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Highlights from the Asia-Pacific Prostate Cancer Conference 2019

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This year’s APCC conference brought together clinicians, allied health care, nurses and scientists. The meeting in Melbourne hosted discussions of the latest breakthroughs, clinical trials and best practice in care for men with prostate cancer. A focus on patient-reported outcome measures was one of the many highlights.

PROMs: Patient reported outcome measures

To improve the quality of prostate cancer management we need two things: to measure the quality of the treatment, and to put in place interventions for improvements once we know where they are needed.

Patient reported outcome measures (PROMs) are a very important measure of the quality of prostate cancer treatment. PROMs report on the success of the treatments as well as the side effects. Research has shown that outcomes such as urinary continence are reported differently by clinicians, on behalf of their patients, than by the actual patients themselves. Hearing from the men themselves is therefore crucial for understanding the real outcomes of the treatment.

PROMs are usually measured using surveys. These can be delivered online, in person or by phone. For prostate cancer, standardised surveys are often used. These same surveys are used in clinical trials world-wide. Having a standard allows us to compare across different clinics, hospitals, states and countries.

A session of the APCC 2019 conference was devoted to PROMs.

Paul Villanti, Executive Director of Programs at The Movember Foundation

Paul Villanti introduced the session on PROMs, giving an description of the importance and evolving use of these measures. PROMs are currently used in research more than any other purpose. Movember has been putting infrastructure in place for PROMs to be used more widely, aiming to directly help men with prostate cancer.

The challenge is to bring PROMs into the real world – to integrate them into usual care for these men. This can be done across all disease stages. The ultimate aim is to improve the quality of prostate cancer care, improving survival. Movember believes that this should be done for free, to ensure men have equity in their access.

Prof Caroline Moore, Head of Urology, University College London

Prof Caroline Moore described the UK system for tracking outcomes from prostate cancer surgery. Surgical outcomes are publicly available in the UK. But this information only includes measures such as transfusion rates and complications encountered during the surgery. These surgical outcomes are not that helpful for men trying to choose a good surgeon for their prostate cancer. Outcomes such as recovery of continence and sexual function are not systematically measured and made available.

Prof Moore has worked on the TrueNTH Movember initiative in the UK. Her research aims to create better measures of outcomes from prostate surgery. Like the Australian version, the UK TrueNTH will allow men to see their progress over time. They can compare their side effects to men like them and be better able to spot problems and seek help.

Surgeons will also be able to see how their patients are doing and offer help where necessary. They will be able to see their own data in comparison to other surgeons.

Prof Moore’s research examined what types of survey questions best captured the experience of men recovering from surgery. They used the EPIC26 survey for side effects before surgery, then 1, 3, 6 and 12 months after. Continence is often measured by asking men how many pads they need per day. However, describing this in more meaningful terms led to different answers. There was a big difference in the proportion of men needing 0 to 1 pad per day, and the proportions who considered themselves pad-free and leak-free.

Prof Moore spoke of how best to improve outcomes from surgery. She noted the importance of measuring outcomes and making this knowledge available. This allows health services to focus on areas where there are problems. But we still have much to do in terms of achieving improvements.

Outcomes from radiotherapy and other management strategies are not yet followed in the same manner in the UK, but these will hopefully be rolled out in the near future.

Dr Amanda Pomery, Director, Prostate Cancer Clinical Care Services, The Movember Foundation

Movember have launched their TrueNTH initiative in Australia. TrueNTH is described as a global collaboration of clinicians, researchers and patients aiming to improve the quality-of-life and outcomes for men with prostate cancer. The aim of TrueNTH is to help men address the significant challenges of living with prostate cancer. This includes support for decisions about which treatments to have, managing incontinence and sexual issues, and how to eat well and exercise effectively. TrueNTH will provide online tools that allow men and their families to keep track of their symptoms, giving them greater opportunities to take charge of their health. This program aims to work with men with prostate cancer to better understand their experiences, perspectives and needs.

Dr Pomery described a pilot study involving men with prostate cancer who gave feedback to optimise the online tools. More information about TrueNTH is available from its website: https://truenth.org.au/

Prof Afaf Girgis, Ingham Institute for Applied Medical Research & The University of New South Wales

Prof Afaf Girgis is a prominent psycho-oncology researcher with a special interesting in care for men with prostate cancer. Her presentation summarised the PROMPT-care program. This stands for Patient-Reported Outcome Measures for Personalized Treatment and Care. This PROM-based initiative is an online system using PROMs for cancer survivors.

Prof Girgis explained that patients' reporting of side effects are not necessary the same as clinicians'. This is especially so for symptoms of psychological distress. Prof Girgis describes the need to ask men directly how they are coping to help them deal with psychological issues. Men sometimes under-estimate their problems when asked face-to-face. PROMs from online surveys have the potential to reduce need to face-to-face follow-up care (which is not well met), but inform patients who do need to seek help.

PROMPT care provides records accessible to anyone involved in a specific patient's care. Problematic issues are flagged if surveys show answers above a threshold. Care coordinators can be sent an email to follow-up with patient where needed.

PROMPT-care has been piloted as a local initiative in South Western Sydney and Illawarra Shoalhaven Local Health Districts.

 

Other interesting presentations at APCC:

Prof Freddie Hamdy, University of Oxford

Prof Hamdy’s talk was titled “Precision surgery and molecular imaging of prostate cancer”. 3459510283?profile=RESIZE_710x

His talk described a new approach for prostate surgery that used infrared light to look for tumours tissue in lymph nodes. The robotic system for performing prostate surgery was modified to include a detector for infrared radiation. Patients are injected with a dye that recognises PSMA on the surface of prostate cells. When this dye reaches lymph node tumours, it releases infrared light that can be detected during the surgery. A lot of work was needed to design a system for recognising the infrared at the same time as normal light. This allows the surgeons to see the lymph nodes with tumours as well as the anatomy at the same time.

Prof Hamdy’s group are currently finishing a pilot study and hope to launch a randomised controlled trial in the UK. They will combine this with genomic information to try to find new targets for prostate cancer treatments.

Dr Stephen Freedland, Cedars-Sinai Medical Center, California, USA

Dr Freedland’s presentation was titled “Obesity and nutrition in prostate cancer”. His research group have performed two prospective randomised trials called CAPS1 and CAPS2.

The CAPS1 trial asked whether low-carbohydrate diets plus walking benefited men with prostate cancer starting hormone therapy (androgen deprivation therapy: ADT). This trial asked whether this intervention reduced ADT-induced metabolic disturbances. Men in the low-carb group only ate 20g a day of carbohydrates. Unfortunately, recruitment to this study was poor and it failed to adequately measure its primary outcome. But there was some indication that the intervention reduced insulin resistance over the study period – indicating that a better study to ask this question is warranted.

A second study called CAPS2 was described as a difficult trial. Recruitment didn’t go well, and some men on the trial went on to other treatments during this time period. But an interim analysis showed that men following the extremely low carbohydrate diet had dramatic weight loss in 6 months. Whether this weight loss slows prostate cancer growth is an on-going question.

PCFA recommends men with prostate cancer follow the Australian Guide to Healthy Eating and consult their doctor or dietitian before making major changes to their diet.

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