EPAD20 Q&A

Here you can find the questions asked during EPAD20 and the answers from the panelists.

Q: How do we get General Practitioners (GPs) to support early diagnosis and use PSA testing?
A: We are reaching out to primary care networks to get their views and hopeful endorsement on the algorithm for risk stratified early detection of well informed men. It will be important to understand any concerns they have, and how we can support them with information and evidence in useful formats. The initial effort must also be to reach out to GPs to make sure they know the latest scientific evidence, so they are not relying on outdated guidance.

Q: Wouldn’t eliminating surgery from the treatment menu favorably shift the cost-benefit ratio of early detection? After all, the most serious side effects (incontinence etc) are due to surgery, not radiotherapy, while effectiveness is equivalent and costs are lower.
A: Radiotherapy may require surgery at 5 and 10 years follow up. This means radiotherapy is usually a good solution for older early detected men. The advantage of surgery appears with longer  life expectancy up to 15 years, where local recurrences become a problem for radio therapy , as well as second tumors (rectal and bladder). In  most countries radiotherapy is more expensive than surgery.

Q: We hear a lot about radioligand therapy. What is your opinion on the effectiveness of this therapy on prostate cancer?
A: Radioligand therapy today is becoming relevant and will soon become an important treatment of advanced, castrate resistant prostate cancer (not for prostate cancer caught early). It holds great promise.

Q: How about the addition of prostate cancer-based assays that monitor gene fusion and PCA3 genes?
A: They will further refine our risk stratification, but it is expensive and not available everywhere, so we should not wait for the new markers to start early detection today because of increasing numbers of too late diagnosis, which means a further rise in prostate cancer mortality in the years to come.

Q: What is you opinion on urine tests, like Select Mdx?
A: Select MDX will further refine our risk stratification, but it is expensive and not available everywhere, so we should not wait for the new markers to start early detection today because of increasing numbers of too late diagnosis, which means a further rise in prostate cancer mortality in the years to come.

Q: What about Bi Parametric MRI vs Multi Parametric Mri?
A: For early detection, if the MR image-quality and reading are good, contrast can be omitted. “Fast-MRI” is bpMRI.

Q: There is a strong case for PSA screening. From what age do you suggest?
A: We  currently have evidence that screening reduces mortality as from age 50. We only start screening in younger men if they are of high risk of developing prostate cancer, i.e positive family history,  etc. The German PROBASE study is assessing the effect of starting at age 45.

Q: What’s the role of PCA and newer markers in screening and diagnosis?  Such as https://edrn.nci.nih.gov/biomarkers/mips-mi-prostate-score-urine-test
A: They will further refine our risk stratification, but they are expensive and not available everywhere, so we should not wait for the new markers to start early detection today because of increasing numbers of too late diagnosis, which means a further rise in prostate cancer mortality in the years to come.

Q: Many countries have formal screening programs done by urologists for men after 60 (eg Austria and Germany) and paid by health insurance. But some countries like Germany have eliminated PSA coverage, based on the American study. What can be done to reinstate coverage of PSA and even mpMRI?
A: This is exactly what our White Paper, this event, and our recommendations are aiming to achieve.

Q: Results of ERSPC trial looks really impressive. Do we know, what would be PSA(+/-MRI)-based screening results on population level?
A: The Rotterdam cohort of the ERSPC trial indeed showed a PCa mortality reduction of 52% at 19 years follow-up in a cohort with about zero contamination, which is impressive indeed. The addition of risk calculators and of MRI will maintain the reduction of mortality and at the same time decrease overdiagnosis, the main blame PSA testing got over the years. The rather low cut-off value PSA of 3 ng/ml is to avoid missing aggressive cancers, where again MRI will find them.

More trials are on the way, in e.g. Sweden and Finland. Knowing that mpMRI will help in detecting selectively potentially aggressive prostate cancer, the expectation is at least a similar mortality reduction, but more favorable numbers are needed to screen and diagnose, and obviously less over-diagnosis.

Q: HIFU avoids local problems of surgery and secondary problems of radiation, preserving quality of life while leaving all options open in case of local recurrence. More directed treatment is possible as long as we know exactly where the cancer is situated = MRI targeted biopsies + random biopsies to detect significant cancer missed by MRI remain mandatory if focal treatment is considered.
A: The EAU-Guidelines-endorsed active treatments of the primary are surgery and radio therapy. HIFU can only be offered within a clinical trial setting or a well-designed prospective cohort study.

Q: Will personalised medicine improve the quality of life for PC patients? Treat the patient not the cancer.
A: We believe it will. The thought alone of knowing that the proposed treatment plan is completely tailored to your cancer and personal wishes will help in increasing quality of life of patients.

Q: Patients having hormones and radiotherapy who report insomnia, is their insomnia related to hot flushes and nocturia.
A: Hot flushes and worrying as well. Nocturia in my view relates to temporary edema of the prostate. Alphablockers and NSAID’s seem to give good results for this.

Q: What barriers are there to mpMRI scans being widely available?
A: 1. Knowledge about the advantages of the technique by patients and primary care (GPs). 2. Trained ‘prostate-MRI’radiologists and urologists 3. General availablility of State-of-the art MRI-scanners. Artificial Intelligence will help in the future.

Q: What’s your opinion about prostate biopsy – between transrectal and transperineall, which is better?
A: The latter, then we avoid life threatening sepsis, which is crucial with growing antibiotic resistance. We did a study on 2600 men: In-bore + Trans Rectal fusion MRI-biopsy are equal to Trans Perineal-biopsy with regard to outcome and side-effects. However, with TR-biopsy you need to use preventative antibiotics. But if you perform in addition to targeted biopsy also a random biopsy, the chance for sepsis increases with TR-biopsy, and thus I would choose for MR targeted TP-biopsy.

Q: Are we going back to the screening era as I see in some lectures?
A: No, this is exactly what will not be endorsed by policy makers and experts. Well informed healthy men, 45-50 years should be offered PSA testing. Many men will continue to ignore that they have a prostate, that they can get Prostate cancer that might imply impact on their virility, potency and sexual performance. So be it. But those well informed men that know what the limited impact of early treatment is will have the right to be tested.

Q: What’s your opinion about maybe someday that MRI can replace the biopsy for diagnosis of the PCa?
A: No you always will need biopsy to confirm a positive MRI (there are false positives in granulomatous prostatitis). But we can reduce the number of needles, and we do not have to use biopsy in a well performed negative MRI.

Q: Early detection is the key factor to reach the goals of Europa Uomo and adapted minimal invasive treatment strategies to the individual situation of each individual patient : as much as is needed without overkill, as little as is necessary, preserving maximal quality of life.
A: This is very true. The strategy of Europa Uomo is very clear: Start with awareness , followed by early detection as explained by Monique Roobol and Hein Van Poppel and finally treat when needed in cancer centres with a multidisciplinary  approach in order to assure maximum quality of life.