Medical management of advanced prostate cancer: a multidisciplinary team approach

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<ul><li><p>10.1586/14737140.7.7.977 2007 Future Drugs Ltd ISSN 1473-7140 977</p><p>Meeting Report</p><p>Medical management of advanced prostate cancer: a multidisciplinary team approachTreating advanced prostate cancer togetherMarch 1617, 2007, Sitges, Barcelona, Spain</p><p>Joaquim Bellmunt Molins* and Antoni Gelabert i Mas* On behalf of the Spanish Multidisciplinary Advanced Prostate Cancer PanelAuthor for correspondence: Hospital Del Mar, Solid Tumor Oncology (GU &amp; GI) Medical Oncology Service, Paseo Maritimo 2529, Barcelona 08003, Spain; Tel.: +34 93 248 3137; Fax: +34 93 248 3366;*Both authors are available for correspondence.</p><p>Expert Rev. Anticancer Ther. 7(7), 977979 (2007)</p><p>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.</p><p>The hormone-refractory patientThe first group of presentations coveredthe therapeutic challenges posed by</p><p>patients with androgen-independentprostate cancer. With regard to the defi-nition of hormone-refractory prostatecancer, Lorente Garn emphasized theneed to establish a definition, by con-sensus, to determine the clinical rele-vance of plasma testosterone levels of2050 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. </p><p>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). </p><p>Assessment of prognostic factors associ-ated with unfavorable outcome afterandrogen-deprivation therapy was dis-cussed by Ribal Caparrs, focusing on therole of PSA progression and PSA doubling</p><p>time, as well as the usefulness of pre-treatment nomograms for the predictionof survival in patients with nonmeta-static and metastatic hormone-refractoryprostate cancer. </p><p>Garca-Palomo Prez 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. </p><p>Finally, Snchez Snchez presented acase report of an asymptomatic patientwith hormone-refractory prostate cancerand Surez 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.</p><p>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</p><p>k.rowlandText BoxFor reprint orders, please</p></li><li><p>Molins &amp; Gelabert i Mas</p><p>978 Expert Rev. Anticancer Ther. 7(7), (2007)</p><p>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.</p><p>Chemotherapy &amp; 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. </p><p>Esquena Fernndez 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. </p><p>A number of approaches to neo-adjuvant and adjuvant therapy withdocetaxel were presented by GmezVeiga. 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</p><p>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. </p><p>The initial results of a multicenterstudy (PROSTAX-NEO) carried out inSpain were discussed by MelladoGonzlez. A total of 57 prostate cancerpatients with clinical stage T1cT2, 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 (</p></li><li><p>Treating advanced prostate cancer together</p><p> 979</p><p>therapeutic strategies, including moreeffective and safer drugs, will arise froma close collaboration between these threemedical disciplines. </p><p>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. </p><p>Affiliations</p><p> Joaquim Bellmunt Molins, MDSection Chief, Hospital Del Mar, Solid Tumor Oncology (GU &amp; GI) Medical Oncology Service, Paseo Maritimo 2529, Barcelona 08003, SpainTel.: +34 932 483 137Fax: +34 932 483</p><p> Antoni Gelabert i MasHospital Del Mar, Urology Department, Paseo Maritimo 2529, Barcelona 08003, SpainTel.: +34 932 483 231Fax: +34 932 483</p><p>Spanish Multidisciplinary Advanced Prostate Cancer Panel</p><p> Dr Antonio Alcaraz AsensioServicio de Urologa Hospital Clnic i Provincial (Barcelona)</p><p> Dr Joaquim Bellmunt MolinsServicio de Oncologa Hospital del Mar (Barcelona)</p><p> Dr Joan Carles GalcernServicio de Oncologa Hospital del Mar (Barcelona)</p><p> Prof Alfredo Carrato MenaServicio de Oncologa Hospital General Universitario de Elche (Alicante)</p><p> Prof Jess Castieiras FernndezServicio de Urologa Hospital Virgen Macarena (Sevilla)</p><p> Dr Gustavo Cataln FernndezServicio de Oncologa Hospital Son Llatzer (Mallorca)</p><p> Dr Jos Manuel Cozar OlmoServicio de Urologa Hospital Universitario Virgen de las Nieves (Granada)</p><p> Dr Salvador Esquena FernndezServicio de Urologa Fundaci Puigvert (Barcelona)</p><p> Dra. Palmira ForoServicio de Radioterapia Hospital del Mar (Barcelona)</p><p> Dr Andrs Garca-Palomo PrezServicio de Oncologa Hospital de Len (Len)</p><p> Prof Antoni Gelabert i MasServicio de Urologa Hospital del Mar (Barcelona)</p><p> Prof Jos Ramn Germa LluchServicio de Oncologa Institut Catala d'Oncologia (Barcelona)</p><p> Dr Francisco A Gmez VeigaServicio de Urologa Complejo Hospitalario Juan Canalejo (A Corua)</p><p> Dr Jos Luis Gonzlez LarribaServicio de Oncologa Complejo Universitario San Carlos (Madrid)</p><p> Dr Antonio Gonzlez MartnServicio de Oncologa Hospital Ramn y Cajal (Madrid)</p><p> Dr Vicente Guillm PortaServicio de Oncologa Instituto Valenciano Oncologa (Valencia)</p><p> Dr Luis A Len MateosServicio de Oncologa Complejo Hospitalario Universitario de Santiago de Compostela (Santiago)</p><p> Dr Jos Lpez TorrecillaServicio de Radioterapia Hospital General Universitario de Valencia (Valencia)</p><p> Dr Jos Antonio Lorente GarnServicio de Urologa Hospital del Mar (Barcelona)</p><p> Dr Xavier Maldonado PijuanServicio de Radioterapia Hospital General Vall d'Hebron (Barcelona)</p><p> Dr Pablo Maroto ReyServicio de Oncologa Hospital Santa Creu i Sant Pau (Barcelona)</p><p> Dr Rafael A Medina LpezServicio de Urologa Hospital Universitario Virgen del Roco (Sevilla)</p><p> Dra. Begoa Mellado GonzlezServicio de Oncologa Hospital Clnic i Provincial (Barcelona)</p><p> Prof Juan Morote RoblesServicio de Urologa Hospital General Vall d'Hebron (Barcelona)</p><p> Dra. M Jos Ribal CaparrosServicio de Urologa Hospital Clnic i Provincial (Barcelona)</p><p> Dr Ernesto Snchez SnchezServicio de Urologa Hospital Virgen Macarena (Sevilla)</p><p> Dr Eduardo Solsona NarbnServicio de Oncologa Instituto Valenciano Oncologa (Valencia)</p><p> Dr Jos F Surez NovoServicio de Urologa Hospital Universitario de Bellvitge (Barcelona)</p></li></ul>