Medicine Matters oncology

So dear colleagues, welcome from ESMO 2019 here from beautiful city of Barcelona. A lot going on in GU oncology. Let's start with prostate cancer.

In prostate cancer we had TITAN results. You know, TITAN is apalutamide and ADT in metastatic hormone-sensitive prostate cancer in an allcomer population. And here we reported the patient reported outcomes. In summary, when adding apalutamide to ADT-- so intensified treatment which resulted in overall survival benefit and PFS benefit-- with a hazard ratio of 0.67.

The patient reported outcome was the same. So no deterioration of health-related quality of life when intensifying the therapy, when getting better results with apa and ADT. So I think this is a good take home message. And I'm personally waiting for approval of apalutamide in Germany in this indication.

There was a lot of discussion from the STAMPEDE trial reporting on docetaxel, reporting on chemotherapy. They looked at the N plus non-metastatic prostate cancer patient, and showed that docetaxel makes no sense. It doesn't prolong overall survival. It is not disease controlling. So please don't use docetaxel in non-metastatic prostate cancer.

On the other hand, out of the same trial, they reported the data on M plus, so metastatic prostate cancer. We know from previous publication out of the STAMPEDE trial that in high volume disease MHSPC, it's a survival benefit of more than one year. There was always the discussion whether or not low volume patient benefit.

And here out of STAMPEDE, it was reported that also the low volume patient benefit from docetaxel treatment. So we have to decide now when we have novel treatment options like enzalutamide, apalutamide available within the next months or next years, which treatment to choose best for our patient, really depending on the health care market, what is approved, what can be reimbursed. But we have a lot of options and a lot of evidence to treat all comers with a good quality of life.

Another topic, when going back more to localized prostate cancer, after prostatectomy, there was a RADICALS trial. An artistic summary-- it's a meta analysis of the three trials, looking at whether or not you should do adjuvant radiation therapy or salvage radiation therapy once it comes to PSA progression following radical prostatectomy. Take home message is no difference in overall survival.

So you can choose. And I would always choose to wait for a salvage situation, because then you can avoid radiation therapy in the first place with some side effects and morbidity. So I think this piece of evidence brought me further in the consulting patients after PSA or after a radical prostatectomy. So some good news for prostate cancer.

Then-- so it's a lot of data. Some RCC data-- the source trial looked at adjuvant sorafenib TKI in high risk localized renal cancer, where you did a radical nephrectomy or partial nephrectomy with a clear cell RCC, and then gave adjuvant treatment one to three years of sorafenib versus placebo. The trial showed no benefit for sorafenib. No over all survival benefit. No disease control benefit.

So this is a fifth trial of a TKI not showing a benefit in this situation. So I would stop it there. I would advise not to use TKIs in an adjuvant setting in high risk RCC post-operation.

Personally, I'm really looking forward to the results of the running IO trials, the immunotherapy trials. There are a lot of trials right now recruiting or just reading out. And I've hoped that this mechanism of action delivers better results for all patients.

Coming back to my last topic, bladder cancer. And in bladder cancer, the EV, enfortumab vedotin I think this is one of the most promising substances we should keep our eyes on now. It's antibody conjugate. And we've seen data from ASCO in second and third and fourth line treated metastatic urothelial carcinoma patient showing a response rate of 40%. Now we saw first line data, seeing response rate of up to 70%.

So I think this is might be a great option for second or third line following IO combination treatment, and might be even an option for first line. There are several trials in planning. So I think EV is a substance we should keep our eyes on. And some good news for patients with metastatic bladder cancer. 

Dear colleagues, thanks a lot. Thanks for your attention. And all the best.