[CCAFU french national guidelines 2016-2018 on prostate cancer]

Real-World Treatment Patterns Among French Patients With Metastatic Castration-Resistant Prostate Cancer Under Abiraterone or Enzalutamide

PURPOSE

Using large French retrospective study cohort of chemotherapy-naïve metastatic castration-resistant prostate cancer patients (mCRPC; n = 10,308) comparing survival between patients who initiated abiraterone (ABI; 64%) and those initiating enzalutamide (ENZ; 36%), the present objective was to describe treatment patterns in the 2 years following initiation.

METHOD

Using the national health data system (SNDS) from 2014 to 2018, we first explored the number of treatment lines, and secondly, patterns of patient management using state sequence analysis; cluster analyses were performed on the 0 to 12 month and 13 to 24 month periods. Age, Charlson score, and duration of androgen deprivation therapy (ADT) were obtained for each cluster in the first year of follow-up.

RESULTS

Patients with only 1 treatment line accounted for 52%. In the 0 to 12 month sequence analysis, the main clusters among ABI/ENZ new users involved patients who continued the initial treatment (54% of 65% respectively) and discontinued active treatment (14.5% for both). Less than 2 years exposure to ADT prior to ABI/ENZ initiation was frequently observed for noncontrolled mCRPC, as shown in the death and switch from ABI/ENZ to docetaxel clusters. The clusters for a switch ABI/ENZ to ENZ/ABI involved 6% to 11% of the patients.

CONCLUSION

Our study suggested fairly similar patterns between ABI and ENZ initiation. The cluster of patients with active treatment discontinuation needs to be further investigated, as well as factors influencing therapeutic choice. Better understanding for the use of second-generation hormone therapy in mCRPC in real life, could improve its implementation by clinicians in the early stages of prostate cancer.

Bone Metastases and Health in Prostate Cancer: From Pathophysiology to Clinical Implications

Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. Distinct phenotypes are described: osteoblastic, the more common osteolytic and mixed. A molecular classification has been also proposed. Bone metastases start with the tropism of cancer cells to the bone through different multi-step tumor-host interactions, as described by the "metastatic cascade" model. Understanding these mechanisms, although far from being fully elucidated, could offer several potential targets for prevention and therapy. Moreover, the prognosis of patients is markedly influenced by skeletal-related events. They can be correlated not only with bone metastases, but also with "bad" bone health. There is a close correlation between osteoporosis-a skeletal disorder with decreased bone mass and qualitative alterations-and prostate cancer, in particular when treated with androgen deprivation therapy, a milestone in its treatment. Systemic treatments for prostate cancer, especially with the newest options, have improved the survival and quality of life of patients with respect to skeletal-related events; however, all patients should be evaluated for "bone health" and osteoporotic risk, both in the presence and in the absence of bone metastases. Treatment with bone-targeted therapies should be evaluated even in the absence of bone metastases, as described in special guidelines and according to a multidisciplinary evaluation.

[De novo or secondary metastatic prostate cancer management in France: Observational study from "sentinel multidisciplinary meeting" of the French Association of Urology]

INTRODUCTION

Metastatic prostate cancer (mPCa) is an heterogeneous disease. Metachronous mPCa (MM) seems to have a better prognosis than synchronous mPCa (SM). However, it is difficult to analyze their specificities from national registries. Data from the so-called "sentinel multidisciplinary meeting" (SMDM) would represent a "real life" data collection. The objective of this national pilot study was to evaluate the concept of SMDM through the description and comparison of the diagnosis, management and follow-up of patients with synchronous or metachronous mPCa in 2018.

METHODS

A survey covering clinical, biological, radiological data as well as treatment initiated and follow-up at 3 and 6 months was sent to the SMDM. All patients diagnosed with metastatic disease (SM or MM) between 01/01/2018 and 11/30/2018 were included.

RESULTS

In total, 780 patients from 39 centers were included, 408 SM and 372 MM. SM were more symptomatic and had a higher metastatic burden than MM. PET were mostly performed in MM without a prior standard staging. SM patients received more chemotherapy than MM patients whereas new generation androgen deprivation therapy was mostly given to MM patients. At 6 months, there were no more significant difference in clinical presentation between the two groups.

CONCLUSION

Specificities of SM and MM patients in terms of clinical presentation, metastatic burden and management were described, validating the concept of SMDM as a source of reliable informations.

LEVEL OF EVIDENCE: 4

Adherence to Treatment Guidelines and Associated Survival in Older Patients with Prostate Cancer: A Prospective Multicentre Cohort Study

The guidelines on prostate cancer treatment in older men recommend evaluating the patient's underlying health status before treatment selection. We aimed to evaluate the frequency of a guideline-discordant treatment (GDT), identify factors associated with GDT, and assess the relationship between GDT and overall survival. We studied patients with prostate cancer aged 70 or older included in the ELCAPA cohort between 2010 and 2019. Multivariable logistic regression assessed GDT-associated factors. The restricted mean survival time (RMST) assessed the 24- and 36-month OS using stabilized inverse probability of treatment weighting of propensity scores. We included 356 patients (median age: 81 years), and 164 (46%) received a GDT (95% confidence interval (CI) = (41-51%)). Patients with metastases were less likely to receive a GDT (adjusted odds ratio (95% CI) = 0.34 (0.17-0.69); p = 0.003). After weighting, the RMST at 24 months was shorter in the GDT group (13.9 months, vs. 17 months for compliant treatments; difference (95% CI): -3.1 months (-5.3, -1.0); p = 0.004). RMST at 36 months was 18.5 months, vs. 21.8 months (difference: -3.3 months (-6.7, 0.0); p = 0.053). GDT is common in older patients with prostate cancer and especially those with non-metastatic disease. GDT was associated with worse survival, independently of health status and tumour characteristics.

Challenge of prostate MRI segmentation on T2-weighted images: inter-observer variability and impact of prostate morphology

Background

Accurate prostate zonal segmentation on magnetic resonance images (MRI) is a critical prerequisite for automated prostate cancer detection. We aimed to assess the variability of manual prostate zonal segmentation by radiologists on T2-weighted (T2W) images, and to study factors that may influence it.

Methods

Seven radiologists of varying levels of experience segmented the whole prostate gland (WG) and the transition zone (TZ) on 40 axial T2W prostate MRI images (3D T2W images for all patients, and both 3D and 2D images for a subgroup of 12 patients). Segmentation variabilities were evaluated based on: anatomical and morphological variation of the prostate (volume, retro-urethral lobe, intensity contrast between zones, presence of a PI-RADS ≥ 3 lesion), variation in image acquisition (3D vs 2D T2W images), and reader’s experience. Several metrics including Dice Score (DSC) and Hausdorff Distance were used to evaluate differences, with both a pairwise and a consensus (STAPLE reference) comparison.

