OLIGORECURRENT PROSTATE CANCER @piet_ost Mail: piet.ost@ugent.be - - PowerPoint PPT Presentation

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OLIGORECURRENT PROSTATE CANCER @piet_ost Mail: piet.ost@ugent.be - - PowerPoint PPT Presentation

Mar 09, 2023 115 likes •322 views

OLIGORECURRENT PROSTATE CANCER @piet_ost Mail: piet.ost@ugent.be DISCLOSURES Type of affiliation / financial interest Name of commercial company Institutional receipt of grants/research supports: Merck, Bayer, Ferring, Receipt of honoraria

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@piet_ost Mail: piet.ost@ugent.be

OLIGORECURRENT PROSTATE CANCER

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DISCLOSURES

Type of affiliation / financial interest Name of commercial company Institutional receipt of grants/research supports: Merck, Bayer, Ferring, Receipt of honoraria or consultation fees (institution): Astellas, Bayer, Ferring, Janssen, Sanofi Participation in a company sponsored speaker’s bureau: None Stock shareholder: None Spouse/partner: None Other support (please specify): None

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Category name De novo oligometastases (synchronous oligometastases) Oligometastatic recurrence (metachronous oligometastases) Oligometastatic progression (induced oligometastases) Primary tumor status

Not controlled Controlled Controlled/ucontrolled

Systemic treatment

Naive Naive Resistant

Location of metastases

N1 or M1 N1 or M1 N1 or M1

Uncontrolled lesion Controlled lesion

OLIGOMETASTATIC RECURRENCE

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NO CONSENSUS DEFINITION OF OLIGOMETASTATSES

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  • Different terminologies used and lesion cut-offs used.
  • EORTC-ESTRO is working on a consensus wording definition to be used

in papers.

  • Future: molecular definition (GAP6 Movember initiative)
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WHAT DO THE GUIDELINES SAY ON RE-STAGING?

Increase in low volume recurrences expected!

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WHERE DO YOU EXPECT RECURRENCES IN GENERAL?

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De Bruycker et al. BJUI 2017, and Eur Urol 2019 Devos et al. Eur Urol 2019

Choline PSMA Median PSA: 3 ng/ml Median PSA: 2,6 ng/ml

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METASTASIS-DIRECTED THERAPY FOR OLIGOMETASTASES

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BIOLOGICAL RATIONALE FOR METASTASIS-DIRECTED THERAPY

If metastases are able to metastasize and systemic therapy induces more resistant and lethal clones, the addition of local therapy directed at metastases might delay lethal disease progression…

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2 YEARS AGO…

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Years

  • 61 year old male; PSA 5.3ng/ml
  • MRI and biopsy: Gleason 3+4=7 in 6/21 cores
  • RARP: pT3a 4+3=7; N0; pos margin
  • Salvage radiotherapy

1 2 3 4 5 6 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 PSA ng/ml

PSA DT calculated on https://www.mskcc.org/nomograms/prostate/psa_doubling_time

A FAMILIAR TALE

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11

SBRT?

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12

SBRT? 68% 32%

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Ost et al. JCO 2018 Tran et al. ASTRO 2018

2 PHASE II TRIALS: MDT VS OBSERVATION

STOMP ORIOLE

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PROGRESSION-FREE SURVIVAL

p = 0.049

10 20 30 50 100

Time from randomization (months) Progression free survival

Ost et al. JCO 2018 Tran et al. ASTRO 2018

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PROGRESSION-FREE SURVIVAL

p = 0.049

Ost et al. JCO 2018 Tran et al. ASTRO 2018

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WHAT ABOUT THE COSTS OF MDT?

Higher cost Les effective Dominant Cost-effective Not cost-effective Lower cost More effective Willingness-to-pay threshold (WTP)

ICER: incremental cost-effectiveness ratio?

  • Perspective: healthcare payer
  • Costs: diagnostics, intervention (with possibility of multiple

rounds of SBRT), FU & side-effects

  • Effects: Quality-adjusted life years (QALY)
  • Time horizon: 5 years (one-month cycle)
  • Discount rate: 3% costs & 1.5% effects
  • Handling uncertainty: one-way sensitivity analysis,

probabilistic sensitivity analysis & scenario analysis

  • WTP threshold: € 40.000 per QALY

Markov Model characteristics

  • Health state transition probabilities
  • STOMP trial (Ost et al., 2018)
  • Expect for ADT-state to CRPC-state (De Bruycker et al.,

2017)

  • Death
  • Other causes (Belgian age-specific life tables, 2017)
  • Risk of dying in CRPC state (De Bruycker et al., 2017)
  • Toxicity per treatment
  • Literature & expert opinion (Walker et al., 2013; Ploussard

et al., 2018; Decastecker et al., 2014)

  • No toxicity cost of next line systemic drugs in CRPC setting
  • Utilities per health state
  • Literature & expert opinion (Stewart et al., 2005; Tengs et

al., 2000; Cooperberg et al., 2013; Heijnsdijk et al., 2016)

  • 80/20 ratio SBRT/surgery was taken in account
  • Costs (€)
  • Belgium National Institute for health and disability

insurance and cross-checked with hospital invoices.

Model inputs (data source)

De Bleser et al. submitted

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MOST COST-EFFECTIVE TREATMENT AT VARYING THRESHOLDS:

̶ the cost-effectiveness acceptability curve (CEAC)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 5000 10000 15000 20000 25000 30000 35000 40000 45000 50000 55000 60000 65000 70000 75000 80000

Probability Most Cost-Effective Threshold (€)

AS MDT ADT

De Bleser et al. submitted

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OTHER TUMOR TYPES?

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  • Gomez et al. Lancet Oncol 2016
  • Palma et al. Lancet 2019

Mixed tumor types (16% prostate cancer) Lung cancer

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OTHER TUMOR TYPES?

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  • Gomez et al. Lancet Oncol 2016
  • Palma et al. Lancet 2019

Olson et al. Red Journal 2019

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CONCLUSION

  • Phase II trials indicate that MDT is feasible, well tolerated and

improve biochemical response and PFS as compared to

  • bservation

̶ MDT in other tumor types: improvement in OS ̶ MDT should not be considered SOC based on phase II trials! ̶ Phase III trial underway

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