PracticeUpdate: Haematology & Oncology

The Asia-Pacific Prostate Cancer Conference (APCC) continues to host world leaders in all aspects of prostate cancer diagnosis, management and cutting-

edge research. This exciting 4-day meeting, 31 August–3 September in Melbourne, remains one of the largest global multidisciplinary forums in prostate

cancer, attracting over 750 delegates from more than 20 countries and showcasing over 20 international speakers. The meeting combined clinical urology,

translational science and integrated nursing and allied health professions in a multidisciplinary environment. In this special feature, Dr Nair and Dr Zargar

discuss clinically relevant new research topics presented at this uear APCC .

onference president Anthony Costello,

MD, FRACS, FRCSI, MBBS, of the

Royal Melbourne Hospital, opened the

meeting alongside Lord Mayor of Melbourne,

Robert Doyle. They reminded delegates of the

cultural and scientific progress Melbourne has

witnessed in medicine and science, and the

progress that has been made in prostate cancer

care worldwide. When discovered, therapeutic

nihilism decreed prostate cancer a rare disease

with no known cure. It is now the commonest

cancer diagnosed in men with ever increasing

therapeutic strategies and research.

Screening, biopsies and surveillance

Stacey Loeb, MD, MSc, of NewYork Univer-

sity, opened the plenary session with ‘Prostate

cancer: a year in review’. This excellent session

described key publications and presentations

from the American Urological Association

on prostate cancer. Perhaps it was the

Euro-

pean Urology

paper, suggesting that men who

ejaculated 21 or more times a month was at a

lower risk of developing prostate cancer,

which

raised the most eyebrows.

Dr Loeb featured throughout the meeting

with an informative talk on prostate biopsy

complications, particularly sepsis, and the role

of template-guided biopsies in the war against

antibiotic resistance. She discussed the role of

active surveillance and current protocols for

selection and monitoring. What was apparent

was the degree of variation in how active sur-

veillance was performed globally, with some

units incorporating PSA alone while others in-

corporated repeat biopsy schedules and MRI.

John Davies, MD, FACS, of MD Anderson

Cancer Centre (United States) and Dr Zargar

described the impact of reduced PSA screening

guidelines issued by the US Preventive Ser-

vices Task Force. The effects of such changes,

although currently immature, show serious

trends toward a reduction in radical treatment

for prostate cancer. Dr Zargar, in particular,

explored the ripple effect of such changes in

Australia, where rates of PSA screening and

radical prostatectomy have dropped synony-

mously. Whether this translates to an increase

in metastatic disease over time remains to be

seen.

Imaging in prostate cancer

Rob Reiter, MD, MBA, of David Geffen

School of Medicine, University of California,

gave an overview of MRI in the United States

for early detection of prostate cancer, signal-

ling an era where MR targeted fusion biopsies

detected more significant tumours and fewer

less significant tumours compared with sys-

tematic biopsies alone.

Robert Nam, MD, MSc, FRCS, of Sun-

nybrook Health Sciences Centre, University

of Toronto (Canada), shared a pilot study

using MRI as a screening test for prostate

cancer. Phillip Stricker, MBBS, FRACS, of

St Vincent’s Hospital in Sydney, expanded on

this concept, describing a nomogram devel-

oped in Sydney incorporating MRI to predict

significant prostate cancer. Dr Reiter then

showed how 3D modelling with MRI could

accurately predict final pathology from radical

prostatectomy specimens.

The strength and experience of Australian

urologists and radiologists in PSMA PET im-

aging was showcased throughout the meeting.

Michael Hofman, MBBS, FRACP, FAANMS,

of Peter MacCallum Cancer Centre in Mel-

bourne, and Nathan Lawrentschuk, MBBS,

PhD, FRACS, of Austin Hospital, Melbourne,

delivered a state-of-the-art lecture on PET im-

aging and presented their systematic review

and meta-analysis of PSMA PET imaging for

prostate cancer. A subsequent panel discus-

sion was chaired by DeclanMurphy, MBBCH,

BaO, FRACS, FRCS, of Peter MacCallum

Cancer Centre and the Royal Melbourne

Hospital, with case-based discussion focused

on how best to integrate this technology into

everyday practice.

John Violet, MD, of Peter MacCallum Can-

cer Centre, described the future of PSMA as

a marker for targeted radiation delivery, as he

discussed early outcomes for 177Lu-PSMA

in the metastatic castration-resistant prostate

cancer setting.

Translational science, genomics and

metastatic disease

One of the novelties of the APCC meeting

is the ability to bring research in basic science

and clinicians under one roof. Peter Carroll,

MD, MPH, of the University of California,

started proceedings by integrating translation-

al science and clinical practice, by reviewing

commercially available tests for genetic profil-

ing in prostate cancer. Clearly the future is the

field of genomics and individualised cancer

care. His description of current RNA and

DNA-based genomic tools risk stratify patients

before and after radical prostatectomy.

Christopher Sweeny, MBBS, of the Dana

Faber Cancer Institute (United States) and

Bertrand Tombal, MD, PhD, of the Université

catholique de Louvain (Belgium), reiterated

this message in an informative presentation

on precision medicine. They described inter-

tumour heterogeneity in prostate cancer on

a molecular and clinical level. The fascinat-

ing descriptions of genomic and radiological

variations seen between primary tumour and

in metastatic disease served to remind all of

the multiple targets that are yet to be studied,

sequenced and targeted by drugs, particularly

in those patients with metastatic-castration

resistant disease.

