MA: Welcome to this SIOG, International Society of Geriatric Oncology, discussion about prostate cancer. I’m here, Matti Aapro, medical oncologist, and I’ll be discussing with Nicolas Mottet, a urologist who doesn’t need any introduction as he has been leading the EAU guidelines committee and has been discussing about the specifics of prostate cancer in the elderly population in many settings including, of course, the EAU guidelines. So, welcome Nicolas.
NM: Welcome to all.
MA: Nicolas, we are going through a bad period. Everyone is hoping that the various vaccines that have been discussed, and actually some of them are being used right now already in some countries, will solve, at least for a while, this pandemic and maybe there is going to be another one, another time. But what is, in your perception, the impact in the prostate cancer field? We know about medicine in general, we know about cancer in general, but what about prostate cancer? What is the impact of the pandemic?
NM: The impact is double. The first worry is there is less and less diagnosis. I have friends especially, for example, in Holland, they had 75% less cancer diagnoses, 75% less prostate biopsies. So the diagnosis of cancer will decrease. Will this translate into a less effective survival? Well, that needs to be seen but at least we will see more advanced disease, that’s quite sure.
The second impact of the pandemic is that patients are reluctant, at least in my country, were very reluctant to go to the hospital and to go and see doctors. So there might be also a waste of time dealing with treatment and especially treatment of side effects. We see this already in everyday practice.
MA: Nicolas, the world at large has experts and excellent doctors who cannot cope with the changes in the literature that happen from time to time and actually sometimes very often in the guidelines and the guidance. Then we need guidance for the older patients as a lot of the data we have is for younger patients. So can you tell me a little bit about the way the International Society of Geriatric Oncology taskforce has chosen to develop the guidelines that are joint guidelines with EAU on prostate cancer in the elderly?
NM: There are two ways for that. The first, SIOG has made its own specific guidelines with medical oncologists, radiotherapists, urologists and they published extensively on the updated guidelines. The problem I see there is that these guidelines are mainly extensively driven on geriatric and less on the disease itself. It doesn’t mean they are poor, they are very good, but what is lacking is a very strong methodology behind. At EAU we have a strong methodology but we were lacking expertise in geriatrics. So we considered two things: initially we just fully endorsed the SIOG guidelines and we had several chapters especially under the guidance of Jean-Pierre Droz in that. We completely incorporated a summary of the SIOG guidelines and now we have a very full official collaboration with SIOG with an official SIOG representative, from the UK, who did an absolutely brilliant job in terms of improving what we have evidence-based and it’s based on the literature. We have to realise that in some cases we wrote positions that were purely positions and not supported by strong evidence. So we had to reorganise a little bit what we had. That’s the way we find the collaboration to keep going.
MA: How much of the guidelines, you mentioned the SIOG with the geriatric oncology perspective and, of course, the EAU expertise, how much were the guidelines also influenced by what our friends on the other side of the ocean, i.e. ASCO, has been developing or maybe the American urologists have been developing or ESMO, the European Society of Medical Oncology, or the European Society of Surgical Oncology? Has there been any interaction with all of these experts?
NM: Regarding the international society, we had official collaboration with ESTRO, with the European Society of Urology, with the Society of Pathology. We hope that once upon a time we will be able to have an official collaboration with ESMO, that seems to be a little bit difficult. In prostate that’s where we are. We are, of course, looking at… we had for the first time an official collaboration with ASCO regarding biomarkers in prostate and that is now fully published in the JCO. We started an official collaboration with ASCO again regarding locally advanced disease but our timelines and their timelines are a little bit different so it was quite difficult to run both things in parallel. So finally it ended with purely the EAU. We absolutely read all that is published in terms of guidelines and our primary selection criteria is the methodology behind. If the methodology is correct, if the work is done by another society, we just use it. If the methodology must be approved we have to do our own if we believe our methodology is better.
MA: The guidelines, as you have emphasised, have been developed with a very precise methodology. But now we are facing a situation that no-one really thought of less than a year ago and we have to adapt. What has been done to adapt the guidelines to the COVID crisis?
NM: That’s a very good question. The first thing we were asked about a year ago when the pandemic started about prioritisation – which disease and which state of disease must be treated and which state of disease or which disease can be postponed for weeks or months or even years? That forced us to reconsider the priority, at least for prostate. To our surprise, it was very clear that for low risk disease postponing treatment for years, at least for a year, had almost no impact. For intermediate risk almost no impact. For high risk localised a very questionable impact, once again, in terms of strong endpoints. Though that was the first step we had to deal with – prioritisation – which sounds to be trivial but, in fact, is not trivial at all.
Second, if we have to choose between various treatments for the most advanced disease, let say, for metastatic androgen sensitive when we have to choose between ADT plus chemo or ADT plus abiraterone or enzalutamide and apalutamide, we had to consider what are the side effects and what are the risks. Initially we thought chemotherapy avoid as much as possible, now we know that probably that was too strong and there have been many papers published with large cohorts showing that the pure impact of chemotherapy death during the pandemic is almost close to zero. There is no extra risk in that. But, at the same time, if there is no extra risk of death there is an extra risk to need to go into an intensive care unit where there was a lot of trouble regarding the number of beds. So we had to consider this, how to prioritise treatment if we have to choose between various treatment strategies. Even if the evidence is poor, we were able to find some evidence to say, well, in that case probably avoiding surgery and considering radiotherapy might be better; or avoiding chemo and considering new anti-androgen treatment therapy might be better. It’s not evidence based, I would say it’s common sense based.
MA: Well, we need common sense, it’s true, when we are lacking evidence and I will come to this point at the end of our conversation. But I would like to hear from you about the approach to the older person. How do you view the recommendation of SIOG to classify the patients as perfectly fit or as frail, as unfit? What’s your perspective? How useful is that in your decision-making process?
NM: On evidence based it’s very relevant; on everyday practice based, to be absolutely honest, it’s quite difficult to achieve. The SIOG started with G8 and the Mini-Cog as two simple screening tools, that’s absolutely perfect. What is much more difficult to achieve in real life, in the intermediate group, we need geriatricians. All the difficulty is to find geriatricians who have time and who are dedicated to oncology. They need to be specialised in geriatrics but they also need to understand what we are doing and why we are doing this, what are the benefits and the side effects of what we are offering, to put that into perspective. To have the geriatricians on board is absolutely needed, there is no discussion, it should be level 1 evidence. In real life it’s more difficult. I’ve been lecturing on that for some time and it’s very attractive to see that there are more and more people aware of that but still the vast majority of physicians are just saying, ‘Well, this guy is 85 years old so he is too old.’ Come on, age per se does not mean anything. This very special point begins to be understood but not fully understood yet.
MA: I think you really said a key message here in your words. It’s not about a number, it’s about who the patient is. It sometimes can be somewhat complicated to evaluate and this really leads me now to the last question. Do you agree with me, I’m kind of hinting that you should, that our main message today to all our colleagues is look at who your patient is, don’t look at the patient’s age. Look at the other diseases and maybe we don’t need a geriatrician but we need someone with internal medicine knowledge to deal with all of these issues before we take a decision.
NM: I couldn’t agree more. You made it perfectly clear that exactly the message we have that is in the SIOG guidelines, that is in the EAU but it’s not only for prostate, it’s for bladder, for kidney, for all the diseases, even outside oncology. The patient is much more important than the age and the date of birth. The date of birth doesn’t mean anything.
MA: Thank you very much, Nicolas, for your insight. Of course everyone should go to the EAU website, to the SIOG website to look at the guidelines of these two societies. Thank you very much for your attention.