Dr Neal Shore - Carolina Urologic Research Center, South Carolina, USA
Prof Karim Fizazi - Department of Cancer Medicine, Institut Gustave Roussey, France
Prof Kurt Miller - Benjamin Franklin Medical Centre, Berlin, Germany
Prof Nicholas James - Institute of Cancer and Genomic Sciences, Queen Elizabeth Hospital, Birmingham, UK
NS: Hello everyone, welcome to our programme today from ecancer. My name is Neal Shore, I’m the Medical Director of Carolina Urologic Research Center. We’re here live today in Chicago at ASCO 2017, today is June 5th. I’m truly honoured to have the opportunity to talk with my friends and my colleagues about some of the highlights that occurred this weekend at ASCO, some of the challenges that we still face in the diagnosis and management of prostate cancer and what is the future, what will it look like? What are some additional learnings that we want to attain? What are some of the newer trials that pique our interest? Most importantly today is that this is an interactive programme so you have the ability to write down and email in your questions. We want to have a very interactive discussion as well as a presentation of some really profound data which potentially should be very practice changing. I’m truly honoured and it’s a great pleasure to introduce to you to my immediate right Karim Fizazi, Professor of Medical Oncology at the Institute of Gustave Roussey in France. Next to Karim my very good friend Nick James who is a Professor of Medical Oncology at University of Birmingham in the UK and also my great friend Kurt Miller, Professor of Urology who is now a [?? 1:27] in Berlin in Germany. So it’s really going to be a fun programme. I really would hope that throughout the programme questions that come up to any one of the individual panel members or to the entire panel, please send those in. We’ll try to address as many questions as possible.
So here are some of our disclosures, as you can see a lot of involvement for all of us with many different industry and with our government sources as well. Here are our objectives today. We want to discuss the current challenges that face you, whether you’re a medical oncologist, a urologist, a radiation oncologist, if you’re devoted to taking care of patients with prostate cancer. What are the issues around diagnosis and management? What’s particularly exciting today is we’re going to review two ground-breaking phase III trials. I’m so happy that the global PIs for both trials, Karim and Nick, are here to discuss them. Will this research change your practice management, that’s ultimately so important to why we do these trials? What does the future hold regarding ongoing and proposed trials and how will the learnings and the evidence that we have at ASCO in 2017, how will that shape our decision making?
Our first question for the audience is we welcome the European Asian audience today and, of note, on ecancer.org you’ll be able to after 24 hours get access to this live programme that you’re seeing today. But what are the greatest challenges today for prostate cancer management? Is it treatment of patients with high risk prostate cancer? Is it the management of castration resistant prostate cancer? Is it understanding the clinical utility of genomic assays, urine serum, tissue biomarkers? Or is it the interpretation and utilisation of diagnostic imaging? Of course all of these are important but we’d like you to just pick the one that’s most germane and interesting and challenging to you as an audience, a member. But let me first start with you, Karim, maybe you can opine a little bit, and they’re big topics. If you could take from the bottom the issues regarding utilisation of markers, whether they be genomic assays, protein and urine serum tissue and diagnostic imaging. A big ask of you but what are the things that just come front of mind for you?
KF: Regarding the last question about imaging, we’ve been living in advanced disease or even in localised disease mainly with bone scan, because metastatic prostate cancer is a bone disease mostly, and with CT scan because you might see some visceral metastases or lymph node metastases. We’ve done that for years and years. In the last decade, let’s say, this has probably evolved a bit with the use of whole body MRI and PET choline but there was still some debate. The next big question for the coming one or two years will be whether PSMA PET will totally change the field. It truly seems that PSMA PET is really able to identify tiny metastases that the other imaging are not able to do. If so, then really we might totally change the way we will treat these patients, not only locally but also systematically.
Regarding the biomarker question, when you think about it amongst the four big cancers, at least in the Western world, breast cancer, lung cancer, colorectal and prostate, prostate cancer is the only cancer where we’re not using really precision medicine. So we’re not making our decision based on a given biomarker. Again, this is just about to change. We thought probably two years ago or three years ago that perhaps the AR-V7 variance would be the first biomarker to come to help us for decision making. I’m not totally sure about that, to be honest, and the biology of the AR is probably much more complex so there’s still much more work to do there.
Actually the first biomarker that may come out very soon is about DNA repair. This is because we now know that much more patients than we originally thought have DNA repair abnormalities, either germline or somatic, and also that we can target that. So I think this will really change quite, quite soon.
NS: You’re hitting incredibly important points, thank you. We’ll get back to that later on when we have some really interesting abstracts which are going to speak to exactly what you’re describing. Nick, you’ve been championing the STAMPEDE multistage multi-arm. It’s exceptional and once again you’ve brought some phenomenal information to us. It’s almost a semi-annual, annual event thanks to you and your colleagues. But let me ask you about the management of castration resistant prostate cancer, just the blue sky look. What are some of the things that you think about for a short answer?
NJ: The thing that is emerging in our practice, and it is being driven by PET imaging, just as Karim said; we’re currently using choline PET, we’re in the process of switching to PSMA. One of the things that we’ve seen which has been actually dovetailing in with the presentations that Karim and I have done over the last two days is we’ve seen spectacular responses to up front abiraterone. Then when these patients become castrate refractory the question arises is the disease different to the disease we saw before? I think the answer to that is yes and one of the things we’ve seen which we’ve been very intrigued by is we’ve seen patients starting with very extensively hot bone scans, getting PSA responses to undetectable levels then relapsing with just one or two sites of disease which we’re mostly imaging on PET because what we find is that some lesions are hot and some of the previous lesions are cold. So we’ve been moving towards giving radical radiotherapy to oligometastatic recurrences in previously polymetastatic disease. Talking to my colleagues, particularly at the Royal Marsden where they’ve got very good access to PET as well, this seems to be a theme that they’ve seen as well. So I think there’s going to be a whole new chapter in, if you like, the post-abiraterone CRPC space where they’ve had abiraterone up front where the treatment paradigm may actually turn out to be different to the CRPC pattern we have at the moment. Unravelling that is going to be really very interesting.
NS: So you’ve touched on great future learnings, controversies, oligometastatic disease and we’ll get into the STAMPEDE and abiraterone data as well as LATITUDE. Kurt, finally in treating patients with newly diagnosed high risk prostate cancer, what are your thoughts?
KM: Yes, it depends really if you’re on the metastatic side or on the non-metastatic side and somewhere in between is what just has been discussed, this oligometastatic disease. There’s a discussion on should we treat the primary in oligometastatic disease. Interestingly, you give one more metastasis and then it’s four and all of a sudden you’re in high volume metastatic disease and discuss chemo-hormone therapy or other combinations which we will discuss probably in a couple of minutes. So still it’s a pretty crude classification and we would need more differentiation here, as Karim has pointed out.