Nial Corcoran, PhD, FRACS, of the Royal

Melbourne Hospital, explored the role of met-

astatic prostate cancer further with a superb

presentation exploring the role of bone biopsy

in men with metastatic disease in genomic

sequencing, and understanding the biology of

metastases. The theme of advanced prostate

cancer was explored further with Professor

Sweeny elaborating on the CHAARTED

and STAMPEDE

trials, both acknowledging

the survival advantage gained in introducing

taxane chemotherapy in addition to andro-

gen deprivation at the time of high volume

metastatic disease. Small cell neuroendocrine

prostate cancers were also discussed. These

are not as uncommon as once thought and

Eric Small, MD, of the University of Cali-

fornia, described their relative resistance to

abiraterone and enzalutamide.

Almost synonymous to the discussion of

metastatic prostate cancer management was

a debate of prostatectomy versus radiotherapy

for localised disease by Robert Nam, MD,

FRCSC, of Sunnybrook Health Sciences

Centre, University of Toronto (Canada). He

presented Canadian data examining long-term

outcomes and meta-analyses favouring surgery

particularly with reference to side effects. Jas-

preet Sandhu, MD, of the Memorial Sloan

Kettering Cancer Centre in New York, then

outlined many of the continence and erectile

function outcomes following radical prosta-

tectomy and some of the strategies utilised in

improving continence outcomes.

Perhaps the highlight lectures of the meeting

included the 4th Patrick Walsh Lecture given

by Martin Gleave, MD, FRCSC, FACS, of

the University of British Columbia (Canada)

titled ‘Two tales of precision oncology’. This

exquisite lecture dissected some of the finer

nuances in precision oncology in castration-

resistance prostate cancer.

Peter Wiklund, MD, of Karolinska Uni-

versity Hospital (Sweden) gave the ERUS

Lecture examining the role of surgery in

high-risk and metastatic prostate cancer. He

was subsequently supported in the programme

by George Thalman, MD of the University

of Bern (Switzerland), Phil Dundee, MD of

the Royal Melbourne Hospital, and John Yax-

ley, MD of Wesley Urology Clinic, Brisbane,

examining the indications and techniques,

and evidence for and against extended pelvic

lymph node dissection.

Open versus robotic prostatectomy:

the Brisbane experience

No conference is without controversy, and

Geoff Couglin, MBBS, FRACS of Wesley

Urology Clinic, Brisbane, and Dr Yaxley

presented one particular debate that engaged

the audience. They reported the early onco-

logical and functional outcomes of open versus

robotic prostatectomy of a randomised con-

trolled multicentre phase 3 study published

The Lancet

recently.

Urinary function and sexual function were

similar at 12 weeks post prostatectomy. Posi-

tive surgical margin rates were also similar at

10% versus 15% in the open versus robotic

groups, respectively. Robot-assisted radical

prostatectomy is associated with clinical out-

comes similar to those achieved with open rad-

ical prostatectomy. Yet, secondary outcomes

show a different picture: the robotic group

demonstrated less blood loss, less postopera-

tive pain, and a shorter hospital stay.

Whilst highly commendable, this study did

not control for individual surgical experience

and trainee involvement, and the outcome pa-

rameters recorded at 12 weeks represented too

short a follow-up period to allow for meaningful

comparison. If anything, this study allows one

to view robotic surgery in a favourable light; a

lesser experienced surgeon is able to deliver

functional and oncological outcomes that an

experienced open surgeon can deliver by adopt-

ing robotic techniques.

References

1. Rider JR, Wilson KM, Sinnott JA, et al. .

Eur Urol

2016

Mar 28[Epub ahead of print]

2. Sweeney CJ, Chen YH, Carducci M, et al.

N Engl J

Med

2015;373:737-746

3. James ND, Sydes MR, Clarke NW, et al.

Lancet

2016;373:737-746

4. Yaxley JW, Coughlin GD,

Lancet

2016;388:1057-66

Dr Nair is a UK-trained urological surgeon

undergoing advanced

fellowship training in

robotics and uro-oncology

at the Royal Melbourne

Hospital. Dr Zargar is

a urological surgeon

with fellowship training

in uro-oncology, and

advanced laparoscopic

and robotic surgery. He is

Consultant Urologist at the

Royal Melbourne Hospital

and Senior Clinical

Lecturer, Department

of Surgery, University of Melbourne.

The APCC faculty

Special roundup of the 17th APCC inMelbourne

By Rajesh Nair,

FRCS (Urol), FEBU, MSc

and Homayoun (Homi) Zargar,

MD, FRACS

Perhaps the highlight lectures of the

meeting included the 4th Patrick

Walsh Lecture given by Martin

Gleave of the University of British

Columbia (Canada) titled ‘Two tales

of precision oncology’. This

exquisite lecture dissected some of

the finer nuances in precision

oncology in castration-resistance

prostate cancer.

PROSTATE

PRACTICEUPDATE HAEMATOLOGY & ONCOLOGY