Results

DSC was 0.92 (± 0.02) and 0.94 (± 0.03) for WG, 0.88 (± 0.05) and 0.91 (± 0.05) for TZ respectively with pairwise comparison and consensus reference. Variability was significantly (p < 0.05) lower for the mid-gland (DSC 0.95 (± 0.02)), higher for the apex (0.90 (± 0.06)) and the base (0.87 (± 0.06)), and higher for smaller prostates (p < 0.001) and when contrast between zones was low (p < 0.05). Impact of the other studied factors was non-significant.

Conclusions

Variability is higher in the extreme parts of the gland, is influenced by changes in prostate morphology (volume, zone intensity ratio), and is relatively unaffected by the radiologist’s level of expertise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-021-01010-9.

Prostate cancer local staging using biparametric MRI: assessment and comparison with multiparametric MRI

PURPOSE

The value of adding dynamic contrast-enhanced (DCE) imaging to T2-weighted (T2W) magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) to improve the detection and staging of prostate cancer (PCa) is unclear. The aim of this retrospective study was to compare the diagnostic performance of non-contrast biparametric MRI (bpMRI) with multiparametric MRI (mpMRI), for local staging of PCa.

METHODS

Ninety-two patients who underwent prostate MRI on a 3-Tesla MRI system before radical prostatectomy for PCa were included retrospectively. Four readers independently assigned a Likert score (ranging from 1 to 5) for predicting extra-prostatic extension (EPE) on T2W + DWI (bpMRI) and then on T2W + DWI + DCE imaging (mpMRI). MRI-based staging results were compared with radical prostatectomy histology. A prediction of EPE generalized linear mixed model was used to assess the added-value of DCE and discriminative power of staging accuracy by area under the receiver-operating curve (AUC ROC).

RESULTS

AUC was not significantly improved by DCE (mpMRI, AUC = 0.73 [95%CI: 0.655‒0.827] vs. bpMRI, AUC = 0.76 [95%CI: 0.681‒0.846]). After applying a selection procedure, only MRI criteria were retained in a multivariate model. The following criteria were significantly associated with local extension: localization in the peripheral zone (p < 0.001), maximal diameter of the lesion (<0.0001), curvilinear capsular contact on T2W (p < 0.0001), capsular irregularity on T2W (p < 0.0001), bulging on T2W (p < 0.001) and seminal vesicle hypo-signal (p < 0.001).

CONCLUSION

Use of bpMRI did not result in a decrease in local staging accuracy.

Epidemiology of metastatic castration-resistant prostate cancer: A first estimate of incidence and prevalence using the French nationwide healthcare database

BACKGROUND

There is a lack of information about the burden of metastatic castration-resistant prostate cancer (mCRPC). The present work aims to estimate the incidence and prevalence of mCRPC in 2014 using the French nationwide healthcare database (SNDS).

METHODS

Prevalence and incidence were estimated based on an SNDS extraction of men covered by the general healthcare insurance (86 % of the French population), and aged ≥40. Patients with mCRPC were identified amongst prostate cancer cases using an algorithm estimating a date of first metastasis management and a date of castration resistance. This algorithm was validated by clinical experts through a blind review of 200 anonymized medical charts from SNDS data. Prevalence and incidence were standardized on the European Standard Population (2013 edition).

RESULTS

Prevalence and incidence of mCRPC were estimated as, respectively, 62 and 21 cases per 100 000 men in 2014. Less than one mCRPC case per 100 000 was observed in men aged 40-49. Maximum mCRPC incidence was in men aged 80-89 (175 per 100 000). The algorithm used for mCRPC identification had 97 % positive and 99 % negative predictive values.

CONCLUSION

The good performances of the algorithm for mCRPC identification and the consistency of the generated results with the existing data highlight the robustness of these first estimates of mCRPC prevalence and incidence. Future updates will call for algorithm adjustment as practices evolve over time. These first real-life data will serve for future follow-up of the impact of changes in the management of prostate cancer.

External evaluation of the Briganti nomogram to predict lymph node metastases in intermediate-risk prostate cancer patients

PURPOSE

The Briganti nomogram can be used with a threshold of 5% to decide when to offer lymph node dissection during radical prostatectomy. The objective of the study was to assess the accuracy of the Briganti nomogram on intermediate-risk prostate cancer patients managed in a single academic department.

METHODS

We retrospectively reviewed the files of all patients managed by radical prostatectomy (RP) and bilateral pelvic lymph node dissection (BPLND) in our center between 2005 and 2017. The overall accuracy of the model in predicting metastatic lymph node disease was quantified by the construction of a receiver-operator characteristic (ROC) curve. A calibration plot was drawn to represent the relationship between the predicted and observed frequencies.

RESULTS

We included 285 patients, among whom 175 (61.4%) were classified as intermediate risk as defined by D'Amico. The median follow-up was 60 (34-93) months. Twenty-seven patients (9.5%) were diagnosed with lymph node metastases. The median number of lymph nodes removed was 10 (7-14). The mean Briganti score was 19.3% in patients with lymph node involvement (LNI) and 6.3% in patients without LNI. Focusing on intermediate-risk patients, 91(52%) and 84 (48%) had a Briganti score < 5% and ≥ 5%, respectively, among whom 6 (6.6%) and 7(8.3%) had lymph node metastases. The accuracy of the score was low for intermediate risk patients with an area under the curve (AUC) of 53.1% (95% CI 0.45-0.61).

CONCLUSION

The Briganti nomogram in our retrospective cohort showed low accuracy for the prediction of lymph node involvement in an intermediate-risk prostate cancer population.

Prostate Cancer and Asbestos: A Systematic Review and Meta-Analysis

INTRODUCTION

Asbestos-related diseases and cancers represent a major public health concern.

OBJECTIVE

To conduct a systematic review and meta-analysis to demonstrate that asbestos exposure increases the risk of prostate cancer.

METHODS

The PubMed, Cochrane Library, Embase, and ScienceDirect databases were searched using the keywords (prostate cancer OR prostatic neoplasm) AND (asbestos* OR crocidolite* OR chrysotile* OR amphibole* OR amosite*). To be included, articles needed to describe our primary outcome: Risk of prostate cancer after any asbestos exposure.

