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EAU 2021 | Radiation therapy for the local treatment of metastatic hormone-sensitive prostate cancer

Piet Ost, MD, PhD, Ghent University, Ghent, Belgium, talks on the pros and cons of radiation therapy in the treatment of metastatic hormone-sensitive prostate cancer, in particular highlighting data from the STAMPEDE trial (NCT00268476), which demonstrated that local radiotherapy of the primary tumor achieved a significant survival benefit in men with a low metastatic burden. Prof. Ost also describes temporary local side effects which may occur with local prostate radiotherapy, and comments on the need for further research into sequencing of radiotherapy and androgen deprivation therapy, which will be explored in the PEACE-1 trial (NCT01957436). Finally, Prof. Ost highlights the introduction of PSMA PET-CT scanning and its impact on clinical practice. This interview took place at the virtual European Association of Urology (EAU) Virtual Meeting 2021.

Transcript (edited for clarity)

So, my name is Piet Ost, I’m a radiation oncologist located in Belgium now actively clinically working in the Antwerp region. I would like to discuss with you the pros and cons of giving radiotherapy in patients that are already metastatic. So, following the data that the STAMPEDE trial offered, we immediately saw that it’s a great opportunity where we can prolong survival of our patients just by irradiating the prostate locally...

So, my name is Piet Ost, I’m a radiation oncologist located in Belgium now actively clinically working in the Antwerp region. I would like to discuss with you the pros and cons of giving radiotherapy in patients that are already metastatic. So, following the data that the STAMPEDE trial offered, we immediately saw that it’s a great opportunity where we can prolong survival of our patients just by irradiating the prostate locally. And those data really changed the world a bit for us as this is clearly new indication where despite patients having metastasis, we can still treat the primary and patients survive longer. But it is only limited for patients with up to three metastases independent whether or not they have lymph node metastasis or not.

So, in that perspective we have a niche within de novo metastatic prostate cancer, where we have now a valuable treatment that can be delivered in 20 fractions or six fractions depending on what you want. So, it’s a very short treatment that comes on top of the standard of care at that time being ADT. Can also be sequenced together with docetaxel because those data was also provided by STAMPEDE.

One of the cons of course of radiotherapy is that you might have temporary local side effects. And some of these patients up to 10, 20% sometimes suffer a bit longer of these local side effects, but the majority of patients recuperate quite fast which was also seen in that STAMPEDE publication.

There’s still a big unknown or some unknowns because we saw some recent data from the improvement in survival by adding novel anti-androgens. And the thing is that none of these trials actually allowed radiotherapy. So, we don’t know if we still have to add radiotherapy on top of these novel drugs. So, the question is how do we sequence that? And that will probably will be solved in the PEACE-1 trial which will hopefully give us more mature data specifically on the radiotherapy part. So, we hope that we can get a better indication what our exact niche is. So, that in my opinion is those data made radiotherapy a standard of care for patients with a limited volume of metastasis.

There’s been a bit of a shook up in the world as well because PSMA PET/CT has now been introduced. And a lot of patients who are low volume on conventional imaging all of a sudden turn into higher volume patients. But for the treating clinician it’s still very important that they base their decision on the conventional imaging. So, whether or not you treat your primary just count your metastases on the bone scan, that is the most important thing to do. And that’s when you decide yes or no to treat the primary locally. Another concept which has hasn’t been solved is do we also need to treat the metastases themself with, for example, SBRT? And that is also still a big unknown. So, we will try to solve that in the upcoming STAMPEDE arm M apparently, which will hopefully start in a couple of months, but we’ll take a couple of years to know the mature data.

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Disclosures

Piet Ost, MD, PhD, has received institutional grants or research support from Merck, Bayer, Ferring and Varian; and has received honoraria or consultation fees from Astellas, Bayer, Ferring, Janssen, Sanofi and Sandoz.

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