APCCC outcome
In “Results of the APCCC meeting”, Prof. Dr. Nicolas Mottet (FR) presented the outcome of the Advanced Prostate Cancer Consensus Conference (APCCC), a consensus meeting which consisted of a round of 123 questions answered by 57 panel members. The members were comprised of medical oncologists (44%), urologists (30%), clinical oncologists (14%) and radiation oncologists (12%) from Europe (42%) and North America (35%). Voting results higher than 75% were considered a consensus.

Specific questions were based on 10 controversial areas of prostate cancer (PCa) such as locally advanced PCa, biochemical recurrence of PCa after local therapy, management of primary tumour in the metastatic setting, to name a few.

Only 36 questions out of the 123 had consensus, such as the 80% vote for PSMA PET CT/MRI (plus/minus pelvic MRI) as the recommended imaging modalities in rising prostate-specific antigen (PSA) levels after radical radiation therapy of the prostate. About 87.3% voted for the same modalities in rising PSA levels after radical prostatectomy. 

ESUI19 recap
In “Highlights from ESUI” by ESUI Chairman Prof. Georg Salomon (DE), presented a recap of the 8th Meeting of the EAU Section of Urological Imaging (ESUI19) which included the shrinked ultrasound scanners to which he underlined that although the devices are getting better, clinical impact is related to the abilities and experience of the doctor with regard to ultrasound. 

Prof. Salomon also reiterated one of the core messages of the ESUI19 lecture “Blessing or curse: Machine learning in MRI reading – Key issues” presented yesterday by Prof. Henkjan Huisman (NL) that although artificial intelligence (AI) help improve the workflow and prevent missing significant cancers, AI does not help the avoidance of unnecessary biopsies. 

EAU RF updates
Prof. Anders Bjartell (SE) shared the future aims of the EAU Research Foundation (EAU RF) in his lecture “The EAU Research Foundation: Trials in progress”.

These aims included expanding EAU RF’s portfolio of investigator-initiated oncology and non-oncology clinical trials through seeding grants and other set-ups; more interactions with the Young Academic Urologists (YAU); connecting with eUROGEN in research projects; holding more consensus meetings; and collaborating with the EAU Guidelines Office.

Prof. Bjartell congratulated Dr. Veeru Kasivisvanathan (GB) and Dr. Melanie Rosalia Hassler (AT) as the recipients of the seeding grant for 2019.

PRIAS overview
In her presentation“Highlights from PRIAS”, Prof. Dr. Monique Roobol (NL) shared an overview of yesterday’s PRIAS meeting.

Initiated in 2006, the PRIAS (Prostate Cancer Research International Active Surveillance) is a web-based international prospective registry study to validate the AS approach for low-risk PCa and to develop an evidence-based algorithm.

“PRIAS continues to grow. It’s a successful concept due to the digital support of the website. Our data is not from a highly-controlled clinical trial; it reflects what goes on and indicates how the Guidelines is translated into daily clinical practice. We also gain knowledge on AS practices worldwide.  And I’m pleased to announce PRIAS is legally up-to-date; we abide by the GDPR.” 

Prof. Roobol stated that the PRIAS website will be updated and that they will address the growing interest in lifestyle and food issues. “Our study is flexible; we can culminate these kinds of pursuits next to our PRIAS protocol.”

According to Prof. Roobol, PRIAS is “alive and kicking” and encouraged the audience to join the “largest prospective AS database which is flexible to adjust to new insights and initiate new studies.”

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The experts gave their view on the continued use of PSA as a screening tool and the current state (and future potential) of imaging or biomarker-based alternatives.

The 11th edition of the European Multidisciplinary Meeting on Urological Cancers is taking place in Vienna on 15-17 November. It was preceded by the 8th Meeting of the EAU Section of Urological Imaging and other supplementary meetings on the 14th. EMUC19 is a collaboration of the European Society for Medical Oncology (ESMO), the European Society for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

A case for timely detection

Prof. Chris Bangma (Rotterdam, NL), urologist, co-chaired the session on early detection and the 40 years of PSA. He suggested that the audience use the coffee break after the session to celebrate the milestone. Its discovery in 1979 had a huge impact on the medical profession, patients and governments alike.

As an illustration of how far we’ve come (and perhaps as a warning if PSA testing is recklessly abandoned) Prof. Roobol (Rotterdam, NL) painted a picture of prostate cancer diagnosis and treatment in the 1970s and 80s. Patients were diagnosed at a point where the cancer had spread to bones and only one in 2-3 patients survived. Following a huge rise in PSA testing in the early 2000s, there followed a reflective period and fear of overdiagnosis. “But stopping PSA testing is not the way to go,” warned Roobol, fearing a return to mortality levels of the 1980s.

