Consensus Statement for Treating Metastatic Hormone Sensitive P Ca in developing Countries

• 20 Apr 2021 11:39:34 AM
• |Onco Urology

Dear All,

In India, performing Radical Prostatectomies have increased exponentially with many centres practicing RARP, with some practicing Lap RP and few centres still adopting Open RP.

But majority of P Ca’s are seen in India are in advanced stages still. Metastatic hsP Ca is still the most prevalent form of presentation. Recent articles from the west indicate that there has been an increase in De Novo mP Ca in recent years, a paradox inspite of all available modalities at disposal to detect early P Ca.

There are numerous techniques for RARP now described with the most recent being ‘HOOD Technique’ proposed by Ashutosh Tewari et al. Recently there are articles suggesting the utility of ‘Perineal RARP’.  This technique is gaining popularity as suggested by Volkan TuÄŸcu, Mithat EkÅŸi* et al (2020). Because of the proximity of the prostate to the perineal region and its extraperitoneal location, previous abdominal surgery does not provide any disadvantage. Also size of Prostate is no hindrance as is performing PLND.

Recently RP’s for even advanced disease are being considered with many articles addressing ‘Role of RP in Oligometastatic Disease’.

Many Drug regimes have developed since 2010, with LHRH agonist; later GnRH Antagonists coming to the fore along with Docetaxel were the treatments available for Metastatic P Ca. Bil. In Under developed countries due to non availability of recently introduced drugs and their unmanageable cost, Orchidectomy is the most preferred method for this situation of mP Ca. To use first line of Androgen Receptor Inhibitor, Bicalutamide, is considered an option along with Orchidectomy in Developing Countries. These issues as what ideal option that could be used in Under Developed, resource poor countries are well discussed in the ‘Consensus for Treatment of Metastatic Castration-Sensitive Prostate Cancer: Report from the First Global Prostate Cancer Consensus Conference for Developing Countries (PCCCDC)’ (PDF provided). The consensus study clearly states that many of the modalities now considered as ideal in developed countries are not possible in Developing Underprivileged countries. The consensus statement urges all to take these facts when considering implementing Treatments for Metastatic Hormone Sensitive P Ca.

I would appreciate all to give considerable importance to this Consensus statement when considering treatments for advance P Ca. The drawback of this consensus statement, however suitable it is for Indian Consumption, is that majority of the participants was Brazilians.  

With warm Regards,

Venu

Comments(3)

• 

  Venugopal P

  23 Apr 2021 11:01:46 AM

  Dear All,

  I had provided only one aspect of the several articles published by JCO Global Oncology in its recent issue on ‘A Report from the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC)’.  I am providing the Links for remaining articles addressing the same issue for the benefit of all those interested.

  As mentioned earlier in my previous write up, mentioned that we should have our own yardstick for decision of Treatments for P Ca along with most of the other diseases. But it should be an honest attempt based on our own Documentation and not Copy and Paste as noticed in few Guidelines that have come out under the aegis of USI. We take all that is provided as Guidelines of Developed world (AUA, EAU, NCCN and the like) as Gospel truth and attempt to implement them in our practice least realizing that many of such treatments now available are beyond the means of an average Indian. This results in Financial Toxicity in an Underprivileged Country like India. Many are bound to give up the treatments because of this. No doubt the treatment options provided with current options as being highlighted from Developed Countries could be superior but if it is beyond the scope of an average Indian, then what its use is. It should be realised that we should ‘cut the sleeve depending on the material available’. Many of our patients are not medically insured and have to provide the needed ‘mool’ from their own pocket. Many of the drugs now being considered are so expensive and there is a doubt whether reimbursement will be offered for such options by the Insurance companies.

  These articles are addressing what are the scopes for treatments for P Ca in developing countries and which treatments could be offered in which situation. Even this should not be taken wholesale but based on this we can and should generate as how we should approach the various scenarios presented in P Ca.

  I have already provided the consensus report for developing Countries on ‘Metastatic Castration-Sensitive Prostate Cancer’ and I am hopeful that you have read it. The other articles addressing several other scenarios are being provided as links and I am sure you will be able to open them and get benefit from what have been offered. 

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00527  

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00515

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00421

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00508

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00507

  https://ascopubs.org/doi/pdfdirect/10.1200/GO.20.00511

  I am sure read collectively will help us as how we could adapt in the treatments of various scenarios that present with P Ca. I have my own doubt whether AS, as being offered for very low, low and some favourable Intermediate risk can be implemented in India. The very well educated and financially well padded could be advised AS but what about our average Indian especially those living in Rural Areas.

  With warm Regards,

  Venu

   

• 

  Ravindra Sabnis

  23 Apr 2021 07:00:10 PM

  When we talk of Indian scenario, we have to accept that India is a one of the most diverse societies in the world. We have ultra rich people & poor. Although average indian is labeled as poor, & % of rich, affordable class  is less in %, but in actual number it is huge & may be bigger than entire population of some of european countries. So when we discuss any treatment, we have to consider all options. 

  I feel looking at the scenario in last 2 decades, pts presenting as metastatic disease is certainly declining. I agree some even affluent class pts also present as metastatic disease, the number is going down. 

  Many trials have shown combination of chemo with hormonal has benefit, in reality it does help. I have seen many pts with metastatic ca pts on presentation are surviving for long time. Surely they would not have survived that long only with orchidectomy. 

  One after another options does help. Survival has not only improved because of better & multiple drugs but also because of remarkably improved imaging modalities. Now we know which pts will be benefited by combination, & which will not. Now we Braca gene mapping we know which pts to be aggressively treated & which not. 

  Very important thing is now cost of medicines have come down dramatically. Now arbirateron, docetaxil, Enza all can be afforded by middle class person. 

  So I feel this consensus statement is of great use even in our country, as we can treat those who can afford. 

  Sabnis 

  
  

• 

  Dr. Roy Chally

  24 Apr 2021 08:56:20 PM

          The incidence of metastatic carcinoma Prostate has not dropped significantly in our country. This is the data from state medical colleges                         

  We do not have universal insurance for quality care for all in our nation. It is insensitive to brush aside the cost in managing these patients.

  It is a pity that surgical castration is not a popular option in medical oncology circles when it is clear to all that this is a cheaper effective option. 

  It is necessary to know low and high volume disease. The challenge is to get this information with one imaging study which is cost effective for the individual. 

  As Sabnis wrote there is a small population in our nation who can follow the protocols prescribed by the developed nations. But for the majority in our nation, in follow up, a cost effective protocol has to be practiced. 

  When the disease show progression in PSA then the information about the disease burden is necessary only if that information changes the treatment for a progressive disease. Repeated imaging studies to detect the disease volume progression, should not be only for academic purpose. 

  When the disease show progression, the molecular structure of cancer should change. Today are we incapable of detecting this change? Should we do a repeat biopsy, in progressive disease, particularly when the PSA is not showing the expected increase.