Yes: it was extremely well organised, and had a well informed and dangerously good looking panel!

Oh, and the outcomes reflect a brilliant snapshot of current evidence-based- and/or world-expert-opinion on a very broad range of topics relating to prostate cancer.

I thank for you bring the report to our atention. The main topic is use of systemic treatment for advanced prostate cancer. The report has a false statement regarding PSMAS based PET/CT. The report has a conservative view on use of funcional imaging of prostate cancer. The report states that ADT is standard for patients with PSA recurrence, where other guidelines prefer salvage radiotherapy. The report does not inform of the potential gain with radiotherapy of oligometastatic PC compared with systemic treatment.

Thank you for your input, we will reply to your letter to the editor to Annals of Oncology, which will cover the topics and questions raised.

Hi Finn, thanks for your reply. I do not speak for the panel so others might also respond.

I could find only one comment relating to PSMA PET in the recommendations, ie "Solid data on new promising tracers (such as PSMA) are still lacking." I think that as of March 2015 (and arguably now) that statement is still true. I believe PSMA PET will undoubtedly find a critical role in PC management but that role still remains unclear. PSMA PET has not been adequately validated yet against other imaging modalities and, most importantly, it is not yet clear that alterations in management as a result of PSMA PET findings lead to meaningful changes in cancer outcomes. The null hypothesis would be that PSMA PET simply leads to stage migration. I do not personally believe that but until the relevant trials are done, I think the statement remains correct.

I cannot locate the text matching your comment regarding ADT in PSA recurrence. Perhaps you might be misreading the text regarding management of rising PSA after local treatment, where iADT is discussed, or the text on management of M0 CRPC.

Yes, there is nothing in there about local therapy of oligometastatic PC. That will be a fruitful area of research and we await long term outcomes data for these approaches. It is interesting to speculate whether such an entity actually exists...! Perhaps information will be available for the second consensus meeting planned in 2017.

Of course we can do a study comparing a tracer for PET/CT tht detects sites for half the patients with PSA < 0.5 with choline PET/CT that only dtects sites for say 10 % of the paatients with PSA< 0.5. To see difference in survival will take the ext 10 years.Meanwhile we will have to decide on this topic without a randomized trial as with many other aspects of management of PC.

We will only detect oligometastatic PC if we use functional imaging and not only conventional iamging with CT and bone scans.

The report of APCCC gave the information of ADT for PDSA recurrence in a Figure, so on the way I and my collegues look forard for the reply for a letter to the editor of Annals of Oncology.In short we argue for a wide use of imaging based treatment of PC.Blind treatment based on on information of the sites maybe past history for prostate cancer.

So thank for for sharing your thought with me and thank you for the reflects. Have a good feeling for dealing with the uncertainties in this field. In most other aspects the APCCC succeeded well like that..

s.

as Nuclear Medicine physician, I guess it is important to distinguish imaging methods that are promising from methods that are fully validated on the basis of literature evidence. We all agree that PSMA PET/CT holds great potential, as PET/CT with other tracers including Choline, and MRI as well. However we absolutely need multicenter prospective studies, with comparison of conventional imaging, and robust definition of reference standard, in order to ascertain the usefulness of new expensive approaches. Furthermore we should consider regolatory issues and availability before recommending any imaging method, and to me this is not a conservative view.

I do not debate that in an optimal wolrd we could have a randomized trial of functional iamging versus no funcional iamging. But some leading Experts have the ipinion that that would be an enterprise only for academic institutions. In my Country academic institutions today only do this kind of research if it is fully sponsored from outside the institutions. Therefore we may have to Work for these studies and hope that proste cancer Foundations may be willing to sponsor such trials or we will have to decide on less available quality research.

Sorry, I forgot to mention. We discussed some years ago a phase III trial on patients with PSA recurrence after RP. Randomised to either PET/CT for ientifing site of recurrence early in the course, blind treatment of the prostate bed at low PSA, or treatment as site of recurrence was detected with CT and vone scans. A rapid consensus on such a protocol at many units could lead to a formal grant application within 3 weeks from now. So Iappeal (Again) for this will be supported by all WHO in writing supports the need of such a trial. So far I am alone but would love a joined effort.

Regarding the discussion of continuous or intermittent ADT you miss an important reference. Hussein et al. NEJM 2013. The Niraula review cited in this paper has only included an abstract of the SWOG trial. When discussing iADT we should consider that the actual overall survival in both groups is longer than expected and how this affect the non-inferiority margin. In the Hussein paper non-inferiority margin was an HR of 1.2. Is this difference still acceptable?

http://www.nejm.org/doi/full/10.1056/NEJMoa1212299#t=article  

Thank you for this important comment, we will correct the manuscript with reference as soon as possible.