10.1586/14737140.7.7.977 © 2007 Future Drugs Ltd ISSN 1473-7140 977

Meeting Report

Medical management of advanced prostate cancer: a multidisciplinary team approachTreating advanced prostate cancer togetherMarch 16–17, 2007, Sitges, Barcelona, Spain

Joaquim Bellmunt Molins†* and Antoni Gelabert i Mas* On behalf of the Spanish Multidisciplinary Advanced Prostate Cancer Panel†Author for correspondence: Hospital Del Mar, Solid Tumor Oncology (GU & GI) Medical Oncology Service, Paseo Maritimo 25–29, Barcelona 08003, Spain; Tel.: +34 93 248 3137; Fax: +34 93 248 3366; jbellmunt@imas.imim.es*Both authors are available for correspondence.

Expert Rev. Anticancer Ther. 7(7), 977–979 (2007)

This 2-day national symposium on recentadvances in the treatment of advancedprostate cancer, organized under the aus-pices of the Spanish Society of MedicalOncology, the Spanish Association ofUrology and supported by Sanofi Aventis,was held in Sitges, Barcelona on March16 and 17, 2007, and attracted over 250participants who were interested in theoptimization of treatment of patientswith advanced prostate cancer. The topicwas presented under a cooperative inter-disciplinary approach of three differentspecialties: urology, medical oncology andradiotherapeutics. A close collaborationbetween these specialists is criticallyimportant for the clinical application ofnew advances in the management ofprostate cancer in daily practice. The finalgoal of developing new treatment strate-gies, including the use of more effectiveand safer drugs, will involve close collabo-ration between the three medical disci-plines. A panel of more than 30 Spanishexperts in the different fields presentedupdated information on the most rele-vant diagnostic and therapeutic aspects ofadvanced prostate cancer.

The hormone-refractory patientThe first group of presentations coveredthe therapeutic challenges posed by

patients with androgen-independentprostate cancer. With regard to the defi-nition of hormone-refractory prostatecancer, Lorente Garín emphasized theneed to establish a definition, by con-sensus, to determine the clinical rele-vance of plasma testosterone levels of20–50 ng/dl, to redefine the goal oftreatment with luteinizing hormone-releasing hormone (LHRH) analoguesbased on bioavailability of testosterone,and to optimize the diagnosis ofpatients under treatment with LHRHanalogues with prostate-specific antigen(PSA) progression prior to second-linehormonal therapy.

The options for second-line hormonaltherapy when androgen ablation failswere reviewed by Cozar Olmo, includ-ing antiandrogen withdrawal, additionof immediate or deferred androgen-dep-rivation therapy, the use of estrogenanalogues (estramustine and diethyl-stilbestrol), inhibition of adrenal andro-gens (ketoconazole and amino-glutethimide) or treatment withprogestagens (megestrol).

Assessment of prognostic factors associ-ated with unfavorable outcome afterandrogen-deprivation therapy was dis-cussed by Ribal Caparrós, focusing on therole of PSA progression and PSA doubling

time, as well as the usefulness of pre-treatment nomograms for the predictionof survival in patients with nonmeta-static and metastatic hormone-refractoryprostate cancer.

García-Palomo Pérez considered theproblems related to a clear-cut definitionof hormone-refractory and androgen-independent prostate cancer, emphasizedPSA behavior during androgen-suppres-sion therapy as an accurate predictor ofthe clinical course in patients with andro-gen-independent prostate cancer, andcommented on therapeutic decisionsaccording to expected survival in low-,intermediate- and high-risk groupsdefined by pretreatment nomogram inpatients with chemotherapy-naiveprostate cancer.

Finally, Sánchez Sánchez presented acase report of an asymptomatic patientwith hormone-refractory prostate cancerand Suárez Novo presented a case reportof a patient with a high-risk hormone-refractory prostate cancer, both of whichsummarized some of the difficulties previ-ously mentioned by other speakers in themanagement of androgen-independentprostate cancer in clinical practice.

Treating prostate cancer in the framework of multidisciplinary medical teamsThe importance of treating patients withprostate cancer in the framework ofmultidisciplinary medical teams was dis-cussed and supported by Antoni Gelaberti Mas, who described the characteristicsand advantages of the functional unitmodel implemented in Hospital del Mar.The main objective was to improve thecare of patients with prostate cancerbased on increasing the efficiency of diag-nostic and therapeutic processes throughthe coordinated actions of urologists,radiation-therapy specialists and oncolo-gists. Other relevant objectives during thedifferent clinical stages of prostate cancerinclude the implementation of evidence-based clinical practice guidelines,improvement of pre- and postgraduatetraining, and development of clinical and

Molins & Gelabert i Mas

978 Expert Rev. Anticancer Ther. 7(7), (2007)

basic research activities. In addition, thecrucial role of the case manager (the per-son with organizational skills and directresponsibility for managing individualpatient care by planning, coordinatingand deploying healthcare resources basedon diagnostic and therapeutic decisions)was also highlighted.