RESULTS

We included 33 studies with 15,687 cases of prostate cancer among 723,566 individuals. Asbestos exposure increased the risk of prostate cancer (effect size = 1.10, 95% confidence interval [CI] = 1.05-1.15). When we considered mode of absorption, respiratory inhalation increased the risk of prostate cancer (1.10, 95% CI = 1.05-1.14). Both environmental and occupational exposure increased the risk of prostate cancer (1.25, 95% CI = 1.01-1.48; and 1.07, 1.04-1.10, respectively). For type of fibers, the amosite group had an increased risk of prostate cancer (1.12, 95% CI = 1.05-1.19), and there were no significant results for the chrysotile/crocidolite group. The risk was higher in Europe (1.12, 95% CI = 1.05-1.19), without significant results in other continents.

DISCUSSION

Asbestos exposure seems to increase prostate cancer risk. The main mechanism of absorption was respiratory. Both environmental and occupational asbestos exposure were linked to increased risk of prostate cancer.

CONCLUSION

Patients who were exposed to asbestos should possibly be encouraged to complete more frequent prostate cancer screening.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]

OBJECTIVE

To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA).

METHODS

Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure).

RESULTS

Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power.

CONCLUSION

Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not.

LEVEL OF EVIDENCE

4.

Cancer de la prostate : souffrir de sa guérison

Le diagnostic précoce du cancer de la prostate permet à des patients de choisir de vivre avec un cancer peu menaçant, via une surveillance active (SA) qui mène souvent à une chirurgie, dont les effets secondaires s’inscrivent dans une forme de chronicité, impactant vie quotidienne, image de soi et sexualité. Qu’implique sur le plan psychique de vivre avec un cancer non traité, mais surveillé ? Comment vivre après une intervention chirurgicale aux conséquences mutilantes, handicapantes, portant atteinte au narcissisme ?

Objectif: Interroger les remaniements psychiques à l’œuvre chez des patients diagnostiqués d’un cancer de la prostate, opérés soit après plus d’un an de SA, soit sans délai.

Méthode: Dans le cadre d’une recherche doctorale en cours, des entretiens semi-directifs sont proposés en préopératoire, six semaines après, puis six mois. Ces entretiens sont appuyés par des autoquestionnaires ainsi que des tests projectifs : le Rorschach et le TAT (Thematic Apperception Test).

Résultats: Les patients opérés après avoir vécu une SA ont bénéficié d’une temporalité particulière au cours de laquelle la plupart d’entre eux ont pu accepter l’inacceptable et tolérer l’idée d’avoir un cancer et vivre avec. Si cette période permet à certains de se préparer à l’évolution de leur cancer et à son traitement par ablation, souvent synonyme de guérison, les effets secondaires de la chirurgie restent parfois très difficiles à vivre, surtout lorsqu’ils s’installent dans la durée et impactent le quotidien, constituant alors une nouvelle forme de chronicité. Vivre avec un « corps cancéreux » en SA n’est pas ici une épreuve physique où le corps est le siège de douleurs physiques et de fatigue, mais essentiellement une épreuve psychique. De façon paradoxale, le « corps guéri » subit des transformations en période postopératoire, des bouleversements qui touchent et atteignent l’image que l’homme a de lui-même.

Conclusion: Compte tenu des progrès de la médecine dans le dépistage et le traitement curatif du cancer de la prostate, quels sont les enjeux actuels du dépistage précoce ? Peut-on réellement parler de guérison lorsque le vécu subjectif des patients va à l’encontre de la définition habituelle de ce terme ? La « guérison chronique » succéderait-elle à la « maladie chronique » ?

[Primary urological cancers in a context of limited resources: Epidemiology and treatment]

OBJECTIVES

To describe the epidemiological, clinical and therapeutic aspects of primary urological cancers in semi-urban areas in Burkina Faso.

PATIENTS AND METHOD

A descriptive study was conducted over the period from 1 January 2008 to 31 December 2017 in the General Surgery Department of the Tenkodogo Regional Hospital, located in the east of Burkina Faso. All patients over 15 years of age who were diagnosed with primary urological cancer were included.

RESULTS

A total of 160 patients were included. One hundred and thirty-one patients were male (81.9%). The sex ratio was 4.5. The average age of the patients was 58.9 years (standard deviation: 18 years). We found 73 cases of prostate cancers (45.6%), 53 bladder cancers (33.1%), 17 kidney cancers (10.6%), 11 testicular cancers (6.9%) and 6 cancers of the male external genitalia (3.7%). The histological types of prostate cancer were adenocarcinoma (88%) and neuroendocrine carcinoma (12%). Thirty-seven prostate cancers (50.7%) were diagnosed at the T3 stage and 12 others (16.4%) at the T4 stage. Prostate cancer treatment was only medical in 23 patients; surgical treatment was indicated in 50 other patients. The 5-year survival was 85%. Sixteen patients (30.2%) had metastatic bladder cancer at the time of diagnosis. The treatment of vesical cancers has been palliative in 50 cases.

[12-year history of radical surgery indications for the treatment of prostate cancer]

AIM

To analyze the indications of radical prostatectomy and lymph node dissection retained during the last 12 years in an academic surgical center in the Paris region in order to ensure their adequacy in relation to the current clinical guidelines.

METHOD

Monocentric retrospective study of prospectively collected data, between 2007 and 2019. Analysis of the clinical and pathological characteristics which were taken into account during multidisciplinary meeting discussion for the treatment decision, and comparison of their evolution over the four 3-year period corresponding to the clinical guideline updates.

RESULTS

Two thousand eighty-eight consecutive patients treated by radical prostatectomy between 16/03/2007 and 17/03/2019 were included. The proportion of patients classified as low, intermediate or high risk according to D'Amico system was 13.2%, 80.8% and 6.0% respectively. An increase in the frequency of surgical treatment of high-risk cancers has been observed. At the same time, there has been a decrease in the frequency of prostatectomies to treat low-risk cancers.

CONCLUSION

The indications for radical prostatectomy and lymph node dissection have evolved in line with the current clinical guidelines which were taken into consideration in a onco-urological multidisciplinary meeting.

LEVEL OF EVIDENCE

3.

The primacy of multiparametric MRI in men with suspected prostate cancer

Background

Multiparametric MRI (mpMRI) became recognised in investigating those with suspected prostate cancer between 2010 and 2012; in the USA, the preventative task force moratorium on PSA screening was a strong catalyst. In a few short years, it has been adopted into daily urological and oncological practice. The pace of clinical uptake, born along by countless papers proclaiming high accuracy in detecting clinically significant prostate cancer, has sparked much debate about the timing of mpMRI within the traditional biopsy-driven clinical pathways. There are strongly held opposing views on using mpMRI as a triage test regarding the need for biopsy and/or guiding the biopsy pattern.

Objective

To review the evidence base and present a position paper on the role of mpMRI in the diagnosis and management of prostate cancer.

Methods

A subgroup of experts from the ESUR Prostate MRI Working Group conducted literature review and face to face and electronic exchanges to draw up a position statement.

