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Strategic decision-making in low-risk prostate cancer

Active surveillance and its role in low-risk prostate cancer remains a challenge for both doctors and patients particularly when progression risks, disease complications and the patient’s own priorities are taken into consideration— issues that were examined during Thematic Session 15 of EAU18.

Chaired by Prof. Chris Bangma (NL) the session looked into methods for selecting patients for active surveillance (AS), monitoring in an era of imaging genomic markers, and individualised or tailored treatment approaches.

“The ideal test in active surveillance would stratify men who need immediate treatment, men would never benefit from treatment and those who may benefit from treatment at some point in the future,” said Dr. Caroline Moore (GB) during the point-counterpoint segment where she took the affirmative stand on the issue that only Magnetic Resonance Imaging (MRI)-targeted lesions are relevant for AS selection.

Moore said MRI detects prostate tumours which need immediate treatment and that MRI  (plus PSAD) tests negative in men on AS who do not need treatment.

“Biopsy compliance is poor and AS for men with small lesions makes sense,” she said.

Dr. Christian Arsov (DE), however, took the opposing view and said that a negative MRI cannot completely exclude high-grade cancers. “In the selection phase of AS, 10 to 20% of high-grade cancers can only be excluded by additional systematic biopsy,” said Arsov. He also argued that the diagnostic quality of MRI and MRI-targeted biopsy “…is strongly dependent on the experience of the investigator.”

Assoc. Prof. Antti Rannikko (FI) in his lecture on “Monitoring: Can we skip biopsies?” said that after proper diagnostics (with or without MRI) and including confirmatory biopsy, “…surveillance biopsies may not be as important as often considered in the intermediate term (~10 years). “MRI is helpful at diagnosis, but there is lack of data for MRI-based monitoring,” said Rannikko.

Variation in PCa monitoring

Variations in PCa surveillance were discussed by Prof. Yoshiyuki Kakehi (JP) for the Asian perspective, Prof. Peter Carroll (US) for North America and Prof. Anders Bjartell (SW) for the European view.

Kakehi said in Japan “unfortunately, very few patients will choose active surveillance.” Patients have a strong fear of cancer, and public awareness of AS is still inadequate. Moreover, Japanese urologists seldom propose AS to patients. A survey of more than 2,000 Japanese urologists, showed more than 75% have no or only have a few AS experiences,” he said.

Carroll said that in North America there is a growing number of patients opting for AS in recent years, while in Europe Bjartell pointed out that selection criteria for AS are “…limited by a lack of prospective RCTs, or findings from a formal consensus meeting.”

Prof. Monique Roobol (NL) spoke on the issue whether there is a need for a protocol, and said that protocols can drop out since AS may soon be obsolete.

“AS is currently done according to strict protocols and with safe inclusion criteria,” said Roobol. “Compliance to the AS protocols is moderate to poor.” She also noted that future directions would include combining MRI with molecular testing to identify those men that might progress.

Prof. Riccardo Valdagni (IT) discussed the issues faced by patients noting the three main critical points encountered by patients in their AS journey, such as decision-making in the early phase, the subsequent emotional uncertainties and his experience during the follow-up.

“What can a patient do? Be empowered! And be supported by clinicians to be the co-leader of his journey. Patients have to take a shared responsibility in the decision-making process”, said Valdagni.

Article by Joel Vega