Treatment of Locally Advanced Prostate Cancer - Murilo Luz
May 10, 2022
Murilo Luz, MD, Urologic Oncologist, A Beneficência Portuguesa, São Paulo, Brazil
Phillip J. Koo, MD, Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona.
Phillip Koo: Hi, I'm Phillip Koo, and welcome back to our coverage of the 13th International Uro-Oncology Congress in São Paulo, Brazil. We have with us today, Dr. Murilo Luz, who's a uro-oncologist at the Portuguese Beneficence Hospital, São Paulo.
He's speaking on several topics at this conference, but we're going to highlight a couple areas that he's speaking on. So number one, you're talking a lot about locally advanced disease and how that impacts urology. So could you give us some of the highlights from your lecture?
Murilo Luz: Yeah, sure. So thank you for having me here, Phillip. So this a very nice meeting and one of the hot topic is definitely it's locally advanced disease for prostate cancer. Because that is a typical point of the disease that involves oncology, urologists, radiation oncology, so everybody's there.
And at the end, the final answer actually, we don't have the ideal or one treatment that actually fits all patients. So at the end, we are still struggling to find the best way to combine treatments most of the times. And we always have this debates about surgery doing better or radiation doing better. Most of what we have is retrospective data.
Most of the data we have in retrospective trials is favoring surgery, but obviously, there is a big bias for surgery. We are sending the best patients, the patients that they have the worst disease, or the worst patients, to radiation most of the times, older ones, more sick ones, and having the best patients, actually younger patients that fit well for surgery. So there's a big bias of selection when we discuss retrospective data, and we don't have still some good comparison in prospective trials comparing surgery to radiation.
At the end of the day, the conclusions we have most of the time is that the best treatment is a combination of two or three treatments. So even when you do surgery, it's very rare, although it happens, but it's very rare that you're going to cure a patient with locally advanced disease or high risk disease only with surgery. That happens with few patients with a localized glycine eight or nine, very small nodule.
And maybe you're going to treat and have a long term control of the disease only with surgery. But most of the times, you're going to have surgery followed by radiation or follow by radiation plus sometimes of hormones. And almost the same happens with radiation as a starting point. So when you start with radiation, definitely you're going to need at least 18 months or 24 months of hormones associated to that.
So what we are seeing right now is trying to select the best candidates. We do have some studies now starting to select based on some genetic testing, some genomic classifiers to see really who are the patients that need a lot of treatments, adding some more treatment, and maybe some of the patients that can have one or the other. So this is the scenario we have right now, but the problem is we still don't have the final answer for that.
Phillip Koo: Very true. So one point we heard is that radiation oncology services, our access is a little limited. And perhaps not at BP, but are you seeing that in the community nationwide that access to radiation oncology and LINACs is a limiting factor?
Murilo Luz: Yeah, that's a factor in Brazil. This is a continental country. You have like a 250 million people here and 25% actually is private insurance right now. And 75% have public insurance. And we don't have available radiation machines everywhere in the country. So at some point you have to take that into account when deciding if a patient is going to surgery and radiation.
And even being a surgeon, I knowledge that the opposite is also true. Maybe you are in a place somewhere in the country that you have a good service of radiation oncologist, a good radiation oncologist working there, and maybe you don't have very experienced surgeons doing prostatectomies, which is a quite challenging procedure, have a good learning curve, even doing open laparoscopic or robotic surgery. No, it's not the more complex surgery we do in neurologic oncology, but it's a very tricky surgery with the oncological and functional outcomes that you have to take into account.
So this happens sometimes. You have to take into account at your decision in treating with radiation or surgery, what you have available and what kind of service you have and what kind of experience you have. We are happy to work in a place that you can have the best of both. So we have good surgeons, we have good radiation oncologists, and then it's easier for us to take the decision and it's easier for the patient's point of view also. But definitely that's not the reality everywhere.
Phillip Koo: Sure. So what is the role of PSMA PET in your practice in patients with local advanced disease? Is it something that you routinely get in patients who are high risk, higher and immediate risk?
Murilo Luz: Yeah. We are happy to have PSMA PET in Brazil since I'd say 2017 or '18. I know the FDA approved recently, but we do have in Brazil quite a few years ago. And we are actually using since two years or a year and a half ago, as a routine for staging when patients have access. Some insurance are not reimbursing that. Public insurance are not definitely. But when patients have, they can pay for it or they are reimbursed for it.
We are ordering PSMA PETs pre-op for high risk disease and some case of intermediate and favorable intermediate risk disease, definitely. And that changed practice. We know we have good data on that, that would change practice sometimes around 25 or 30% of the time, depending what kind of disease you're talking about, but that can really change what you're planning to do with that patient.
Some major changes, operating or not operating anymore. Or maybe some minor changes or an extended lymph node dissection, or maybe the radiation field. So, but whenever we can, we are ordering PSMA PETs for staging and for biochemical recurrence.
Phillip Koo: Great. So one thing I'm learning at this meeting is that there's clearly a new focus on clinical research in Latin America, especially. And I think clinical research for urology might be something even newer to the field. So what messages do you have for urologists and urologic oncologists who are looking to get into clinical research?
Murilo Luz: Yeah, this very interesting topic. I'm actually particularly interested in that. We do have a good potential of recruiting patients everywhere. Our patients and our population, actually, we do need access to new drugs and new treatments. So those things fits very well in getting more and more clinical trials in Brazil.
The problem is, we still need some more sites, some more centers. We need to train people to run those trials properly in a good way, actually, to benefit our patients. And urologists, now we as a Brazilian society of urology, now we really want, we have a department specifically looking for that and we want urologists to be more involved in clinical research because they see lots of patients that actually candidates for entering in many of the trials.
So it's very important to have this cooperation between urology and medical oncologists and on clinical trials. And this is a reality for us now. And we see that thing is, it's growing in Brazil. We're having more and more trials. More and more patients have been recruited. Some of trials actually initiated by Brazilian investigators in the last few years, which we are really happy with that. So this is a field that we're going to explore much more in the near future.
Phillip Koo: I think that's exciting and there's so much potential, there's so much professional satisfaction in that space and I look towards... So many urologists have had such an impact. I mean, Burton Tomball, Fred Side, Neal Shore. I mean, these people have just done amazing work from the urologist perspective. Any final thoughts you have to share with the audience?
Murilo Luz: Yeah, I think, again, this is actually a great meeting that we're bringing people, that we are very happy to have people in person again this year. It's hybrid. Some people feel safe at home and they can watch the meeting. But we are really happy to see people interact and have some networking again. I think this is good. This is good for science. This is good for us as persons. And definitely, we're going to have very good information from here that at the end of the day is going to benefit our patients.
Phillip Koo: That's great. So I encourage all the urologists out there who are watching, all the medical oncologists, put this on your calendar, and radiation oncologist, nuclear medicine, radiology, everyone, put it on your calendars and join us here next year. Thank you very much.
Murilo Luz: Thank you.