EMUC17: Weighing the gains and drawbacks of modern PCa treatment options

Urological cancer experts expressed concern over the efficacy, costs and long-term effects of emerging techniques on the quality of life and survival of prostate cancer (PCa) patients, saying that although there are benefits, doctors must also be aware of the drawbacks.

At the opening plenary session of the 9th European Multidisciplinary Meeting on Urological Cancers (EMUC17), which opened today in Barcelona, urological cancer experts from across Europe examined the benefits and drawbacks of technologies such as Magnetic Resonance Imaging (MRI) and focal therapy, particularly in detecting and treating clinically significant PCa. There were nearly 1,160 participants, coming from 30 countries, in this year's EMUC.

The debate query “MRI before biopsy for all men?” involved the affirmative positions of urologist Hashim Ahmed (GB) and radiologist Harriet Theony (CH) who argued on the benefits of MRI before biopsy, as against the contrary views of radiologist Olivier Rouvière (FR) and urologist Jochen Walz (FR).

“With the introduction of MR/TRUS-fusion-guided targeted biopsies there has been a higher detection rate of clinically significant prostate cancer compared to the higher detection rate of insignificant PCa by randomTRUS biopsy,” said Theony, whilst reiterating that image quality has to be excellent. “The dedication and experience of the radiologist and urologists is absolutely mandatory,” she noted.

Ahmed followed-up on Theony’s statements by saying that “looking at MRIs is like predicting the weather.” “No one remembers the huge numbers of times, we get it right. Everyone remembers the big misses….everyone forgets how bad it was before MRI,” he said.

Rouvière, although presenting the dissenting opinion, gave a more nuanced comment when he noted that MRI is indeed recommended in the repeat biopsy setting, but not in biopsy-naïve patients where there are conflicting results. Walz, on the other hand, said the quality of mpMRI outside of expert centers “…is too poor to recommend routine use.”

“Standardisation, certificiation and quality assurance are necessary before any recommendation can be given,” said Walz.

In the “Last Judgement” segment, Nicolas Mottet (FR) gave the concluding opinion when he said that indeed normal MRI results avoid biopsy and the consequent complications , although there are costs involved. Mottet stressed that doctor’s decision should be evidence-based, as he re-directed attention to current guidelines which recommend the use of a risk calculator or an additional serum or urine-based test (e.g. PHI, 4Kscore or PCA3) or imaging for asymptomatic men with a PSA between 2-10 ng/ml, before performing a prostate biopsy.

Focal therapies

Regarding focal therapies, the debate question “Will Level 1 Evidence influence our practice in focal therapy?”, urologist Mark Emberton (GB) presented pro arguments, while radiation oncologist Alberto Bossi (FR) took the opposite position.

“Focal therapy has emerged as a new class of therapy which now commands legitimacy,” said Emberton as he noted there is patient acceptance, harm-reduction and health/economic gains. “Focal therapy has forced an order of precision in terms of risk stratification that was previously missing,” he added.

On the other hand, Bossi stated that alternatives to “whole organ” therapy such as focal therapy must have the ability to reliably identify suitable candidates, provide acceptable morbidity, improve QoL outcomes, and the ability to monitor for ‘treatment failures.’ He concluded that salvage robot-assisted radical prostatectomy (RARP) after focal therapy (FT) failure “is feasible with acceptable complication rates.”

“However, patients assigned to primary FT should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of future salvage surgery,” according to Bossi.

Again, in the concluding or wrap-up segment, Arnauld Villers (FR) pointed out there is agreement on FT ‘failures’ such as ablation, targeting and patient selection failure. He discussed issues such as follow-up treatments for residual cancer and whether these are suitable for active surveillance or focal therapy.

“There is agreement on multi-focality, and FT should be targeted to the index lesion…Multi-focal cancer should not preclude focal therapy,” Villers said.