Grant guides urologists on gaps in advanced PCa guidelines

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A two-part grant is designed to provide guidance on gaps in existing guidelines on the management of advanced prostate cancer, Neal D. Shore, MD, reported at the LUGPA annual meeting in Chicago.

The first project is a practical guide to the optimization of androgen deprivation therapy (ADT). The second is a practical guide to the management of metastatic castration-resistant prostate cancer (mCRPC), said Dr. Shore, LUGPA’s immediate past president who is in practice at Atlantic Urology Clinics in Myrtle Beach, SC.

The projects are supported by an unrestricted educational grant from Tolmar Pharmaceuticals. Both are expected to be published in separate papers in early 2020.

“We're not rewriting guidelines but trying to look at where there were gaps in the existing guidelines, whether it was NCCN, or AUA, or ESMO, or ASCO,” Dr. Shore said. “That's what our goals were.”

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A 14-member panel of experts was developed for each project. Urologic oncologists and medical oncologists were chosen based on their experience and expertise in the management of advanced prostate cancer. Four academic panel members (two medical oncologists, two urologists) served as section leaders. Eight panel members were chosen from LUGPA practices with extensive experience in advanced prostate cancer management.

To develop expert opinion, a modified Delphi consensus was created. This entailed a series of debates, presentations, and then a vote, Dr. Shore explained. To get consensus, nine to 14 votes were needed.

In project one (submitted to The Prostate, September 2019), topics for ADT utilization were addressed, including:

• role of primary ADT in newly diagnosed prostate cancer

• neoadjuvant ADT prior to radical prostatectomy or radiation therapy

• ADT as salvage therapy

• ADT for biochemical recurrence patients, post-definitive therapy

• ADT for castration-sensitive prostate cancer (CSPC) and CRPC

• management of ADT adverse events and prevention strategies.

The final paper will include an algorithm that Dr. Shore said will serve as an excellent resource “for thinking about how to deal with androgen deprivation therapy across the entire spectrum of prostate cancer.”

Project two focuses on the management of CRPC, with genetic and molecular testing front and center, Dr. Shore said. “This is a big initiative that's really important moving forward.”

Next: Part two topicsPart two topics addressed were:

• biomarker monitoring and the role of genetic and molecular testing in mCRPC

• strategies and optimal sequencing of approved CRPC therapies, including hormonal, cytotoxic chemotherapy, radiopharmaceuticals, and immunotherapy agents

• adverse event management and monitoring

• implications of novel biomolecular and imaging advances.

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Dr. Shore showed attendees a sample consensus statement, along with the results of voting:

In mCSPC, the distinction between low- and high-volume disease has not been studied in this context. Thus, ADT + abiraterone is a reasonable standard of care irrespective of metastatic burden.

The panel’s vote: 86% Yes, 14% Indeterminate.