EAU 2018: Local Control is Needed

Local Control is Needed 1

Local Control is Needed 2
Presentation: Dr. Joniau, as the urologist in the session, argued for local therapy for local control. Though, it is important to note, he did not argue it should be done in isolation.   He approached this in a systematic fashion. Prostate cancer presents in a spectrum of clinical presentation, ranging from localized disease to oligometastatic disease to metastatic disease.

High-risk localized disease – based on conventional imaging

At the end of the day, this patient was likely included in many prior trials for high-risk localized disease. He is cN0M0 on conventional imaging. As such, his outcomes should mirror those populations.

  • SPCG7 trial – additional of local radiotherapy to ADT vs. ADT alone for cT3+N0M0 patients provided CSS and OS benefit
  • PCBaSe (Stattin P EU 2017) – population-based analysis, found that increasing utilization of localized therapy (surgery or radiation) was associated with less cancer-specific deaths in both high-risk and locally advanced disease.
  • STAMPEDE trial, control arm – control arm received just ADT +/- RT in newly diagnosed cM0 nmPCa. RT addition improved PFS in the cN0M0 cohort and the cN+M0 cohort
  • Seisen EU 2017 – population-based analysis, local therapy was associated with better survival outcomes in cN+ localized PCa patient
The clinical and biologic rationale for treatment of the primary tumor exists.

  • Avoidance of the morbidity associated with locally progressive disease – which can be symptomatic and limit ability to continue systemic therapy
  • Biologic rationale:
  • Tumor shedding from primary
  • Tumor self-seeding from CTCs
  • Surgical removal of primary may reverse tumor-induced immunosuppression
  • Cross-talk between tumor and microenvironment
And, early cM1 data, albeit retrospective or population-based, may suggest some benefit to local therapy

  • Rusthoven JCO 2016 – NCDB study demonstrating OS benefit to RT / RP in cM1 patients
  • Ongoing clinical trials in this disease space are pending
As such, local treatment may help supplement systemic therapy in the cM1 space, whether it be oligometastatic or not.

Presented by: Steven Joniau, MD, PhD, Leuven, Belgium

Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark

Read More Treatment Options for this Case Presented at EAU 2018:

Treatment Option: Systemic Therapy is the Standard of Care - Silke Gillessen Sommer, MD, St. Gallen, Switzerland
Treatment Option: Local and Metastasis Imaging Targeted Treatments are Needed - Gert De Meerleer, MD, Ghent, Belgium