PracticeUpdate: Haematology & Oncology

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Special roundup of the 17th APCC inMelbourne By Rajesh Nair, FRCS (Urol), FEBU, MSc and Homayoun (Homi) Zargar, MD, FRACS

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 . C onference president Anthony Costello, MD, FRACS, FRCSI, MBBS, of the Royal Melbourne Hospital, opened the 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

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. 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. 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, 1 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

The APCC faculty

cancer was explored further with Professor Sweeny elaborating on the CHAARTED 2 and STAMPEDE 3 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 in The Lancet recently. 4 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.

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