“We have to preserve the achievements of recent decades and work on preventing the excesses. In two words: Risk Assessment.” Roobol proposed an approach for 2019 and beyond that started with baseline PSA, then risk stratification, imaging, further risk stratification, biopsy, and then treatment  (including active surveillance) if required.

Earlier in the session, Prof. Hein Van Poppel lamented the recent decline in PSA screening and the associated increase in mortality in several Western European countries. “This could be prevented with early detection and appropriate treatment.” Van Poppel warned the audience for what he termed “anti-PSA propaganda” and the discouragement of PSA use. He concluded that effective use of supplementary tools and technologies like new biomarkers and MRI can avoid overdiagnosis and overtreatment.

Crucially, Van Poppel argued that Europe’s adult male population “needs to be informed” directly, thereby increasing awareness of PSA testing and the importance of early detection. The EAU is also working in a wider coalition of experts and patient organisations to lobby the European Commission to recommend population-based screening and hopefully change national guidelines. This is part of a longer strategy that was outlined at the EAU’s National Societies Meeting earlier this year and further detailed in an opinion piece on behalf of the EAU.

Van Poppel also hailed EMUC as a major achievement, a real multidisciplinary meeting that reflected the reality that urinary cancers no longer belong to a single specialty.

A voice to be heard

The morning’s session progressed to include the current state and (near-)future potential of various early detection options including MRI (specifically PI-RADS), the grading system used by pathologists, and biomarkers and genomics. A lot of discussions took place in between the talks, covering topics like certification for hypothetical prostate imaging centres, and the role of artificial intelligence in risk stratification.

One discussion focused on the needs of patients and their experiences with their GPs: Dr. Erik Briers (Hasselt, BE) who was in the audience and identified himself as a prostate cancer patient mentioned the “own way of thinking” that general practitioners had when it came to their patients and prostate cancer.

“They feel that they have to protect men from overdiagnosis and overtreatment. But actually, men want to know about their prostate cancer when it is still curable. It might help to adjust the training of GPs, they have to learn that urologists and other disciplines are not out to take our prostates. They want to help us in the best possible way, and our doctors should not be afraid to refer us to a specialist.”

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The symposium is co-organised by the EAU Sections of Uro-Pathology (ESUP) and Urological Research (ESUR) and the Uropathology Working Group of the European Society of Pathology. Expert speakers were drawn from these bodies, with speakers of a variety of pathology-related backgrounds.

This year, the ESUP Symposium examined the current state of liquid biopsies in uro-oncology, and it possible future applications. What emerged over the course of the afternoon was a future with a promising perspective, but still a lot of work to be done for researchers and pathologists.

Dr. Michelangelo Fiorentino (Bologna, IT), a clinical pathologist, gave an introductory talk on the current applications, and what uro-oncologists should know before using them. Liquid biopsies refers to the use of blood and other bodily fluids as an alternative to tissue samples for diagnostic purposes.

The potential of liquid biopsies is significant, according to Fiorentino: “The major advantages are the non-invasiveness, removing the need for biopsies. Also, liquid biopsies can give a better representation of all the tumour profiles and genetic mutations. Finally, liquid biopsies can give a better indication on the extent of tumour burden.”

In theory, any lab test for tissue can be used to analyse liquids, but they have to be adapted for much lower concentrations of tumour cells. Some tests can require up to 80ml of blood. As it stands, liquid biopsy is currently much more expensive than conventional histology. The reliability of diagnostic accuracy is also inferior. It is also not entirely clear which professional should be in charge of liquid biopsies: pathologists, biochemists, geneticists or (uro-)oncologists.

Potential for BCa

Following talks on kidney cancer (by ESUR Chairwoman Prof. Kerstin Junker, pictured) and prostate cancer and the potential suitability of liquid biopsies for those urological cancers, Prof. Thomas Gevaert (Leuven, BE) spoke on bladder cancer. “In contrast to other urological cancers, BCa has advantage: we can look at blood as well as urine. By combining analysis of the liquids, and with a variety of techniques we can investigate different substances.”

“The majority of patients with metastatic BCa have circulating tumour DNA. This means there is potential value to stratify patients for clinical trials, as well as potential value in diagnostic and follow-up flowcharts. cfDNA/ctDNA is a very sensitive tool to detect early recurrence and minimal residual disease.”

Gevaert postulated that by combining analysis of cfDNA (mutational landscape) and CTC’s (protein expresession), these could be complementary tools with even better results.

