Prof Heather Payne – University College Hospital, London, UK
Dr Luis Martinez-Piñeiro – La Paz University Hosital, Madrid, Spain
HP: I think one of the other really interesting topics at the Prostate Cancer Debate in Madrid has been castration resistant prostate cancer. The big take-home message is that we’re in a little bit of an evidence-free zone for those men who are treated with abiraterone or docetaxel for their hormone sensitive disease. Because it’s difficult to know if the other studies still apply, that can we look at those results and now apply them in this setting. We had quite a lively debate presenting a case of a man who has relapsed after ADT and docetaxel and then relapses. What were your thoughts on the audience’s opinion on that, so with the ADT and docetaxel?
LMP: Actually we try to use common sense in our treatment. There are actually not many news and changes because the treatments are quite established in this scenario. So patients who relapse after having docetaxel, the tendency is to give cabazitaxel, not to rechallenge with docetaxel. Patients that relapse after abiraterone, for instance, they will get docetaxel; they usually are not treated with enzalutamide because the results are not very good, with just a 20-30% response rate. So among all the treatments we have to keep in mind that radium is there and we can choose for some patients radium-223 although we have to select the patients adequately, just with bone metastases, symptomatic in most cases but also in some countries you can treat patients that are not symptomatic and without visceral disease. So the thing that came out also in the discussion is that some patients after several lines, after they’ve failed several lines, some of them don’t want any treatment anymore. They are exhausted, they are in a frail condition and some of them actually decide not to go on with further treatments. So actually we try to use common sense and the most important thing in this patient group is to give them the best quality of life because we know that we are not going to cure the patients so quality of life after the first couple of lines is the number one choice and aim in our practice.
HP: And with a lot of the novel hormone drugs coming through, and certainly with abiraterone and prednisolone and using that as first line for CRPC, certainly in my group of patients I worry about potential toxicities rather than they report side effects to me. Obviously we need to monitor the very reversible side effects of low potassium or a small risk of abnormalities in the liver function and monitor their cardiac status. But some of these drugs have been so well tolerated that it has changed completely the way in which we treat patients with CRPC and are able to give sequential therapy. One of the questions that came up a few times was about evidence and until we have prospective studies something like the St Gallen consensus can be a good way to start to just look at what experts are doing around the world and how they are sequencing treatment after hormone sensitive.
LMP: Sure. We try to follow guidelines but sometimes you have to treat outside of the guidelines so the St Gallen consensus which was published in European Urology quite recently is a way to orient yourself and to try to give the patient the best alternative.
HP: It’s quite good, actually, that the clinical practice is leaping ahead of the evidence and the guidelines because things are changing so quickly. One of the other things that we discussed quite a lot in my breakout group was how to manage prostate cancer in the elderly. Over the years I’ve had some sort of dealings with SIOG, the International Society for Geriatric Oncology and I’ve incorporated their basic principles into my practice hugely in that treatment should never depend on age but on comorbidities and patient wishes. They very clearly distinguish four groups of patients and for prostate cancer men it would be those fit men who should have exactly the same treatment as their younger counterparts; the patients who are vulnerable, who can have comorbidities retreated and for some men a diagnosis of prostate cancer highlights the hypertension or their early cardiovascular disease and we can actually treat that and get them to a stage when they can have standard prostate cancer therapy by treating the comorbidities. Then we have the frail men who probably need adapted therapy and, very sadly, the ones who wouldn’t be suitable for treatment. But we talked quite a lot about how to adapt different therapies to the older population who are going to be more and more of our practice as we go on and, thankfully, we live longer.
LMP: Yes, and in my group the same – age was not the limit, it was the comorbidities and the performance status of the patient. So this is probably the most important thing to know – if a patient is able to receive more toxic or less toxic treatment, yes.
HP: I think that probably concludes our discussion from the Prostate Cancer Debate. My name is Heather Payne and it’s been a great pleasure to be with you today and thank you very much for listening.
