The ESTRO update: prostate cancer today and tomorrow
During the joint ESTRO-EAU session held at the ESTRO 30th Anniversary Congress in London, two plenary sessions aimed to cover some of the most pressing and controversial issues of prostate cancer management.What is the evidence-based that is being created right now?Dr. Ficarra (University of Padua, Italy) lectured on the future of robotic surgery, he highlighted that results of Robotic Assisted Laparoscopic Prostatectomy (RALP) series analysis do not seem to be mature enough for a definitive rigorous oncologic evaluation. However, RALP provides a less invasive approach, with apparently similar oncologic outcomes and probably slightly better functional outcomes (especially in terms of potency recovery).
The subsequent lecture focused on radiotherapy treatment with particle beams. Dr. Zietman (Massachusetts General Hospital, Boston, USA) pointed out that particle beams will be widely accepted if: they prove that further dose escalation is safe and increases cure, they show a benefit in quality of life, there is a broadening in the indications of treatment such as prostate cancer, the cost can be dramatically reduced, novel technology proves a safer way to adjust beams and verify dose and if finally, overuse does not discredit the technology.
The following presentation was related to brachytherapy. Dr. Hoskin (Mount Vernon Hospital, Northwood, UK) mentioned that Low dose rate (LDR) brachytherapy is a well-established treatment option for low risk prostate cancer and that High dose rate (HDR) brachytherapy is gaining popularity. The favourable biological characteristics of prostate cancer make HDR brachytherapy using large doses per fraction an attractive proposition. Both LDR and HDR brachytherapy have been reported to be further options for relapsing patients seeking local salvage. Dr. Hoskin finally brought up that new indications will include LDR brachytherapy for intermediate risk disease, HDR monotherapy for low and intermediate risk disease and both LDR and HDR techniques for salvage after local relapse
The last presentation dealt with the salvage options for biochemical failure after radiotherapy. Dr. Ahlgren (Skane University Hospital, Lund, Sweden) indicated that radical prostatectomy is the main option for highly selected patients but other salvage options such as brachytherapy, cryotherapy, HIFU and photodynamic therapy are being investigated. Systemic failure after radiation therapy should be treated with early (PSA<10 ng/ml) hormonal therapy. He finally stated that ongoing trials are testing the combination of docetaxel with HT, and androgen receptor blockers like MDV3100.
Vision for the future: Translational research / High technology
Prof. Schalken (Radboud Universtiy, Nijmegen, Netherlands) conducted the first presentation of this plenary session. He commented on new biomarkers better than PSA in the screening of prostate cancer. Until now only two markers, PCA3 and ETS gene fusions are clinically available or close to implementation. Meanwhile, targeting high-risk population by stratiﬁcation based on SNPs identiﬁed by Genome Wide Association Studies (GWAS) has been suggested. Prof. Schalken also commented that recently, gene variants are found to correlate with serum PSA levels, and has been also found that men carrying BRCA2 mutations have a high chance to develop prostate cancer.
Finally, Dr. Widmark (University Umea Norrlands Universitetssjukhus, Umea, Sweden) talked about the importance of reducing toxicity while maintaining efficacy in low risk prostate cancer patients. Examples of these objectives are: implanted fiducial gold seeds to reduce margins in RT treatments, rectal fixation probe and injection of hyaluronic acid in Dennoviliers fascia to separate the rectal wall from the prostate in prostate brachytherapy. In high-risk tumors the developmental aim is to improve outcome with combined or more efficient treatments (even higher dose escalation or combination of HDR brachytherapy and external radiotherapy).
Dr. Widmark ended his presentation indicating that the future translational studies should probably focus on the interaction between prostate cancer cells and the metastatic bone tissue, including its stroma, with bigger focus in the interaction betwee