Results

This paper considers diagnostic strategies for clinically significant prostate cancer; current national and international guidance; the impact of pre-biopsy mpMRI in detection of clinically significant and clinically insignificant neoplasms; the impact of pre-biopsy mpMRI on biopsy strategies and targeting; the notion of mpMRI within a wider risk evaluation on a patient by patient basis; the problems that beset mpMRI including inter-observer variability.

Conclusions

The paper concludes with a set of suggestions for using mpMRI to influence who to biopsy and who not to biopsy at diagnosis.

Key Points

• Adopt mpMRI as the first, and primary, investigation in the workup of men with suspected prostate cancer.

• PI-RADS assessment categories 1 and 2 have a high negative predictive value in excluding significant disease, and systematic biopsy may be postponed, especially in men with low-risk of disease following additional risk stratification.

• PI-RADS assessment category lesions 4 and 5 should be targeted; PI-RADS assessment category lesion 3 may be biopsied as a target, as part of systematic biopsies or may be observed depending on risk stratification.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06166-z) contains supplementary material, which is available to authorized users.

68Ga-PSMA-11 PET-CT study in prostate cancer patients with biochemical recurrence and non-contributive 18F-Choline PET-CT: Impact on therapeutic decision-making and biomarker changes

BACKGROUND

In this retrospective study, we investigated the impact of ⁶⁸ Ga-PSMA-11 PET-CT (PSMA PET-CT) upon the treatment plan and therapeutic response obtained for Prostate Cancer (PCa) patients presenting an occult biochemical recurrence.

METHODS

Forty-two patients with previously negative or doubtful 18F-Choline (FCH) were enrolled. PET images were recorded 1 h after injection of tracer. Only a few months after treatment ended, a PSA assay was requested to evaluate the therapeutic efficacy of the treatment based on PSMA results.

RESULTS

PSMA-positive lesions were detected in 34/42 (80.9%) patients. Detection rates were 85.7% and 89.3% for serum PSA levels lower than 2 ng/mL, and >2 ng/mL, respectively. One hundred seventy-three lesions were detected: 132/173 in lymph nodes (76.3%), 22/173 as metastatic sites (bone or lung) (12.7%), and 19/173 in the prostate bed (10.9%). As a result of the PSMA PET-CT, therapeutic management changed in 31/42 patients (73.8%). With a follow-up of 4.9 ± 2.27 months, 32/42 (76.2%) PSA assays after treatment guided by PSMA PET-CT were collected. For 37.5% (12/32) of patients, the serum PSA level was lower than 0.2 ng/mL and a PSA decrease of over 50% in 8 (25.0%) other patients were obtained.

CONCLUSION

Performing a PSMA PET-CT when FCH PET-CT was doubtful or negative allows the recurrence localization in more 80% of patients and this had a major clinical impact, as it resulted in treatment change in more than 70% of patients as well as a significant decrease in PSA levels in more than 60% of them.

Patterns of Bone Failure in Localized Prostate Cancer Previously Irradiated: The Preventive Role of External Radiotherapy on Pelvic Bone Metastases

Introduction: External beam radiation therapy (EBRT) can cure localized prostate cancer (PCa) by sterilizing cancer cells in the prostate gland and surrounding tissues at risk of microscopic dissemination. We hypothesized that pelvic EBRT for localized PCa might have an unexpected prophylactic impact on the occurrence of pelvic bone metastases. Material and Methods: We reviewed the data of 332 metastatic PCa patients. We examined associations between the number (≤5 vs. >5) and the location of bone metastases (in-field vs. out-of-field), which occurred at first relapse, and a previous history of EBRT for PCa (EBRT vs. No-EBRT). Results: One hundred and ten patients M0 at baseline were eligible. Fifty-six patients (51%) were in the No-EBRT group, and 54 patients (49%) in the EBRT group. The proportion of patients who developed >5 bone metastases in the bony pelvis was higher in the No-EBRT group vs. the EBRT group: 10 patients (18%) vs. 2 patients (4%), respectively (p = 0.02). By multivariate analysis EBRT was associated with a lesser occurrence of patients who had >5 bone metastases in the bony pelvis (OR = 0.17 [95%CI, 0.04-0.87], p = 0.03). Time to occurrence of bone metastases ≥5 years (OR = 0.10 [95%CI, 0.05-0.19], p < 0.01), prior curative prostate treatment (OR = 0.58 [95%CI, 0.36-0.91], p = 0.02), >5 bone metastases in bony pelvis (OR = 2.61 [95%CI, 1.28-5.31], p < 0.01), >5 bone metastases out of bony pelvis (OR = 1.73 [95%CI, 1.09-2.76], p = 0.02) were all predictive of overall survival. Conclusion: Previous pelvic EBRT for PCa is associated with a lower number of pelvic bone metastases, which is associated with better overall survival.

Long-term survival of patients with prostate cancer in Martinique: Results of a population-based study

BACKGROUND

Martinique has one of the highest incidences of prostate cancer (PCa) worldwide. We analysed overall survival (OS) among patients with PCa in Martinique, using data from a population-based cancer registry between 2005 and 2014.

METHODS

The log-rank test was used to assess the statistical differences between survival curves according to age at diagnosis, risk of disease progression including Gleason score, stage at diagnosis and Prostate Specific Antigen (PSA). A multivariable Cox model was constructed to identify independent prognostic factors for OS.

RESULTS

A total of 5045 patients were included with a mean age at diagnosis of 68.1±9.0 years [36.0 - 98.0 years]. Clinical stage was analysed in 4999 (99.1% of overall), 19.5% were at low risk, 34.7% intermediate and 36.9% at high risk. In our study, 8.9% of patients with available stage at diagnosis, were regional/metastatic cancers. Median PSA level at diagnosis was 10.4 ng/mL. High-risk PCa was more frequent in patients aged 65-74 and ≥75 years as compared to those aged <65 years (36.6% and 48.8% versus 28.7% respectively; p<0.0001). One-year OS was 96.3%, 5-year OS was 83.4 and 10-year OS was 65.0%. Median survival was not reached in the whole cohort. High-risk PCa (HR=2.32; p<0.0001), regional/metastatic stage (HR= 9.51; p<0.0001) and older age (65-74 and ≥75 years - respectively HR=1.70; and HR=3.38), were independent prognostic factors for OS (p<0.0001).

CONCLUSION

This study provides long term data that may be useful in making cancer management decisions for patients with PCa in Martinique.

