Expert Panel Offers Guidance on PCa Controversies

BY JOHN SCHIESZER

FINDINGS arising from a consensus conference may help clinicians navigate controversial areas in the treatment of men with advanced prostate cancer (PCa).

The 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed an international panel of experts for their opinions about key dilemmas in clinical management to help supplement evidence-based guidelines.

The consensus conference is convened to address only controversial areas in which high-level evidence is scant. “We specifically go for these topics with our questions,” said first author Silke Gillessen, MD, of the Oncology Institute of Southern Switzerland, EOC, Bellinzona. “Therefore, clinicians who have less experience with prostate cancer because they treat a wide variety

Psma Pet

The panel reached consensus on the use of prostate-specific membrane antigen-positron emission tomography (PSMA PET) in various clinical situations. For systemic staging of clinically localized PCa, in addition to prostate magnetic resonance imaging (MRI),

78% of panelists voted to recommend upfront PSMA PET with or without subsequent conventional imaging, according to the report’s authors. For patients with clinically localized PCa with PSMA-positive findings consistent with bone metastases on the computed tomography (CT) component of upfront PSMA PET, 78% of panelists voted not to recommend additional imaging such as MRI or bone scintigraphy. For patients with clinically localized high-risk PCa, 77% of panelists voted to recommend PSMA PET.

The panel reached strong consensus for not recommending PSMA of different tumors, can check in the report what world experts are doing in specific situations where there is no strong evidence. We hope that therefore their patients will profit from the transfer of ‘concentrated knowledge’ of experts to their treating physician.”

Multidisciplinary Panel

Before the conference, a multidisciplinary international panel of 117 PCa experts developed multiple-choice consensus questions related to 7 controversial areas. At the conference, 105 panelists voted on the questions. Of this group, 50% were medical oncologists, 29% were urologists, and 21% were clinical oncologists and radiation oncologists. The panel defined consensus as 75% or greater agreement on an answer option and strong consensus as 90% or greater agreement.

Survey findings are detailed in a report in European Urology. The authors wrote that “although this report captures what experts in the field think today, it should be interpreted and integrated into clinical practice with the same scrutiny that any other major paper would receive, and with the knowledge that consensus does not constitute or substitute for evidence.”

PET in the majority of patients with clinically localized favorable intermediate-risk (according to the National Comprehensive Cancer Network definition) localized PCa. The panel also reached a strong consensus not to recommend whole-body, diffusionweighted MRI for systemic staging in the majority of men with clinically localized intermediate- or high-risk disease.

The survey revealed no consensus as to whether to give systemic therapy along with salvage radiotherapy, or for how long, even though this is a relatively common clinical scenario, Dr Gillessen said. “In terms of hormonal treatments, we found that there is consensus to check for drug-drug interactions when starting an ARPI [androgen receptor pathway inhibitor],” she said. “Interestingly, only a minority of panelists voted for an ECG or more intensive cardiac evaluation before starting treatment with hormonal treatment for the majority of patients.”

A Welcome Effort

“I believe that expert panels are beneficial to brainstorm and synthesize the evidence and help identify knowledge gaps,” said Nirmish Singla, MD, Director of Translational Research in GU Oncology and an Associate

Professor of Urology and Oncology, Johns Hopkins Medical Center, Baltimore, Maryland. “It is important to have a well-balanced, multidisciplinary panel given the role for multimodal approaches in managing advanced prostate cancer.” Further, he noted that a panel made up of experts in urology, medical oncology, and radiation oncology is critical to ensure a balanced discussion and mitigate bias.