SIU 2019 39th Annual Society of International Urology Congress

SIU 2019: Non-Metastatic Castrate-Resistant Prostate Cancer - Does It Exist?

Athens, Greece (UroToday.com) Dr. Boris Hadaschik presented on the disease entity of non-metastatic castrate-resistant prostate cancer (nmCRPC). According to Dr. Hadaschik, the short answer to whether this disease is: YES, as there are guideline-approved drugs for this unique disease entity.

This disease entity is unique and it is the bridge to metastatic castrate-resistant prostate cancer (mCRPC), (Figure 1).

Figure 1 – Non-metastatic castrate resistant prostate cancer:

SIU19_nmCRPC.png

There have been three recent randomized controlled trials assessing the endpoint of metastases-free-survival (MFS) in patients with nmCRPC: SPARTAN1 – assessing apalutamide, PROSPER2 – assessing enzalutamide, and ARAMIS3 – assessing Darolutamide (Figure 2). All studies showed a 59%-72% reduction of distant progression or death, and all studies demonstrated a statistically significant improvement of MFS.

Figure 2 – Metastasis-free-survival in three randomized prospective controlled trials assessing patient with nmCRPC:

SIU19_MFS.png

However, with the added benefit of these new medications, there was also a report showing the increased adverse events that are associated with these medications. These include mainly fatigue, rash, and fractures.

The next topic discussed was the role of PSMA PET scanning in the identification of metastases in patients who were initially defined as being in the nmCRPC state. In a study assessing 200 nmCRPC men, 55% of men demonstrated distant metastases despite having negative conventional imaging. This argument actually supports the fact that nmCRPC does not really exist, as more sensitive imaging diagnoses these men and shows that they have metastatic disease.

Dr. Hadaschik concluded is talk supporting the use of PET PSMA imaging as early as possible when biochemical recurrence is present. It is important to be aware of the mode of imaging used in registrational trials. Better imaging may cause stage migration without oncological benefit. Moreover, the value of PET-imaging for the treatment guidelines should be tested in future studies. Lastly, despite all these advancements, it is always important to continue to treat men according to evidence and guidelines.

Presented by: Boris Hadaschik, MD, Chairman, Department of Urology, University Hospital Essen, Essen, Germany 

Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, New-York, USA @GoldbergHanan at the 39th Congress of the Société Internationale d'Urologie, SIU 2019, #SIUWorld #SIU2019, October 17-20, 2019, Athens, Greece

References:

  1. Smith MR, Saad F, Chowdhury S, et al. Apalutamide Treatment and Metastasis-free Survival in Prostate Cancer. New England Journal of Medicine 2018; 378(15): 1408-18.
  2. Hussain M, Fizazi K, Saad F, et al. Enzalutamide in Men with Nonmetastatic, Castration-Resistant Prostate Cancer. New England Journal of Medicine 2018; 378(26): 2465-74.
  3. Fizazi K, Shore N, Tammela TL, et al. Darolutamide in Nonmetastatic, Castration-Resistant Prostate Cancer. New England Journal of Medicine 2019; 380(13): 1235-46.
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