APCCC 2021: Summary of Panel Responses Regarding PSMA in Diagnostics and Therapy

(UroToday.com) The second session of the Advanced Prostate Cancer Consensus Conference 2021 which was hosted in the context of the COVID-19 pandemic focused on the role of prostate specific membrane antigen (PSMA) imaging in prostate cancer diagnostics and therapy. Following the conference presentations, Dr. Neal Shore and Dr. Alberto Bossi led a discussion of the consensus panel responses to questions relating to the role of PSMA diagnosis and theranostics.

Addressing first question #47, Dr. Bossi summarized the results of the question of whether PSMA-PET/CT would be recommended for stating of localized prostate cancer. Notably, 50% of patients recommended its use for patients with high-risk disease only while 23% of respondents recommended its use for both intermediate and high-risk disease. A very small proportion of respondents (4%) suggested that it would be used in the majority of patients independent of risk.

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The audience response was similar with the majority (55%) recommending its use for those with high-risk disease alone.

Secondly, Dr. Bossi addressed question #50 regarding whether extended pelvic lymphadenectomy can be omitted for patients undergoing radical prostatectomy for high-risk localized disease on the basis of negative PSMA imaging. Here, there were consensus results with 77% of respondents suggesting that they would still recommend pelvic lymphadenectomy.

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Dr. Declan Murphy emphasized that the clinical benefit of pelvic lymphadenectomy is still uncertain and that it has a risk of morbidity. Thus, in his experience, negative PSMA results may influence treatment decisions. Further, Dr. Michael Morris highlighted that this reflects the fact that PSMA-PET/CT has relatively low sensitivity. Further, the negative predictive value declines as prostate cancer risk increases. Dr. Briganti emphasized that the utility of PSMA to omit lymphadenectomy may be in patients with a lower risk of nodal involvement. A number of consensus panel members emphasized that this is a topic requiring further data.

Moving forward, Dr. Bossi summarized results for question #52 which addresses patients with high-risk localized prostate cancer for whom radical prostatectomy is planned who have no evidence of nodal disease on conventional imaging but 1-3 PSMA-PET/CT positive lymph nodes. The majority (53%) of respondents suggested that treatment should proceed as planned.

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The audience response was similar though only 40% endorsed proceeding with treatment as planned.

The next question (#58) addressed a similar question among patients with high-risk localized prostate cancer for whom radical local therapy is planned who have no evidence of nodal disease on conventional imaging but 1-3 PSMA-PET/CT positive bony lesions. Just over a majority (51%) of respondents recommended radical local therapy as planned, plus metastasis-directed therapy, and systemic therapy.

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Dr. Gillessen emphasized that some PSMA-tracers may have false-positive bone lesions. This may be particularly influential in this disease space.

Dr. Bossi then discussed the results of question #63 assessing the role of Lu-PSMA therapy in chemotherapy-fit patients with mCRPC after one line of AR-pathway inhibitor and one line of taxane-based therapy in patients with PSMA-positive lesions. The consensus majority (77%) of panel members recommended the use of Lutitium-PSMA.

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Addressing question #68, of whether we should recommend lutetium-PSMA therapy in patients with metastatic castration-sensitive prostate cancer, 86% of the consensus panel recommended against this approach.

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This concluded the discussion of the consensus panel responses regarding the role of PSMA in both prostate cancer diagnostics and treatment.

Presented by: Alberto Bossi, MD, Goustave Roussy Institute, Villejuif, France and Neal D. Shore, MD, FACS is the Medical Director for the Carolina Urologic Research Center. He practices with Atlantic Urology Clinics in Myrtle Beach, South Carolina

Written by: Christopher J.D. Wallis, University of Toronto Twitter: @WallisCJD during the 2021 Advanced Prostate Cancer Consensus Conference, Saturday, October 9, 2021.

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