The first point is that it has been recognised now that more and more senior adults exist, they have more and more advanced disease because the older you get the higher the risk of local disease you have. That’s the first point, the second point is that surgery improves survival at a cost of increased incontinence and, of course, increased impotence, provided this is still a question in senior adults. The third point is about radiotherapy – radiotherapy is probably as effective as surgery, at least based on a randomised trial which is ProtecT which is the only one which compared surgery and radiotherapy and there was absolutely no difference at ten years but in this trial it was only low risk disease. Probably the third point is that for low risk disease, especially the patients included in ProtecT, there was absolutely no benefit for any form of local treatment compared to some form of active surveillance and that’s a major point suggesting that at ten years, if OS is a key objective, you probably should think twice or even three times before doing anything because the patient will not die from their prostate. At ten years the specific survival was close to 96-97%, suggesting that clearly local treatment is a non-issue.
Where do you see treatment going in the near future?
Probably the main change will be the biology that might be able to tell us who really needs to be treated and who does not need to be treated, to be more precise than the standard Gleeson or biopsy that we have. The biology will help us to decide where and how to biopsy, biopsy is not a trivial process, it’s the only way to make a diagnosis and it’s the only way to be sure that the disease is low risk or intermediate or high risk localised. Second, surgery probably in senior adults will decrease and probably will come very close to zero. Radiotherapy might increase but this will remain a patient’s choice decision. Some patients really want to have the disease out, that is remove the prostate, some others absolutely reject the idea to have still their prostate in place. It’s not evidence based, it’s purely personal opinion but I guess it will be the key change in the future, from five years from now.
Have there been any interesting questions raised at the conference?
One of the questions was what about rising PSA after local treatment and the question was what do we need to do with this? The question is absolutely relevant for two things. The first one is we know that the link between PSA relapse, and the question was only on PSA relapse, we know that PSA relapse precludes symptomatic relapse by 5-10 years. Second, we know that there is almost no link, or a very, very, very weak link between PSA relapse and survival. The third message is, and that’s the only practical one, that probably the PSA relapse should only be treated if it’s a high risk of subsequent death and the patients at this risk are those with a very short PSA doubling time, again a PSA doubling time here, at least a PSA doubling time of less than 12 months, probably less than 6 months. Those are the patients really at risk of dying. The patients with 2-3 years PSA doubling time, probably they will never die from their relapsing disease and if there are symptoms 10-15 years later it will be feasible to treat them with ADT, that will be very effective in treating symptoms without prolonging their life but saving them at least 10-15 years from all the side effects of the treatment of the relapse.
