, MRI [magnetic resonance imaging] has become really the adjunct to high PSA [prostate-specific antigen]. Now, at least for a country like mine, France, it’s getting to be more of an exception to have a biopsy without an MRI. Certainly incorporating an MRI from the work of a UK trial, like the PROMIS trial and PRECISION trial, have shown that basically a 12-core blinded biopsy. It’s like tossing a coin. So now we’re getting more confidence in the biopsy, meaning that we have a safety net. We can now start to monitor patients with MRI and get rid of further biopsy. Interestingly, in Europe, it’s opening a totally different field, which is those with identifiable cancer. That’s opening the field for focal therapy, which is very rapidly growing, especially with 2 technologies: the TOOKAD technology and the HIFU [high-intensity focused ultrasound] technology.

What’s happening now is that we’re bringing these strategies to the intermediate risk. This means today, if you’re 55 years old and you have a PSA at 5, and you’ve got 1 single PI-RADS [Prostate Imaging Reporting and Data System] 4 lesion and a Gleason score of 3 or 4, people are asking why do you want to get rid of my prostate? We’re building a whole world of a selective indication of cancer. In Europe, it’s getting very valuable, to the point of how can we get better use on the MRI resources, which are still limited? But clearly, you see that the trend today, the standard of care for low-risk, has become active surveillance.

Dan George, MD: We certainly do that kind of focal-therapy approach in kidney cancer.

Bertrand Tombal, MD, PhD: Exactly.

Dan George, MD: And in other settings. So it makes sense. There’s a little bit of an extrapolation from the active surveillance to include that piece. But it certainly goes along with the tenets of how we manage early cancer in other settings.

Transcript Edited for Clarity