Despite aforementioned advantages of liquid biopsies, particularly for BCa, like its non-invasiveness, the combination of urine and blood, and the pre-screening and monitoring, Gevaert pointed out certain hurdles that need to be cleared before liquid biopsies are adopted.

“As with many new techniques, we are still waiting for prospective validation. We also need standardization in our approach. Crucially, we should not be using liquid biopsies unless there is a clear superiority when compared to traditional biopsies. Sensitivity and specificity of liquid biopsies also need to be determined.”

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Core of the lecture
“My lecture will focus on urine biomarkers in NMIBC. Most studies in the field have focused primarily on urine DNA isolated from intact cells in the urine (urine pellets). These inform us about the presence of tumour in the bladder, and may be used for optimised surveillance,” stated Prof. Dyrskjøt. “We have performed studies of cell-free DNA in urine which may originate from the blood stream, and indicate if the disease is already invasive/metastatic. Consequently, this may be used for additional monitoring of disease state, and not just presence of tumour cells.”

Inspiration for the research
The research by Prof. Dyrskjøt and his team was inspired by the liquid biopsy/plasma analysis in the detection of circulating tumour DNA.  He explained, “This was mostly focused on the late stage of the disease, for the detection of residual tumour after surgery, and for the detection of metastatic disease. Using biobank materials from patients with long-term follow-up, it was possible to select patients to investigate this mutated DNA in both urine and plasma samples from patients that were initially diagnosed with early stage disease.”

Potential of the findings
If validated in larger cohorts, cell-free analysis of tumour DNA in urine and plasma may be used for monitoring disease aggressiveness in NMIBC, and may complement other standard urine tests for tumour detection.

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Get the rest of the essentials during Prof. Dyrskjøt’s highly-informative lecture on Friday, 15 November during the Plenary Session “Novelties in muscle-invasive bladder cancer”.

Explore the rest of the EMUC19 Scientific Programme for vital information on GU cancers. We look forward to welcoming you in Vienna!

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The session will feature insights of esteemed urologist Dr. Rafael Sanchez-Salas (FR) who specialises in intervention and surgery; and  prominent radiooncologist Prof. Dr. Thomas Wiegel (DE). The renowned specialists will provide a binary perspective on the patient cases.

“The session’s objective is to show where things can go wrong especially with alternative treatment, and how to approach that optimally,” stated Prof. Dr. Arnulf Stenzl (DE), EAU Adjunct Secretary General – Executive Member Science.

Prof. Stenzl and Dr. Cesare Cozzarini (IT) will chair the session, which is part of the popular Nightmare Session series introduced at the EAU’s annual congress held in London in 2017.

The EMUC19 Nightmare Session will show varied perspectives and outcomes of opting for an intervention (e.g. focal therapy) or a radiooncological treatment. “It is interesting for both the radiooncologists and urologists to know which treatment addresses and solves the case,” said Prof. Stenzl said. “It is also important to know where the problems and pitfalls lie in each treatment possibility.”

The cases
Each discussant will present patient cases where treatment were done with curative intent.

“The cases in the session represent typical clinical situations commonly feared by clinicians. For example, a patient was just treated with curative intent with either radical prostatectomy or radical radiotherapy. However immediately after, the clinician realises that metastasis was already present even before the patient underwent radical treatment. Unfortunately for some reason, this was not initially recognised. How should the clinician approach this situation? This is the type of cases that the Nightmare Session will highlight,” stated Dr. Cesare Cozzarini.

Radiooncologist viewpoint
“The objective of my lecture is to inform urologists and radiation oncologists about a significant pitfall in the treatment of patients with locally advanced PCA,” explained Prof. Wiegel. “In locally advanced PCa, one standard is radiation therapy (RT) plus two to three years of Luteinising Hormone Releasing Hormone (LHRH)-analogue; the increase of overall survival of about two years is proven in phase III trials.”

Prof. Wiegel will present a case wherein a patient conformed to start androgen-deprivation therapy (ADT) treatment. Then after 50 Gray (Gy), the prostate-specific antigen (PSA) was controlled and showed a significant increase in contrast which was expected. However according to the patient, he had not received ADT due to fear of the side effects concerning potency. “This has been detected with the PSA and if it wasn’t, the treatment was not standard in combination with the clear early progression of the disease,” said Prof. Wiegel.

During the Nightmare Sessions at EMUC19, Prof. Wiegel and Dr Sanchez-Salas will share more valuable insights and advice.

About EMUC19
EMUC19 is a frontline, multi-disciplinary congress designed to encourage relevant discussions on innovative treatment, the limits of standard therapies, and the impact of new research outcomes. Its reputation as prime European platform for professional and scientific exchanges in genitourinary oncology has been well-established throughout the years.

