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“Guidelines have to be criticised to be improved”

“Guidelines have to be improved. To be improved, they have to be criticised. If they are well criticised, it’s an improvement.” These are the words of Prof. Nicolas Mottet (FR), chairman of the EAU Guidelines panel for Prostate Cancer.

Mottet hailed the EAU Guidelines Controversies specialty session on the second day of EAU18 as a very positive development in the discussion of the EAU Guidelines. The session was organised as four hour-long debates between a moderator, two opposing views, a third, independent, view and much audience discussion and voting. It drew large crowds, particularly when it came to combining systemic treatment of metastatic prostate cancer.

Examining the Guidelines

“It’s not always possible for us to detail all the arguments that support what we write in the EAU Guidelines,” Mottet explained. “So it’s nice to have a session like this, where we can explain our position, particularly when they are hot topics, like bladder preservation vs. removal. It’s good to hear arguments in favour and against, and then somebody completely outside of that paradigm, particularly when they address methodology.”

Mottet was referring to the presence of Dr. Laurence Collette (BE) in the debate on prostate cancer. Dr. Collette is the Chief Statistician for the EORTC. Following a debate between Prof. Noel Clarke (GB) and Mr. Philip Cornford (GB) on the merits of combining systemic treatments for every patient or only a small selection, Dr. Collette weighed in on the data that both discussants were citing:

“How much does the subgroup contribute to the full picture? We should consider the percentage of events, rather than the patients.” In the example of the CHAARTED trial, low volume disease accounted for 35% of the patients, but only 25% of events in its latest update. Definitions of “high volume disease are also debatable, relying on bone scans alone, distinguishing aggressive vs. slow-growing disease, and so on.

Based on the audience’s votes before and after this particular debate, it seems Dr. Collette swayed many of those present. Before the debate, the audience was split almost evenly between four possible answers to a question about newly-diagnosed M1a disease (enlarged retroperitoneal nodes only): ADT combined with Abiraterone acetate, ADT combined with Docetaxel, either drug or ADT monotherapy. Following the debate, nearly half of the audience voted for the third option, a combination of ADT and either drug.

Shades of grey

Mottet reflected on the choice of topics when the session was over. “When something is not black or white, the guidelines need to say something, and we have to explain our recommendations. At some point we might realise that we made mistakes, and that’s OK. Through evidence, discussion and criticism, we ultimately improve our guidelines.”

Some of these “grey” topics that were debated in Saturday’s session include muscle-invasive and metastatic bladder cancer and the prospects of organ preservation becoming the gold standard; mesh vs. non-mesh surgery for genital prolapse and urinary incontinence and testis cancer.

Article by Loek Keizer