AUA 2018: Crossfire Debate: Controversies in Prostate Cancer (Con) – ADT plus Abiraterone is Key to Prolonging Survival in Oligometastatic Prostate Cancer

San Francisco, CA (UroToday.com) The management of patients with oligometastatic prostate cancer remains a controversial topic in urology.  The crossfire debate at the 2018 American Urologic Association’s Annual meeting discussed the role of focal ablation of oligometastatic disease as opposed to using systemic androgen deprivation therapy (ADT) with the addition of abiraterone.  The participants taking the “con” side of the debate argued that ablation of oligometastatic disease is not an appropriate treatment and that early ADT with the addition of abiraterone is what the best evidence suggests should be the treatment of choice for men with oligometastatic prostate cancer. Martin Gleave, MD provided the first half of the “con” debate and Robert Dreicer, MD provided the negative rebuttal.

The index patient in the debate was a 68-year-old gentleman with a PSA of 9.2.  His biopsy revealed 3 cores of Gleason 4+3=7 prostate adenocarcinoma in ~40% of the biopsy volume.  He underwent a nerve-sparing radical prostatectomy with final pathology showing Gleason 4+4=8 disease with negative surgical margins.  Unfortunately, the patient is noted to have a PSA of 8.2ng/mL 18 months postoperatively.  He undergoes a bone scan and CT which reveal metastatic bone lesions of the iliac wing and the sacrum, which are 1.2cm and 1.4cm in size.

Dr. Gleave began his argument by noting that there is level 1 evidence that ADT and abiraterone is the cornerstone of life-prolonging therapy and is the best option for most men with oligometastatic castrate-sensitive prostate cancer.  Several randomized, controlled trials have shown that early systemic treatment is superior to deferred treatment, and that combination treatment is superior to sequential treatment.  He notes that the main goal of ablative techniques is to delay ADT, which he believes compromises the gains in overall survival that have been shown in trials of early ADT.  He further discussed the several trials showing that ADT enhances the anti-cancer effects of radiotherapy in men with castrate-sensitive disease. He also referenced the LATITUDE and STAMPEDE trials which showed the efficacy of ADT and abiraterone in improving overall survival. 

Dr. Dreicer then provided the negative rebuttal, stating that the overall survival advances we have seen in men with oligometastatic prostate cancer are mainly driven by advances in systemic therapy.  He believes that there is a preponderance of data to suggest that early systemic ADT and abiraterone should be the standard treatment for men with oligometastatic disease, and that presently that there is very little strong data to suggest that focal ablation has as much efficacy.

Debaters - Con(s)
Martin Gleave, MD, FRCSC, FACS, UBC
Robert Dreicer, MD, MS, MACP, FASCO, University of Virginia School of Medicine

Written by: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia PA at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

Read the Opposing Debate: A Crossfire Debate: Controversies in Prostate Cancer (Pro) – Focal Ablation of Oligometastatic Prostate Cancer
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