Chemotherapy & prostate cancerNew therapeutic strategies with docetaxelin patients with advanced prostate cancerwere the focus of the second group ofpresentations. Updated information onthe most recent chemotherapeutic strate-gies using a combination of docetaxelwith new drugs directed to different ther-apeutic targets was reviewed by MarotoRey. Promising preliminary results withthe administration of docetaxel com-bined with drugs, such as pertuzumab,gefitinib, bortezomib, oblimersen,atrasentan, imatinib, calcitriol, bevacizu-mab, sorafenib and radioactive isotopes,have been obtained in Phase II and IIIclinical trials. However, results ofongoing clinical trials of different combi-nations of docetaxel with these new mol-ecules will provide more solid data on therole of these combinations for advancedandrogen-independent prostate cancer.

Esquena Fernández discussed the prosand cons of early chemotherapy in high-risk or locally advanced prostate cancer,with the primary objective of improvingoverall survival or progression-free dis-ease interval. At present, there is a lack ofconsensus regarding the most appropri-ate strategy (neoadjuvant vs adjuvantchemotherapy). The use of early chemo-therapy in patients with high-risk local-ized prostate cancer continues to be amatter of debate.

A number of approaches to neo-adjuvant and adjuvant therapy withdocetaxel were presented by GómezVeiga. In light of the results from pub-lished studies, high-risk patients withprostate cancer represent a subgroup inwhich single therapy is not adequate. Forexample, hormonal neoadjuvant treat-ment alone prior to radical prostatectomydoes not appear to offer significantadvantages. By contrast, chemotherapywith docetaxel has a satisfactory tolerance

profile and is not detrimental to patientswho are candidates for radical prostatec-tomy. Furthermore, preliminary resultsare encouraging in terms of local controlaccording to data from radical prostatec-tomy surgical specimens. However, fur-ther clinical trials are needed to establishwhen and which neoadjuvant chemo-therapy should be used in the treatmentof locally advanced prostate cancer.

The initial results of a multicenterstudy (PROSTAX-NEO) carried out inSpain were discussed by MelladoGonzález. A total of 57 prostate cancerpatients with clinical stage T1c–T2, aGleason score of at least 7 (4 + 3) andPSA of at least 20 ng/ml or stage T3were treated with the standard regimenof docetaxel 35 mg/m2 in associationwith goserelin every 3 months and fluta-mide (750 mg/day) for 3 months, afterwhich patients underwent radical pros-tatectomy. In the 51 patients who wereevaluable for pathological response,complete response was observed in 3.9%of cases, isolated microscopic foci in7.8% and residual disease (<5%) in 15%of cases. Additionally, negative surgicalmargins were found in 65% of cases andorgan-confined disease in 53%. Thesefindings indicate that neoadjuvant ther-apy with docetaxel in patients with hor-monosensitive high-risk localized pros-tate cancer is a feasible strategy withacceptable toxicity.

In a discussion of second-line chemo-therapy for patients with androgen-inde-pendent prostate cancer, Bellmunt Molinspresented the most exciting current thera-peutic developments related to chemo-therapy with mitoxantrone, epothilone Banalogues (ixabepilone and BMS-247550), nanoparticle albumin-boundpaclitaxel (abraxane and ABI-007), satra-platin, aflibercept, new taxanes (larotaxeland XRP 6258) and S-1 compound. Thebeneficial effect of these second-linechemotherapies to increase duration ofresponse, survival, clinical symptoms(pain), progression-free survival andquality of life are still preliminary.

Carles Galcerán and León Mateosreviewed salient features of two interest-ing clinical cases, one of which wasrelated to a patient with long survival

and the other to a patient who was not acandidate for chemotherapy at the timeof initial presentation.

Managing the patient with advanced prostate cancerGermà Lluch presented an interesting talkon the human aspects of the patient–doc-tor first encounter. He covered a diverserange of topics, such as:

• Role of the physician in being able tocope with the emotional concerns ofthe patients

• Understanding of secondary effectsinduced by androgen-deprivationtherapy

• Usefulness of docetaxel in the treatmentof hormone-refractory prostate cancer

• Future expectations related to the cur-rent research of new molecules directedto specific targets

• Importance of balancing efficacy andquality of life at the time of chemo-therapy during the last months of thepatient’s life

This philosophical presentation washighly appreciated by the audience.

