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Welcome and introduction: An overview of the current prostate cancer treatment landscape

Francesco Montorsi

welcome without slides_1-HD

For localized prostate cancer, Dr Montorsi explains that local treatment is likely to be beneficial in most patients. For node-positive or metastatic prostate cancer, androgen deprivation therapy is appropriate, preferably with docetaxel. For metastatic castrate-resistant prostate cancer, chemotherapy including docetaxel may prolong survival; options are increased by novel agents targeting the androgen receptor.


Welcome and Introduction - Francesco Montorsi

Welcome and Introduction - Francesco Montorsi

Good evening everyone and welcome to this exciting session, which is devoted to the management of prostate cancer. The title of the symposium is “Selecting the right treatment for the right patient”; indeed an important topic.

My name is Francesco Montorsi. I am a urologist in Milan, Italy and I am delighted to Chair this symposium this evening.

Meeting objectives

We are going to review for you a number of topics which are of importance for your daily clinical practice. We will talk to you about patients with prostate cancer, highlighting the issues of comorbidities, side effects and available treatment options for this disease.

We will discuss the risk/benefit ratio of treatments based on the profile of each and every patient and discuss how patients themselves can play a very substantial role in the management of their disease with the lifestyle changes.

Programme and faculty

I am a urologist, like a majority of you. I spend my mornings in the OR doing prostate essentially and the afternoons seeing patients, so I share the problems of everyday activity like you do and I am delighted to have a wonderful team with me this evening. Professor Michiel Sedelaar, coming from the prestigious Department of Urology, Nijmegen in The Netherlands, that we have discussed for you how to best manage patients with advanced PCa who present with very bad disease – you know that there are a lot of novelties going on.

Dr Heather Payne, I am happy to see her again at the EAU; well respected and world-expert of radiation oncologist, working in London, UK – will talk to you how to determine the right patients for neoadjuvant and adjuvant therapy. Clearly we are talking about radiation therapy here.

Dr Alexander Lyon is a cardiologist and we are happy to welcome him here at this urology meeting, who will discuss with you the prevalence of cardiovascular disease in patients with prostate cancer – how to evaluate those patients, how to look at those who have risk factors.

Finally, I will conclude by talking about the management of treatment side effects through lifestyle changes, which is a new concept, and clearly that is where we can be really protagonist.

We have cards that you can use to write down your questions. There will be hostesses coming over and picking those cards up and we will discuss them at the end of the symposium.


An overview of the current PCa treatment landscape

Initially I would like to share with you some concepts as an overview of the current prostate cancer treatment landscape.

Local treatment of the primary tumour: Radical prostatectomy and radiotherapy

We all know that for patients with localised prostate cancer we don’t have a role for surgery if the patient comes in with metastatic disease, we know that when we do surgery or radiation therapy complications may arise and we know that we want consider a definitive treatment if the patient in front of us in the office has a life expectancy of 10 years or more.

Local treatment of the primary tumour: Radical prostatectomy and radiotherapy

Most of us are surgeons; we believe in the role of radical prostatectomy. There is a level 1 evidence which you all know, a series of these papers published in the New England Journal of Medicine by our Swedish colleagues showing that for patients with low and intermediate risk disease there is a significant impact on overall mortality, while there is retrospective evidence supporting the role of radical prostatectomy in patients with high-risk disease. Indeed this is an area of major interest for all of us and more and more urologists are starting to use also surgery in these patients.

Once again, radiation therapy represents also an option in men with no metastatic prostate cancer.

Systemic therapies: ADT

What is the role of androgen deprivation therapy? Typically only a few patients, according to the very last version of the guidelines, of the EAU guidelines, may find an indication if they don’t have metastases. It is standard of care according to the guidelines of node positive disease; a little bit controversial because we know that one can argue that I can use radiation therapy also in these patients, I can use surgery. Indeed, that is true but if you think about the concept of multi-modal treatment, then androgen deprivation therapy is clearly a key pillar of this, treatment of choice for patients with metastatic disease and should not be stopped in patients who show progression to castration-resistant prostate cancer.

Systemic therapies: advantages and disadvantages of different types of ADT

This is what you can do. Clearly this evening we will focus specifically on GnRH antagonists, showing to you what are the advantages of these types of drugs.

Systemic therapies: ADT and chemotherapy in metastatic PCa – two practice changing trials

When you think about the overall management of patients with bad disease, this is very recent news – I think that all of you are aware of the CHAARTED trial, which has been showing that in patients who present to you with a significant burden of metastatic disease, if you add systemic chemotherapy to androgen deprivation therapy, you have a significant improvement on overall survival.

Systemic therapies: ADT and chemotherapy in metastatic PCa – two practice changing trials

This was also shown by another very well-known study, the STAMPEDE trial from the UK, which has been showing very similar results. Clearly these two studies will be picked up by the EAU guidelines in the very last edition and will be changing our practice.

Systemic therapies: mCRPC

When patients do not respond any longer to hormones there are a number of options which are summarised in this cartoon.

Systemic therapies: docetaxel

Docetaxel has been approved, after these first in type study that was done several years ago, showing that docetaxel did have a role compared to standard therapy at that time and this has been used by ourselves and our colleagues – medical oncologists for many years.

Systemic therapies: novel androgen receptor – targeting agents for mCRPC

More recently enzalutamide has been added to our armamentarium, both in the pre-docetaxel and post-docetaxel phase of treatment of this study and indeed, it is a very valuable drug.

Systemic therapies: novel androgen receptor – targeting agents for mCRPC

Abiraterone was launched more or less at the same time. You know that if you want to use this drug you must add prednisone in these patients, but again they can be used both before docetaxel, or after docetaxel.


[Presentation concluded]