Outcomes after salvage radical prostatectomy and first-line radiation therapy or HIFU for recurrent localized prostate cancer: results from a multicenter study

INTRODUCTION

Despite no consensus on the optimal management of recurrent prostate cancer after primary radiation or HIFU therapy, salvage prostatectomy (sRP) is reserved for only 3% of patients because of technical challenges and frequent post-operative complications. We assessed outcomes after sRP in a series of patients with localized PCa and that had received radiation therapy or HIFU as a first-line treatment.

MATERIALS AND METHODS

Data from nine French referral centers on patients treated with sRP between 2005 and 2017 were collected. Pre- and post-operative data, including oncological and functional outcomes after first treatment and sRP, were analyzed to determine the predictors for biochemical recurrence (BCR) and cancer-specific survival (CSS) after sRP.

RESULTS

First-line treatments were external beam-radiation therapy (EBRT) for 30 (55%), brachytherapy (BT) for 10 (18%), and high-intensity focused ultrasound (HIFU) for 15 (27%). Median (IQR) PSA at diagnosis was 6.4 (4.9-9.5) ng/mL, median PSA at nadir was 1.9 (0.7-3.0) ng/mL, and median (IQR) to first BCR was 13 (6-20) months. Of the 55 patients, 44 (80%) received robot-assisted salvage radical prostatectomy and 11 (20%) received salvage retropubic radical prostatectomy. Restoration of continence was achieved in 90% of preoperatively continent patients; 24% that had received nerve-sparing (NS) procedures were potent after surgery. Prolonged catheterization due to anastomotic leakage was the most common complication. Age, preoperative clinical stage, NS procedure, and a pathological Gleason score were predictors for BCR.

CONCLUSIONS

sRP was safe, feasible, and effective using either an open or robot-assisted approach, in experienced hands. Age, preoperative clinical stage, NS procedure, and pathological GS were linked with BCR after sRP.

Polymorphisms in XPC gene and risk for prostate cancer

Single nucleotide polymorphisms (SNP) in repair gene DNA such as XPC gene can reduce the DNA repair capacity (DRC). Reduced DRC induce genetic instability and may increase the susceptibility to prostate cancer (PC). We conducted a case-controls study to examine the relationship between XPC Lys939Gln and XPC-PAT polymorphisms and the risk for prostate cancer in Tunisian population. We have also correlated molecular results with clinical parameters (Gleason score and TNM status) and lifestyle factors (tobacco status, alcohol consumption, and exposition to professional risk factors) of prostate cancer patients. We have found that the XPC Lys939Gln polymorphism was not associated with a risk of prostate cancer. However the XPC PAT I/I genotype was found to be associated with 3.83-fold increased risk of prostate cancer compared to controls (p = 0.00006; OR 3.83; 95% CI (1.83-8.05)). The test of linkage disequilibrium showed that XPC-PAT polymorphism is in linkage disequilibrium with XPC Lys939Gln variants. The combined analysis of XPC Lys939Gln and XPC-PAT variants showed that patients who inherited (Lys/Gln + PAT D/D) genotypes were protected against prostate cancer development compared to controls. In the other hand, no significant association has been found between XPC polymorphisms and clinical parameters or between XPC polymorphisms and lifestyle factors.

Pattern of care of prostate cancer patients across the Martinique: results of a population-based study in the Caribbean

BACKGROUND

The French West-Indies rank first for both prostate cancer incidence and mortality rates. Analyzing diagnostic and therapeutic procedures among patients with prostate cancer, using data from a population-based cancer registry, is essential for cancer surveillance and research strategies.

METHODS

This retrospective observational cohort study was based on data from the Martinique Cancer Registry. Records of 452 patients diagnosed with prostate cancer in 2013 were retrieved from the registry. Data extracted were: socio-demographic and clinical characteristics, circumstances of diagnosis, PSA level at diagnosis, Gleason score and risk of disease progression. Stage at diagnosis and patterns of care among prostate cancer patients were analyzed.

RESULTS

Mean age at diagnosis was 67 ± 8 years; 103 (28.5%) were symptomatic at diagnosis. Digital rectal exam was performed in 406 (93.8%). Clinical stage was available in 385 (85.2%); tumours were localized in 322/385 (83.6%). Overall, 17.9% were at low risk, 36.4% at intermediate and 31.9% at high risk; 13.8% were regional/metastatic cancers. Median PSA level at diagnosis was 8.16 ng/mL (range 1.4-5000 ng/mL). A total of 373 patients (82.5%) received at least one treatment, while 79 (17.5%) had active surveillance or watchful waiting. Among patients treated with more than one therapeutic strategy, the most frequent combination was external radiotherapy with androgen deprivation (n = 102, 22.6%).

CONCLUSIONS

This study provides detailed data regarding the quality of diagnosis and management of patients with prostate cancer in Martinique. Providing data on prostate cancer is essential for the development of high-priority public health measures for the Caribbean.

Migration in last decade to high-risk prostate cancer after radical prostatectomy

OBJECTIVE

There is controversy around prostate cancer (PCa) screening through the use of PSA, due to the risk of overtreatment. The current trend observed in various European and American studies is a decrease in the number of radical prostatectomy (RP) in low-risk PCa and an increase for intermediate or locally advanced diseases. The objective of this study was to observe the migration of the pathological stages from radical prostatectomy (RP) over 10 years in France through 2 French centers.

METHODS

It was a multicentric retrospective study, where all the RP realized in 2 French tertiary centers, in a laparoscopic or retropubic approach for each of the years 2005, 2010 and 2015 were included. Preoperative data (age, PSA, clinical stage, number of positive biopsies, Gleason biopsy score) and postoperative data (pTNM, pathological Gleason score (pGS)) were analyzed and compared.

RESULTS

In all, 1282 RP were realized (503 in 2005, 403 in 2010, 376 in 2015). Respectively between 2005, 2010, 2015 the average number of positive biopsy increased significantly from 2.30 vs. 2.88 vs. 5.3 (P=0.0001). The distribution of D'Amico's risk evolves with time: low-risk: 49.9 vs. 44.4 vs. 15.7% (P=0.0001); intermediate risk: 40.95 vs. 43.92 vs. 64.1% (P=0.0001) and high-risk: 9.15 vs. 11.66 vs. 20.2% (P=0.0001) between 2005, 2010 and 2015 respectively. pGS evolved to higher score with SG<7: 22.8 vs. 29.9 vs. 7.1% et SG≥7: 77.2 vs. 70.1 vs. 92.9% (P=0.001). Also, pTNM increased to non-organ-confined disease: pT2: 66.9 vs. 51.9 vs. 48.7%; pT3: 33.1 vs. 48.1 vs. 51.3% (P=0.0001).