Comments from the post-ASCO Prostate Cancer SymposiumThe most relevant posters and oral com-munications at the ASCO Prostate CancerSymposium, which was held in Orlando,Florida on February 22–24, 2007, weresummarized by Maldonado Pijuan fornewer radiotherapeutic novelties, byMedina López for novel approaches inurology and by González Martín forrecent advances in oncology.

ConclusionThis meeting presented a well-roundedprogram covering a wide range of topicson the treatment of patients withadvanced prostate cancer. Takentogether, the presentations demon-strated that a multidisciplinary approachinvolving urologists, radiation-therapyspecialists and medical oncologists iscritical to ensure new developments areimplemented into clinical practice. Thefuture of advanced prostate cancertreatment and development of new

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therapeutic strategies, including moreeffective and safer drugs, will arise froma close collaboration between these threemedical disciplines.

The Spanish Society of MedicalOncology and Spanish Association ofUrology, with the support of SanofiAventis, plan to meet next year in Barce-lona to discuss continuing developmentsin this field.

Affiliations

• Joaquim Bellmunt Molins, MD

Section Chief, Hospital Del Mar, Solid Tumor Oncology (GU & GI) Medical Oncology Service, Paseo Maritimo 25–29, Barcelona 08003, SpainTel.: +34 932 483 137Fax: +34 932 483 366jbellmunt@imas.imim.es

• Antoni Gelabert i MasHospital Del Mar, Urology Department, Paseo Maritimo 25–29, Barcelona 08003, SpainTel.: +34 932 483 231Fax: +34 932 483 433agelabert@imas.imim.es

Spanish Multidisciplinary Advanced Prostate Cancer Panel

• Dr Antonio Alcaraz AsensioServicio de Urología Hospital Clínic i Provincial (Barcelona)

• Dr Joaquim Bellmunt MolinsServicio de Oncología Hospital del Mar (Barcelona)

• Dr Joan Carles GalcerànServicio de Oncología Hospital del Mar (Barcelona)

• Prof Alfredo Carrato MenaServicio de Oncología Hospital General Universitario de Elche (Alicante)

• Prof Jesús Castiñeiras FernándezServicio de Urología Hospital Virgen Macarena (Sevilla)

• Dr Gustavo Catalán FernándezServicio de Oncología Hospital Son Llatzer (Mallorca)

• Dr José Manuel Cozar OlmoServicio de Urología Hospital Universitario Virgen de las Nieves (Granada)

• Dr Salvador Esquena FernándezServicio de Urología Fundació Puigvert (Barcelona)

• Dra. Palmira ForoServicio de Radioterapia Hospital del Mar (Barcelona)

• Dr Andrés García-Palomo PérezServicio de Oncología Hospital de León (León)

• Prof Antoni Gelabert i MasServicio de Urología Hospital del Mar (Barcelona)

• Prof José Ramón Germa LluchServicio de Oncología Institut Catala d'Oncologia (Barcelona)

• Dr Francisco A Gómez VeigaServicio de Urología Complejo Hospitalario Juan Canalejo (A Coruña)

• Dr José Luis González LarribaServicio de Oncología Complejo Universitario San Carlos (Madrid)

• Dr Antonio González MartínServicio de Oncología Hospital Ramón y Cajal (Madrid)

• Dr Vicente Guillém PortaServicio de Oncología Instituto Valenciano Oncología (Valencia)

• Dr Luis A León MateosServicio de Oncología Complejo Hospitalario Universitario de Santiago de Compostela (Santiago)

• Dr José López TorrecillaServicio de Radioterapia Hospital General Universitario de Valencia (Valencia)

• Dr José Antonio Lorente GarínServicio de Urología Hospital del Mar (Barcelona)

• Dr Xavier Maldonado PijuanServicio de Radioterapia Hospital General Vall d'Hebron (Barcelona)

• Dr Pablo Maroto ReyServicio de Oncología Hospital Santa Creu i Sant Pau (Barcelona)

• Dr Rafael A Medina LópezServicio de Urología Hospital Universitario Virgen del Rocío (Sevilla)

• Dra. Begoña Mellado GonzálezServicio de Oncología Hospital Clínic i Provincial (Barcelona)

• Prof Juan Morote RoblesServicio de Urología Hospital General Vall d'Hebron (Barcelona)

• Dra. Mª José Ribal CaparrosServicio de Urología Hospital Clínic i Provincial (Barcelona)

• Dr Ernesto Sánchez SánchezServicio de Urología Hospital Virgen Macarena (Sevilla)

• Dr Eduardo Solsona NarbónServicio de Oncología Instituto Valenciano Oncología (Valencia)

• Dr José F Suárez NovoServicio de Urología Hospital Universitario de Bellvitge (Barcelona)