Thereafter 45 experts of the Italian scientific societies engaged in the multidisciplinary and multiprofessional management of the disease, expressed their agreement level using a RAND 9-point numerical rating scale.
Fig.1: Estimate-talk-estimate method applied
Three items concerned the use of: a) PSMA PET, b) biological and clinical assessment, and c) local and systemic therapies; finally, one item was dedicated to critical issues in multidisciplinary and multiprofessional management.
The use of PSMA PET, even largely adopted for its accuracy, could be used to identify further sites of disease, although in the absence of evidence concerning its impact on survival outcomes. For this reason and the fact that it has been used in pivotal studies, conventional imaging (CT and bone scan) should still be considered. Radiotracers, such as Choline or Fluciclovine should only be used in selected cases.
Proper clinical assessment of the patient (fit, unfit, frail) is mandatory in the choice of systemic treatment along with disease characteristics (volume, de novo vs recurrent).
Clinicians should consider concomitant medications and toxicity profiles too. In the case of drug-drug interaction between the oncological and concomitant drug, the latter should preferably be modified (dose reduction or drug substitution).
The use of ADT could be considered only in cases with severe comorbidities and/or short life expectancy. Local treatment, whether on primary tumor or metastatic disease, should be evaluated on a case-by-case basis in a multidisciplinary setting, with careful definition of the benefit-to-harm ratio.
Although liquid biopsy has been proven to be a valuable tool for identifying biomarkers (prognostic and predictive), to date there are no validated prospective data available to recommend its use to monitor response to ARSi in prostate cancer.
Finally, in the continuum of the treatment of patients with mHSPC and nmCRPC, the upper and lower urinary tract should be systematically monitored to detect any obstruction or functional pathology earlier. Similarly, bone imaging should also be performed to detect symptomatic and/or fracture-prone bone lesions in order to adopt palliative radiotherapy (for symptomatic and/or consolidation purposes).
Written by: Prof. Rolando M. D'Angelillo, Professore Associato di Radioterapia, Università degli Studi di Roma Tor Vergata, Rome, Italy
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