Zach Klaassen: Hi, my name is Zach Klaassen, and we are in Cartagena, Colombia for SCU 2025. We're delighted to be down in South America to cover this meeting. I'm joined by Dr. Julian Chavarriaga, Dr. Luis Salgado, and they're hosting a symposium here looking at ADT in this era of treatment intensification, ARPIs.

Gentlemen, thanks so much for joining us on UroToday. It's great to be here.

Julian Chavarriaga: Thanks for having us.

Luis Salgado: Thank you.

Zach Klaassen: This symposium, just a high-level overview, Julian, why is it important to have these symposiums when we're looking at treatment intensification? Maybe just a highlight of what topics you guys discussed at this symposium.

Julian Chavarriaga: I think one very important thing is ADT remains the cornerstone management of prostate cancer. We need to keep talking about ADT. I know it should be one of the most used treatment strategies in prostate cancer, at least in advanced prostate cancer, or even localized for some time. But as you understand, a lot of uro-oncologists come to these meetings. But there's also general urologists, endo-urologists, and there's people who see these patients, but they don't treat them all the time, so we need to reinforce the concept.

Treatment intensification, it used to be only ADT. Now you can't think of metastatic prostate cancer without treatment intensification. It cannot be taken outside of that box. I think it's very important.

One of the problems we face, not only in Colombia or South America, I think it's all over the world, is the uptake of these treatments. As we put it before, it could be between 40% to 50% of the patients with metastatic [inaudible 00:01:37] are getting ARPIs. I think this is a concept that we need to reinforce.

Zach Klaassen: Yeah, well said. Luis, you guys discussed PSMA PET, MRI in the setting of recurrence. When should we be using both of these imaging modalities?

Luis Salgado: Both are complementary. The MRI or PET PSMA is... MRI is for local recurrence, and PET PSMA is for systemic, so we need to do in many scenarios, but it's complementary.

Zach Klaassen: Yeah, absolutely. Do you use both on most patients in your practice?

Luis Salgado: Maybe. All patients need MRI or PET PSMA, but it's complementary for me.

Zach Klaassen: Yeah, absolutely. Julian, you guys discussed biomarkers for treatment intensification. I know this is a hot topic that you obviously do a lot of work with. What were the discussions, and what's the reasoning behind these biomarkers for MHSPC?

Julian Chavarriaga: Yeah, I think the goal for us is we are trying to personalize treatment for metastatic prostate cancer patients. For sure, we've gotten better and we intensify all the patients now.

But do all these patients need treatment intensification? For example, if you have high volume disease, do all these patients need chemotherapy? As we saw recently, inactivation of PTEN could be a predictive biomarker of response to docetaxel. Maybe if you have a patient with high-volume disease who is doing well on ADT and ARPI, getting ultra-low PSAs, fast respond to the treatment, and they don't have a PTEN inactivation.

Maybe down the road in the future you'll be comfortable offering this patient docetaxel, so I think that that's the goal. Yeah, exactly.

Zach Klaassen: Absolutely. Luis, I know Julian talked a little bit about treatment intensification uptake in Colombia. Even in the United States where there's ubiquitous availability of all these agents, there's still only 70, maybe 80% treatment intensification. What's the rate here in Colombia, and why do you think the rate is what it is?

Luis Salgado: Okay, I start with we need more education in the world. The identification era is very important in prostate cancer. In Colombia, it's maybe the 30 or 50%. I think more education, more congress, more interview, just like that.

Zach Klaassen: More UroToday interviews.

Luis Salgado: Exactly. It's very important with the percent is growing up.

Zach Klaassen: Yeah, absolutely. I think that's a good point, not just for South America and Colombia, but also for the United States and across the globe.
Julian, I'll ask a spin-off question. In your practice, we've got great data for doublet therapy, we've got great data for triplet therapy. How are you differentiating between who you're going to do triplet therapy versus double therapy?

Julian Chavarriaga: Yeah, that's a very good question. I think in my practice, I have the discussion with all the patients. I go straight in and tell them these are the options. Of course, for patients with low volume disease, I prefer to go for double therapy. These patients are usually going to do well unless they don't get an ultra-low PSA or they're taking long to get to the ultra-low PSA. Those patients, I do not prescribe chemotherapy, but at least I send a referral to the medical oncologist so they can at least have the discussion with them. Maybe they don't even never received chemotherapy, but they at least had it in their mind and they went and had discussion.

High volume patients, at least if they're de novo, these patients usually go for the medical oncology clinic. They often get chemotherapy.

Zach Klaassen: I know in my practice, and that's the same way I handle my patients too, we still see young patients with high volume disease in the United States. Is that similar in Colombia?

Julian Chavarriaga: Oh yeah, unfortunately. PSA screening is actually is pretty good, I think. But there's some patients, there are some rural areas where patients, they don't have awareness. They don't know they have to do it. When they come to our clinics, sometimes it's too late.

One of the troubles we have, at least here, is these patients from rural areas, we may not see them again soon. What are we going to offer them, and how is going to be done? It's critical to decide what we're going to offer these patients, yeah.

Zach Klaassen: Absolutely. Great discussion, guys. I'll give you each a chance for some concluding statements. Luis, any concluding take home messages for our listeners?

Luis Salgado: Thank you. The intensification era in prostate cancer is very important. We need to grow up in the world. It's very important for me is the message.

Zach Klaassen: Absolutely. Great message. Julian, final word?

Julian Chavarriaga: Yeah, I think for South Americans, we should be aware that treatment of prostate cancer has changed significantly. It's not anymore only ADT. We need to strive towards intensification for at least all our patients with ARPIs. We decide if we're going to do triplet or doublet based on different biomarkers and patient factors, but at least every patient should get intensification with ARPIs.

Zach Klaassen: Absolutely. Congratulations on a great symposium on this topic at the SCU. It's great to have both of you on your own today.

Luis Salgado: Thank you.

Julian Chavarriaga: Thank you.