CONCLUSION

This study showed a change in the management of PCa since new recommendations from medical authorities about PSA screening and evolving of conservative treatment. Number of RP increase for higher risk PCa. This change corresponds to better patient selection for RP: decrease for low-risk and increase for high-risk organ-confined disease.

LEVEL OF EVIDENCE

3.

French recommendations for osteoporosis prevention and treatment in patients with prostate cancer treated by androgen deprivation

Androgen-deprivation therapy (ADT) in patients with prostate cancer can be achieved surgically or chemically, notably by prescribing LHRH analogs. Major bone loss occurs rapidly in both cases, due to the decrease in testosterone levels, and can increase the fracture risk. The objective of developing these recommendations was to achieve a practical consensus among various scientific societies, based on a literature review, about osteoporosis prevention and treatment in patients on ADT. The following scientific societies contributed to the work: Société française de rhumatologie (SFR), Groupe de recherche et d'information sur les ostéoporoses (GRIO), Groupe européen d'études des métastases osseuses (GEMO), Association francophone pour les soins de support (AFSOS), Association française d'urologie (AFU), Société française de radiothérapie oncologique (SFRO). Medication prescription and reimbursement modalities in France were taken into account. The recommendations state that a fracture-risk evaluation and interventions targeting risk factors for fractures should be provided to all patients on ADT. Those patients with a history of severe osteoporotic fracture and/or a T-score < -2.5 should receive osteoporosis therapy. Patients whose T-score is between -1.5 and -2.5 should be treated if they exhibit at least two other risk factors among the following: age ≥ 75 years, history of non-severe fracture after 50 years of age, body mass index < 19 kg/m², at least three comorbidities (e.g., cardiovascular disease, depression, Parkinson's disease, and dementia), current glucocorticoid therapy, and repeated falls. When the decision is difficult, FRAX^® score determination and an assessment by a bone disease specialist may be helpful. When osteoporosis therapy is not indicated, general measures should be applied, and bone mineral density measured again after 12-24 months. The anti-tumor effects of bisphosphonates and denosumab fall outside the scope of these recommendations.

[Focal HIFU vs robot-assisted total prostatectomy: Functionnal and oncologic outcomes at one year]

OBJECTIVE

To analyse the functional and oncologic outcomes at one year of focal therapy with HIFU compared with total prostatectomy in patients with localised prostate cancer (PCa).

PATIENTS AND METHODS

Retrospective and monocentric study from 2008 to 2014 comparing 2 cohorts of patients with localised PCa (T1/T2 clinical stage, Gleason score≤3+4=7 and PSA<15ng/mL), one treated by focal therapy (HIFU-F group), one by robot-assisted total prostatectomy (RATP group). Primary outcome was a trifecta defined as: absence of urinary incontinence, erectile function with sexual relations without treatment, negative PSA with negative surgical margins (RATP group) or negative biopsy cores (HIFU-F group).

RESULTS

The 53 patients included in the "HIFU-F" group and the 66 patients in the "RATP" group were similar in terms of preoperative PSA, D'Amico risk group, erectile function but were different in terms of age, prostatic volume, length of cancer, Gleason score. Complication rate was not different. In multivariate analyse with propensity score, "HIFU-F" group achieved a better trifecta score than "RATP" group (OR=8,3, p=0,005).

CONCLUSION

In case of low or intermediate risk localised PCa, "HIFU-F" group had better functional outcomes than initial learning curse "RATP" group, at one year. A long-term evaluation by a common endpoint is necessary to judge the oncological equivalence of both techniques.

LEVEL OF EVIDENCE

3.

[Prostate brachytherapy: New techniques, new indications]

Prostate brachytherapy has been for a long time one of the standard treatments for low risk prostate cancer, with high rates of biochemical control and low levels of urinary and sexual late toxicity compared to other available techniques, namely external beam radiotherapy and radical prostatectomy. The aim of this article is to review the recent innovations of prostate brachytherapy, which suggest a bright future for the technique. We will discuss the extension of indications of permanent implant brachytherapy to favorable intermediate-risk patients, the use of novel isotopes such as Palladium 103 and Cesium 131, and the benefit of brachytherapy as a boost following external beam radiotherapy for intermediate and high-risk patients. We will also discuss the rise of high dose rate brachytherapy, as a boost or monotherapy, the increasing use of MRI for patient selection and treatment planning, as well as the development of brachytherapy as a means of focal therapy.

[Pathology findings after radical prostatectomy for prostate cancer in patients eligible for active surveillance: Contribution of multiparametric MRI to treatment decision]

OBJECTIVES

To analyze, in patients with prostate cancer (PC) potentially eligible for active surveillance (AS), whether multiparametric-MRI (mp-MRI) predicts presence of clinically significant cancer on radical prostatectomy (RP) specimen.

METHODS

We identified 77 men with PC eligible for AS (PSA≤15ng/mL, stage≤T2a, Gleason score≤6, up to 3 positive cores, maximal cancer core length≤5mm) who underwent RP between 01/2008 and 08/2015. All patients had prebiopsy mp-MRI followed by systematic±targeted biopsies. For each patient, the likelihood of the presence of cancer on mp-MRI was assigned using Likert scale (1 to 5). The predictive factors for the presence of significant cancer on RP specimen (Gleason score≥7 and/or tumoral maximal diameter>10mm) were evaluated using logistic regression.

RESULTS

Median age was 61 and median PSA was 6.7ng/mL. Overall, 49 (64%) patients had a positive mp-MRI (score≥3). Clinically significant cancer on RP specimen was found in 45 (58%) patients (69% in MRI-positive patients vs 39% in MRI-negative patients). In multivariate analysis, a positive MRI was a predictive factor for the presence of significant cancer on the surgical specimen (OR=3.0; CI95% [1.01-8.88]; P=0.04), as was age (OR=1.17; CI95% [1.05-1.31]; P=0.004) and PSAD (OR=1.10; CI95% [1.01-1.20]; P=0.02).

CONCLUSION

Mp-MRI is a useful exam for selecting patients eligible for AS even if the situation remains unclear after prostate biopsies including targeted biopsies. Upon confirmation by further studies, mp-MRI should be considered as an independent criterion before entering an AS program.

LEVEL OF EVIDENCE

4.

New approach of ultra-focal brachytherapy for low- and intermediate-risk prostate cancer with custom-linked I-125 seeds: A feasibility study of optimal dose coverage

PURPOSE

To present the feasibility study of optimal dose coverage in ultra-focal brachytherapy (UFB) with multiparametric MRI for low- and intermediate-risk prostate cancer.

