Closing out their discussion on a clinical scenario of metastatic HSPC, expert panelists consider optimal patient monitoring strategies and novel imaging.
Evan Y. Yu, MD: Pedro I'm going to ask you this last question on this case here which I think Andy nicely led in which is when you do see a patient like this one and you start treating them- this patient got ADT and 6 cases of docetaxel, PSA dropped nicely. What sort of monitoring do you do? How often do you see them? How often do you check PSA? How often do you image and what imaging do you do? What's your plan?
Pedro C. Barata, MD, MSc: I congratulate Andy for that because it's such an important message and we do rely on PSA perhaps too much and that this study shows as well not so fast. The reality is it seems like it's one of those cases where in real world we don't act exactly like we do it on trials because on trials we plan scans every 3 months for the most part in general but often we scan these patients in real world far less often, sometimes once a year, sometimes not even that. It's common I'll have some second opinions and we'll go through the scans and the last set of scans was done 2 years ago and we all know those cases. That's an important message so having scans more often is important. Knowing the data also helps us because it improves our ability to predict. When you know that median rPFS is going to land let's say in 2 years if you take it in general, you're not expecting to have problems the first 6 months although that can happen in 8 months or 9 months and that helps you a little bit to help plan the scans. For all these studies were conveyed in the context of conventional CT and bone scan as we talked earlier. It is true that we have an emergence of novel imaging and that will impact the way we're going to stage our patients in the metastatic setting. The big push right now is for lutetium PSMA because it's an FDA approved drug so we have a good reason, and we select patients for that based on that scan although most patients will be PSMA positive disease. What this is going to allow us to do is to start developing or craft some kind of studies where we're going to monitor disease response on novel imaging and we're probably going to start with head to head and then we're going to move to studies that are just implementing that kind of scanning. Do I use them in clinical practice? I have to say I do, and I do it for 2 reasons. I mentioned one of them is obviously when I can see the PSMA therapy which happens to be a bit later although we do have some trials pre-chemotherapy which might be close to this setting as they progress into CRPC. I would like to highlight 2 points; they are not level one evidence-based but I think it's important in practice we do it and one has to do with oligo-progression. In other words, it's these patients that for the most part they have disease under control, but we have 1, 2, or 3 new spots in the scans and the question is are we going to think about metastasis directed therapy and keep them on the same regimen, whatever that regimen might be and in general that's NHT because it's what most of us are using. That would be one aspect of it and so in those circumstances I've done novel imaging in that scenario. It's not for all the patients but I've considered that in certain scenarios so that's something I try to do. The other piece is we've been trying to understand the serial changes in the molecular profiling of tumors and that means that upon let's say biochemical recurrence and sometimes of course radiographic occurrence we do tend to repeat molecular profiling. A lot of times these patients do not have available site for biopsy. In those cases, we tend to do repeated liquid biopsy but I do believe that over time we're going to start getting smarter, understanding how we can use liquid biopsy to help us decide what we're going to do upon chemical progression.
Transcript edited for clarity.