22 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE The focus of the discussion was the current recommendation on the management of mHSPC. Dr Conray Moolman, a Cape Town based urologist and a partner at Cape Urology, provided a case presentation of de novo metastatic prostate cancer. The case was that of a • 71-year-old male • Currently well with an ECOG performance score of 0 • Presenting with de novo metastatic prostate cancer • Imaging conrmed regional pelvic lymph node metastases and low volume bone metastases • The patient had not received any prior systemic therapy including hormonal therapy Dr Hugo Van der Merwe, from the The Urology Hospital in Pretoria, led the discussion on the optimal treatment options for this patient. His discussion was based on clinical guidelines to date including the AUA, EAU, NCCN and ESMO recommendations with regards to the management of mHSPC. These expert recommendations are based on clinical data including over 10 000 patients treated over a decade. These studies conrm the benet of androgen receptor targeted therapy in reducing the risk of death by 30% in mHSPC. These treatments have acceptable toxicity while maintaining patient quality of life. Dr Van der Merwe emphasized the importance of an individualized treatment approach taking into consideration the following key factors to guide the choice of therapy. 1. Synchronous (de novo) vs metachronous (relapsed) mHSPC Metastatic HSPC may present as either de novo (at the time of primary diagnosis) or as metachronous disease with metastases developing after completion of local treatment. Based on EUA ndings, 12% of patients diagnosed with prostate cancer present with de novo metastatic disease. Metachronous mHSPC has been shown to have a better prognosis compared to de novo presentation. Patients presenting with metachronous disease should be managed differently from de novo metastatic disease and the clinical response may also differ depending on prior therapy which may have included local therapy (surgery or radiotherapy) as well as systemic therapy (ADT). 2. High volume vs. low volume disease • The volume of metastatic disease (high vs. low) is based on the results of two pivotal trials (LATITUDE and CHAARTED). Refer Table 1 • The volume of metastatic disease and onset (de novo/metachronous) inuences the choice of the therapy • Docetaxel is benecial in high volume, de novo metastatic disease • ART is benecial regardless of disease volume or timing of presenting metastatic disease • The risk classication applies to localised diase and is predictive of the risk of metastatic disease after local treatment and should not be confused with disease volume. A practical approach to the management of metastatic hormone sensitive prostate cancer (mHSPC) – feedback from SAUA Astellas Trade Symposium Table 1: Volume denition vs. Risk classication Visceral disease and ≥4 bony mets, with ≥1 beyond pelvis and vertebral bodies De novo mets(M1), ≥2 bone mets, visceral mets, GS ≥8 Locally advanced (M0), ≥2 of the following: T3/T4, GS ≥8, PS≥40 CHAARTED: High volume disease LATITUDE: High volume disease STAMPEDE: High risk disease
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