METHODS AND MATERIALS

UFB provisional dose plans for small target volumes (<7 cc) were calculated on a prostate training phantom to optimize the seeds number and strength. Clinical UFB consisted in a contour-based nonrigid registration (MRI/Ultrasound) to implant a fiducial marker at the location of the tumor focus. Dosimetry was performed with iodine-125 seeds and a prescribed dose of 160 Gy. On CT scans acquired at 1 month, dose coverage of 152 Gy to the ultra-focal gross tumor volume was evaluated. Registrations between magnetic resonance and CT scans were assessed on the first 8 patients with three software solutions: VariSeed, 3D Slicer, and Mirada, and quantitative evaluations of the registrations were performed. Impact of these registrations on the initial dose matrix was performed.

RESULTS

Mean differences between simulated dose plans and extrapolated Bard nomogram for UFB volumes were 36.3% (26-56) for the total activity, 18.3% (10-30) for seed strength, and 22.5% (16-38) for number of seeds. Registration method implemented in Mirada performed significantly better than VariSeed and 3D Slicer (p = 0.0117 and p = 0.0357, respectively). For dose plan evaluation between Mirada and VariSeed, D₁₀₀% (Gy) for ultra-focal gross tumor volume had a mean difference of 28.06 Gy, mean values being still above the objective of 152 Gy. D₉₀% for the prostate had a mean difference of 1.17 Gy. For urethra and rectum, dose limits were far below the recommendations.

CONCLUSIONS

This UFB study confirmed the possibility to treat with optimal dose coverage target volumes smaller than 7 cc.

[Long-term outcomes of prostate cancer patients with lymph nodes metastasis after radical prostatectomy and pelvic lymph node dissection]

INTRODUCTION

The aim of this study was to evaluate biochemical recurrence-free survival (RFS) and to identify useful predictors of such survival in localized prostate cancer patients (cN0) and pelvic lymph node metastasis (pN+) treated with radical prostatectomy and pelvic lymph node dissection.

PATIENTS AND METHODS

This multicenter and retrospective study, assessed overall survival (OS), cancer specific survival (CSS) and biochemical recurrence-free survival (RFS), between January 2005 until December 2010 with 5 years of distance. We evaluated factors predicting long-term RFS in node positive prostate cancer patients.

RESULTS

Thus, 30 patients were included. Median follow-up was 89.9±27.4 months. After surgery, patients were treated with surveillance (n=4, 13.5%), adjuvant hormone therapy (n=22, 73%) or combination of radio and hormone therapy, (n=4, 13.5%). During the follow-up, 50% of patients had biochemical recurrence, with a mean time period of 38±30 months. Five and 10-year RFS were 57% and 41% respectively. Extra lymph nodes extension (P=0.00021) and pathological margin status (P=0.0065) were independent predictors of 5-year RFS.

CONCLUSION

Biochemical RFS of patients treated with radical prostatectomy and subclinical lymph node metastatic disease is adequate and multifactorial. However, this study identifies pathological margin status and extra lymph node extension as independent factors of b RFS.

LEVEL OF EVIDENCE

4.

[Prostate cancer diagnostic by saturation randomized biopsy versus rigid targeted biopsy]

INTRODUCTION

Optimal diagram teaming up randomized biopsy (BR) to targeted biopsy (BC) is still missing for the diagnostic of prostate cancer (CP). This study compares diagram of 6, 12 or 18 BR with or without BC rigid.

METHODS

Between January 2014 and May 2016, 120 patients had prostate biopsy BR and BC. Each patient had 18 BR and BC. Results compared sextant (6 BR), standard (12 BR) and saturation (18 BR) protocol with or without the adding of BC for the detection of CP.

RESULTS

Rectal examination was normal, mean PSA at 8.99ng/mL and mean volume at 54cm³. It was first round for 48% of patients. Forty-four cancers were found by the group 18 BR+BC (control). The detection rate was respectively, for 6, 12 and 18 BR of 61%, 82% and 91%. The add of BC increased this detection of +27% for 6 BR+BC, +13% for 12 BR+BC and +9% for 18 BR+BC. BC found 70% of all CP. Nine percent of CP were missed by BR only. Significant CP (Gleason≥7) diagnostic was the same for 12 BR+BC and 18 BR+BC.

CONCLUSION

The add of BC to BR increase the detection of CP by 10%. Twelve BR+BC is the optimal diagram for the diagnostic of CP finding 95% of CP and 97% of significant CP.

LEVEL OF EVIDENCE

4.

[Focal therapies: An alternative option for low-risk prostate cancer management?]

Recommended options for low-risk prostate cancer treatment are active surveillance, radical treatments or watchful waiting. Focal therapies are currently assessed for low risk prostate cancer treatment. Focal therapies can be performed in research protocols. Oncologic results of these focal treatments are encouraging and show excellent tolerance with few complications. Radical treatments are still possible after focal therapies failure. Focal therapies are a possible solution to over-treatment issue of low risk prostate cancers.

[Ablative therapy in urology: Good practice and perspective]

INTRODUCTION

To expose the main point of discussion from present ablative therapies' guidelines and propose global perspectives.

MATERIALS AND METHODS

A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com/) using different associations of keywords "ablative therapy" ; "prostate cancer"; "kidney cancer"; "guidelines"; "hybrid operating room". Publications obtained were selected based on methodology, language and relevance.

RESULTS

Present guidelines on ablative therapies in urology are, considering authors and organs, either particularly prudent (EAU guidelines for prostate and kidney) or relatively optimistic (CIRSE guidelines). This discrepancy is related to a low level of proof. So, a new approach is mandatory: more homogeneous in methodology, and especially more open to a new organization sparing economic efficiency. The objective will be to get multifunctional and multidisciplinaries platforms, in facts and in minds. It will induce, in the future, a deep reflection about training and boundaries' specialties.

CONCLUSION

Ablative therapies represent a crucial stake for urology and a clear example of medicosurgical evolution in future, based on new technologies (energy, robotic, imaging). A serious and deep reflection is necessary to prepare it and be deeply involved in.

[Combination of radiotherapy and androgen deprivation therapy for localized prostate cancer]

Combination of radiotherapy and androgen deprivation is now considered as the standard of care for patients with a localized prostate cancer but poor prognosis factors. Two groups of randomized trials have led to this recommendation: some have compared radiotherapy alone versus hormonal treatment and radiotherapy: these trials demonstrated, now with a long follow-up, an improvement in 10-year survival for the combined treatment. Three recent trials compared androgen deprivation alone or combined with radiotherapy; a benefit in survival was also demonstrated in favour of the combination. Some questions remained concerning the optimal duration of hormonal treatment, in view of its potential side effects. Patients in the intermediate prognostic groups could receive a short-term androgen deprivation, but those with a high Gleason score must be treated with a long-term hormonal treatment. Modalities of radiotherapy, regarding volumes and dose must also be précised in the next years.

