Ann Oncol. 2015 Aug;26(8):1589-604. doi: 10.1093/annonc/mdv257.

Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015.

 

Gillessen S, Omlin A, Attard G, et al.

 

Abstract

The first St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) Expert Panel identified and reviewed the available evidence for the ten most important areas of controversy in advanced prostate cancer (APC) management. The successful registration of several drugs for castration-resistant prostate cancer and the recent studies of chemo-hormonal therapy in men with castration-naïve prostate cancer have led to considerable uncertainty as to the best treatment choices, sequence of treatment options and appropriate patient selection. Management recommendations based on expert opinion, and not based on a critical review of the available evidence, are presented. The various recommendations carried differing degrees of support, as reflected in the wording of the article text and in the detailed voting results recorded in supplementary Material, available at Annals of Oncology online. Detailed decisions on treatment as always will involve consideration of disease extent and location, prior treatments, host factors, patient preferences as well as logistical and economic constraints. Inclusion of men with APC in clinical trials should be encouraged.

KEYWORDS: advanced prostate cancer; castration-naïve prostate cancer; castration-resistant prostate cancer; consensus; therapeutics

PMID: 26041764

 

Supplements:

Authors: Gillessen S and Omlin A on behalf of the APCCC panel and authors.

Many uncertainties remain in daily clinical treatment of men with advanced prostate cancer (APC) because there are clinical questions or scenarios topics where there is a lack of available evidence from the literature or the existing data are conflicting, sparse, or only low-level.

The inaugural St.Gallen Advanced Prostate Cancer Consensus Conference (APCCC) was held in March 2015 with the aim to address clinically relevant questions important for management of men with advanced prostate cancer in daily practice.

The APCCC conference concluded with an expert panel discussion and vote on almost 100 pre-defined and agreed-upon consensus questions. Based on these voting results expert recommendations have been formulated and summarized in a manuscript published at Annals of Oncology.

 

Some of the key recommendations following the APCCC conference are summarised here.

The following recommendations were given by the panel votes: 

  • Total testosterone should be measured before classifying disease as castration resistant. Confirmed PSA rise on androgen deprivation therapy (ADT) in the presence of a documented suppressed testosterone level was recommended for the definition of CRPC.
  • Baseline staging examinations including laboratory parameters and conventional imaging should be performed in every man with CRPC before starting a new treatment. Without baseline staging information, subsequent interpretation of antitumor outcome is very challenging.
  • Disease activity should be monitored (including imaging) for men on agents that have been shown to prolong survival. Monitoring by PSA alone is insufficient.
  • Patients should be informed of the availability of and the possibility to participate in a clinical trial to offer them novel therapies. Further advances in the treatment of men with CRPC can only be achieved through clinical trials.
  • A man with castration-naive prostate cancer and bone metastases should not be treated with bisphosphonates or denosumab in the dose established for reduction of risk of skeletal-related events or symptomatic skeletal events in patients with CRPC. However, adequate calcium and vitamin D supplementation, lifestyle changes, and bisphosphonates or denosumab at lower dose and schedule for the prevention of osteoporosis or osteoporotic fractures should be considered.
  • A man with CRPC and M0 disease by standard imaging (computed tomography and bone scintigraphy) should not be treated with one of the agents that have been shown to prolong overall survival in the metastatic CRPC setting (abiraterone, cabazitaxel, docetaxel, enzalutamide, radium-223, or sipuleucel-T) outside of a clinical trial. Large phase III clinical trials with different androgen receptor–pathway inhibitors in this indication are ongoing, and patients should be included in these trials.
  • Bicalutamide should not be routinely added for the treatment of metastatic disease progressing on ADT if abiraterone or enzalutamide are available. For the definition of CRPC, the addition of bicalutamide to ADT and confirmed PSA rise on combined ADT is no longer required.
  • Because it is unknown whether abiraterone or enzalutamide is better in terms of antitumor activity, the main question that should be evaluated is when to use a novel endocrine agent and when to use chemotherapy, radium-223, or sipuleucel-T in a man with metastatic CRPC.
  • Treatment with an agent with proven OS benefit (abiraterone, cabazitaxel, docetaxel, enzalutamide, radium-223, or sipuleucel-T) in a man with CRPC should not be stopped based on PSA rise only in the absence of clinical or radiological progression. A combination of at least two out of the three progression criteria (PSA and/or symptoms and/or radiographic evidence) is recommended for stopping or switching treatment.

 

For more details please read the full publication, which is available open access at Annals of Oncology (Gillessen et al. Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015 Ann Oncol (2015) 26 (8): 1589-1604)

 

Based on the very successful completion of the first consensus conference, a large number of questions that remain open, and ongoing studies that will possibly change the landscape again, the organizers will hold another consensus conference in 2017. The scientific committee has been formed, and the 10 areas of controversy covered in the next conference will be identified soon. Please visit www.apccc.org for details.

 

About the Authors: Drs. Omlin and Gillessen, Department of Oncology and Haematology, Cantonal Hospital St.Gallen, Switzerland; aurelius.omlin@kssg.ch and silke.gillessen@kssg.ch

 

Reference:

  1. Gillessen S, et al. Ann Oncol. 2015; 26:1589-1604.

 

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