The congress brings together esteemed specialists and healthcare professionals from various disciplines, thanks to the collaborative efforts of the European Society for Medical Oncology (ESMO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

EMUC19 will take place on 15-17 November 2019 in Vienna, Austria. For more information about the congress and how to join, explore the EMUC19 website.

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The 11th European Multidisciplinary Congress on Urological Cancers (EMUC19)  is coming to Vienna on November 14-17. The meeting is co-organised by the European Association of Urology (EAU), the European Society for Medical Oncology (ESMO) and European SocieTy for Radiotherapy & Oncology (ESTRO). Also on November 14th, the EAU Section of Urological Imaging is holding its 8th meeting, ESUI19. Abstract submission for EMUC19 is currently open, until July 1st.

The organizing parties have appointed representatives from their ‘young professionals’ wings to sit on the EMUC19 scientific committee to ensure that the scientific programme reflects their interests and professional requirements. We spoke to each representative about their role and their views on the important topics.

A voice for young professionals

Dr. Evanguelos Xylinas (Paris, FR) is Associate Professor of Urology at Bichat Claude Bernard Hospital. He represents the EAU’s Young Academic Urologists (YAU) on the EMUC19 scientific committee. Dr. Xylinas describes his role as proposing speakers and topics to be covered on behalf of YAU.

Jean-Emmanuel Bibault (Stanford, CA, USA) is a radiation oncology Associate Professor from Paris currently doing a postdoctoral research fellowship in the Laboratory of Artificial Intelligence for Medicine and Biomedical Physics, at Stanford University School of Medicine: “I’m involved in EMUC19 as a member of ESTRO’s Young Committee. I help design the programme of the annual meeting, particularly on the sessions where radiation oncology is relevant.”

Dr. Christoph Oing is on the EMUC19 Scientific Committee as a member of the ESMO’s Young Oncologist Committee (YOC). He is specialised in Internal Medicine, Haematology and Medical Oncology. He is a clinical fellow at the Dept of Oncology, Haematology and Bone Marrow Transplantation with Division of Pneumology, University Medical Center Hamburg-Eppendorf (DE), among several other affiliations.

“I have been invited to participate in the EMUC19 scientific programme committee as ESMO Young Oncologists Committee (YOC) representative to establish involvement and address interests of young Medical Oncology professionals in the upcoming EMUC conferences. As such, the YOC contributes to scientific abstract reviewing with 5 supporters and I have been invited to actively participate in the programme including a case presentation on testicular cancer and a discussion on localised prostate cancer.”

Important Topics

Asked about which topics are of particular interest to young onco-urology professionals, Xylinas (YAU) points to state-of-the-art lectures. “We like these for giving an overview of the current evidence on a topic. Sessions that address the current guidelines are popular, as are clinical cases discussion by key opinion leaders.”

Bibault (ESTRO YC) considers the topics that will define the standard of care and best practice for young professionals in radiation oncology in prostate cancer and bladder cancer the most important. “When should you consider radiotherapy, what volumes, what dosage? How does radiation therapy can be combined and coordinated with surgery and systemic treatments?” These and more will be part of the three-day scientific programme.

“Both well-structured introductions to current standards and discussion of areas with lacking evidence or practice-changing, up-to-date developments are highly relevant for young professionals to increase their knowledge and confidence in GU cancer care,” says Oing (ESMO YOC).

“Rare cancers, i.e. testicular and penile cancer, will are also important to address, as individual experience with such cancers may be scarce. In addition, case discussions are of particular importance to provide practical advice and illustrate the beneficial impact of multidisciplinary GU cancer care.”

Multidisciplinary reality

Oing also sees a tendency in genitourinary oncology: “It is rapidly evolving irrespective of the subspecialty involved in GU cancer care. The multidisciplinary approach of EMUC, with its multifaceted expert scientific committee and conference structure is outstanding and a key to success in sharing knowledge on current standards and future developments for both the attendees and faculty.”

Bibault concurs: “Multidisciplinarity is essential in uro-oncology if we want to give the best possible treatment to our patients. We absolutely need to work, discuss each case with our friends and colleagues from surgery and medical oncology. Comprehensive cancer centers are essential in that setting.”

Xylinas: “I think oncology and onco-urology in particular equals multidisciplinarity. The aim is to provide, all together, the best care for our patients.”

EMUC19 has a comprehensive scientific programme featuring expert speakers from all onco-urology-related fields. The ESUI meeting, as well as ESU courses and the ESUP Symposium are all optional elements of the programme on November 14th. Discounted registration fees are available for EAU, ESMO and ESTRO members, as well as residents.

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