[Neuroendocrine prostate cancer: Natural history, molecular features, therapeutic management and future directions]

Neuroendocrine prostate cancer is a rare malignancy with a an adverse prognostic. Histologically, It can be pure (small cells or large cells neuroendocrine carcinoma) or mixed with a adenocarcinoma component. Rarely diagnosed de novo, neuroendocrine prostate cancer is generally associated with advanced stage disease resistant to castration. As such, this histological subtype could represent an aggressive evolution of prostatic adenocarcinoma, through the epithelio-neuroendocrine transdifferentiation mechanism (phenomenon of lineage plasticity). Nonetheless, neuroendocrine prostate cancer is a heterogeneous malignancy with multiple histopathological variants showing distinct clinical features. The broad variety of molecular analyses could help to understand the ontogeny of this histological subtype and its signaling pathways. This may also allow identifying diagnostic and prognostic biomarkers as well as potential molecular targets. However, treatment options are currently limited and consist only in platinium-based chemotherapy for advanced stage disease.

[Salvage radical prostatectomy for recurrent prostate cancer. Morbidity, oncological and functional results]

INTRODUCTION

Salvage radical prostatectomy (sRP) for radiorecurrent prostate cancer (PCa) is a challenging procedure. To report our experience with sRP for selected patients with local recurrence after primary treatment for localised PCa.

METHODS

From 2005 to 2015, 24 patients underwent sRP for recurrent PCa in our center and were included in this retrospective study. Local recurrence was suspected by PSA increase>nadir+2ng/mL and was confirmed by biopsy. Perioperative complications according to Clavien-Dindo classification, oncological and functional results were analysed.

RESULTS

Overall, 24 patients with a median age of 59 years (IQR: 55-60) were included. Median follow-up was 25 months (IQR: 9-26). Procedures were performed with open-retropubic approach in 50 % and robot-assisted laparoscopic approach in 50 %. Overall, 5 (21 %) and 2 (8 %) patients experienced grade≤IIIa and grade≥IIIb postoperative complication, respectively. Surgical margins were positive in 46 % of cases. Three out of 4 patients with postoperatively detectable PSA (>0.2ng/mL) had positive surgical margins. Seven patients experienced biochemical recurrence in a median delay of 19 months (9-62). Seventy-one percent (5) of these patients experienced clinical recurrence in a median delay of 24 months (10-113). Severe urinary incontinence (≥3 pads/day) and erectile dysfunction were reported in 25 % and 63 %, respectively.

CONCLUSION

sRP for patients is a feasible procedure with encouraging local control rate and acceptable morbidity. This technique should be discussed as a treatment option for locally recurrent PCa in well-selected patients.

LEVEL OF EVIDENCE

4.

Les traitements combinés dans les formes à haut risque évolutif du cancer de la prostate (localisé ou non)

The high-risk group of prostate cancers is a heterogeneous group. A better definition of the criteria could bring a better selection of patients' selection in the combined local treatment or even in the general treatment. A treatment of these forms is the hormonoradiotherapy. The modalities of the radiotherapy and the hormonotherapy are to be defined and to be adapted according to prognostic factors of these patients. The surgery is also a possible treatment under certain conditions of selection of the patients and the adaptation of the surgical techniques. It can be combined either with other local treatments, radiotherapy for example, or even general ones. The pathological evaluation allows to identify overstaging and to avoid some unnecessary androgen therapy and also side effects. For the oligometastatic forms, the interest of the local treatment remains to appreciate. In the metastatic forms, a chemotherapy associated with the hormonotherapy must be proposed and seems to become a reference.

[Management of a progressing prostate cancer: results of a national study]

INTRODUCTION

The introduction of new treatments in metastatic castration resistant prostate cancer (mCRPC) requires a close follow-up to detect a progression and then to adapt the treatment. In that context, a national survey was proposed to a group of experts and the aim was to identify the modalities of surveillance in different clinical situations.

METHODS

A questionnaire was sent to 1464 urologists, medical oncologists and radiotherapists, about a clinical case; it was about a patient presenting a prostate cancer, evolving from a biologic progression after radical prostatectomy to a situation of metastasis resistant to the castration. The questionnaire contained ten questions about reasons of changing treatment because of progression, and about modalities of the follow-up.

RESULTS

A total of 318 questionnaires were analyzed (response rate of 22%). The results showed comparable practices between the different types of specialists, even if a more frequent rhythm of surveillance was reported by medical oncologists and radiotherapists. At progression after radical prostatectomy, a clinical and biological surveillance was generally realized every 3 or 6 months, and imaging exams were done on demand. Then, as the cancer progresses, the surveillance became systematic and more and more close, with imaging done every 3 months or on demand. While the definition of progression was essentially based on PSA testing at the beginning of the castration resistance, it then combines different clinical, biological and radiological criteria.

CONCLUSIONS

There are few recommendations available about follow-up of patients with a mCRPC. In that survey, the oncologists and urologists reported a more intensive rhythm of surveillance as the prostate cancer progresses.

LEVEL OF EVIDENCE

4.

[Prevalence and diversity of management of prostate cancer patients classified as low risk using D'Amico group or Cancer of the Prostate Risk Assessment (CAPRA) score: A French multicenter study]

OBJECTIVES

Currently, the French High Authority for Health does not recommend mass screening for prostate cancer (PCa), due to the risk of over-treatment, notably of low risk patients. Our study is intended to reflect the therapeutic attitudes for the management of patients classified as low risk of progression in French clinical centers.

METHODS

For all positive prostate biopsies performed during 2012 and 2013 in five French departments of urology, clinicopathological characteristics required to calculate the d'Amico risk group and the Cancer of the Prostate Risk Assessment (CAPRA) score were filled. Information on the first treatment of "low risk" patients was collected.

RESULTS

A total of 1035 patients were included, with a median age at diagnosis of 66 years old. According to d'Amico and CAPRA classifications, 30.4% and 35.0% of patients were at low, 34.5% and 33.2% at intermediate, 35.1% and 31.8% at high risk. The diagnosis severity increased with age (P<0.0001). The main treatment for low risk patients was radical prostatectomy (41.6% and 42.0% for d'Amico and CAPRA, respectively), but active surveillance was the most frequent treatment if diagnosed after 75 years old. The management of low risk patients varied significantly between centers (P<0.0001), according to the therapeutic platforms available within the hospital.

CONCLUSIONS

In absence of strong progression predictor, the management of low risk PCa remains based on center habits and local therapeutic platforms. New predictive markers, such as multiparametric MRI or molecular tests, are needed to guide rational management of low risk PCa.

LEVEL OF EVIDENCE

4.