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PROSCA 2019 - case 6

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Your case challenge

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You answered: D
You answered: D
A) Watch and wait
B) ADT monotherapy
C) ADT + additional systemic agent (e.g. docetaxel, abiraterone)
D) Stereotactic RT to bone lesion +/- systemic drug
E) Stereotactic RT to bone lesion +/- systemic drug within a clinical trial
What would Piet Ost do?


The patient has a high-risk prostate cancer based on his high ISUP score and presents himself rather late with a biochemical recurrence. The probability of an isolated, local recurrence is rather low in this patient. Unsurprisingly, conventional imaging is negative and probably should not have been performed in this patient. The 2019 EAU guidelines recommend PSMA PET-CT in these patients only in case the outcome would change your management.

Option A and B are correct options according to the EAU guidelines. For patients with a biochemical recurrence and negative conventional imaging, there appears to be no survival benefit from immediate ADT over delayed ADT for patients with a biochemical recurrence based on the TOAD trial [Duchesne GM et al. Lancet Oncol 2016;17:727-37]. For option C, there are insufficient data in support for adding an additional systemic drug as these populations were not included in trials such as STAMPEDE. For option D, there are only phase 1 and 2 data in support of stereotactic body RT (e.g. STOMP, SABR-COMET, POPSTAR, ORIOLE). In the absence of level 1 evidence this option should not be considered as a standard treatment option.

Personally, I would opt for option E as there are different trials running or being setup in different countries.


I’m happy to discuss all these options in more detail during PROSCA on 23-24 October in Paris.  
 
 


What would Piet Ost do?

The patient has a high-risk prostate cancer based on his high ISUP score and presents himself rather late with a biochemical recurrence. The probability of an isolated, local recurrence is rather low in this patient. Unsurprisingly, conventional imaging is negative and probably should not have been performed in this patient. The 2019 EAU guidelines recommend PSMA PET-CT in these patients only in case the outcome would change your management.

Option A and B are correct options according to the EAU guidelines. For patients with a biochemical recurrence and negative conventional imaging, there appears to be no survival benefit from immediate ADT over delayed ADT for patients with a biochemical recurrence based on the TOAD trial [Duchesne GM et al. Lancet Oncol 2016;17:727-37]. For option C, there are insufficient data in support for adding an additional systemic drug as these populations were not included in trials such as STAMPEDE. For option D, there are only phase 1 and 2 data in support of stereotactic body RT (e.g. STOMP, SABR-COMET, POPSTAR, ORIOLE). In the absence of level 1 evidence this option should not be considered as a standard treatment option.

Personally, I would opt for option E as there are different trials running or being setup in different countries.


I’m happy to discuss all these options in more detail during PROSCA on 23-24 October in Paris.  
 

Do you have an interesting case of your own?

Up to 3 case reports will be selected by the scientific committee for discussion in the official programme of PROSCA 2019.
 

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