Joint meeting builds a solid foundation
for multidisciplinary cooperation

By Evgenia Starkova

Thought-provoking, stimulating and inspiring was the 2nd European Multidisciplinary Meeting on Urological Cancers (EMUC), according to the delegates who gathered for this three-day event in Barcelona, Spain, last month.

The meeting, which was attended by more than 1100 urologists, medical oncologists and radiologists, covered a wide variety of current research- and practice-oriented issues in today’s management of oncourology patients.

This edition of EMUC, which is a bi-annual meeting organised by the European Association of Urology, European Society of Medical Oncology and the European Society for Therapeutic Radiology and Oncology, took place on 27-29 November 2009.

“Not only is this multidisciplinary congress unique in its approach, it is also vital in today’s world of medical subspecialisation,” said Prof. Per-Anders Abrahamsson, EAU Secretary General, in his welcoming speech. “Without this cooperation we are bound to overlook some of the many developments that take place in research, industry and training today.”

“Interdisciplinary cooperation is the only way to ensure that our patient receives truly individualised treatment,” he said.

The scientific programme was designed to provide the critical update on the management of kidney, prostate, bladder and testicular cancers, discuss some the most controversial issues in these fields and, in the context of debates, confront the opinions of internationally renowned specialists.

Imaging today and tomorrow
The first day kicked off with a session on imaging techniques in the diagnosis and treatment of prostate cancer. Chaired by Prof. Bob Djavan New York University of Medicine and Prof. Richard Pötter from Medical University of Vienna, it featured a series of state-of-the-art lectures and a debate on the potential benefits and burdens of prostate cancer screening.

In his lecture “What imaging does the surgeon need?” Prof. Alcaraz from Hospital Clinico de BCN, Spain, reviewed the imaging techniques that are available to prostate cancer specialists today. These techniques are aimed at meeting the most pressing needs in the diagnostic work-up of cancer patients: tumour, lymph node, and bones staging, as well as guided prostate biopsy and recurrence detection. He mentioned, however, that urologists still have to wait for significant technological advances that would allow them to individualise each patent’s PCa management strategy.

Prof. Anthony Zietman, from Massachusetts General Hospital Cancer Centre in US, continued this line of thought by presenting the radiation oncologists’ point of view on the use of imaging in the management of prostate cancer: diagnosis, planning, treatment and follow-up.

“We have learned a lot over the recent years,” said Prof. Zietman, who is also President of the ASTRO. “Higher doses of radiation eradicate more cancer, whereas better targeted therapy allows the delivery of high radiation doses and reduces morbidity.”

“Until recently we have had the tools to deliver accurate radiation therapy but we have been limited by the insufficient accuracy of imaging tools,” he said. “However now, we are moving beyond the world of CT-scans into the world of smart imaging that matches the smart radiation delivery systems.”

This section also included a lecture by Prof. Peter Hammerer from Stadtisches Klinikum Braunschweig in Germany and Prof. Jelle Barentsz from Radboud University Nijmegen Medical Centre, the Netherlands. These outstanding lectures reviewed novel imaging approaches to the treatment of urological cancer, and received great response from the audience and the panel.

Controversies in the treatment of prostate cancer
Many reports presented at the meeting dealt with controversial issues surrounding the management of locally advanced PCa. These were addressed in various formats including state-of-the-art lectures, debates and round table discussions. In one such discussion Prof. Raymond Miralbell from Hôpitaux Unoversitaires Genève, Switzerland, and Prof. Hein Van Poppel, from Leuven University Hospitals, Belgium, assessed the results of surgery and radiation therapy used as first line treatment.

While discussing the results of several recent studies, Prof. Miralbell emphasised that modern technology enables safe dose-escalation with adapted short- or long-term biochemical non-evidence of disease of more than 70% and cancer-specific survival rates of more than 80%. He also discussed the role and the potential benefits of hyperfractionation in the treatment of stage T3 prostate cancer.

In response to these arguments, Prof. Van Poppel presented data from various trials, concluding among other things that surgery allows to achieve better local control of the disease and in 25 % of cases leads to the adjustment of the patients’ original staging with cT3 cases relegating to pT2.

Prostate cancer treatment was also discussed in the context of post-prostatectomy erectile dysfunction.

“The prevalence of post-surgery erectile dysfunction is extremely high,” said Prof. Alberto Briganti from Vita-Salute University - San-Rafaele Hospital in Milan, Italy, in his state-of-the-art lecture. “However we have to be cautious when we compare post-prostatectomy results in terms of pre- operative definition of erectile function and its post-operative assessment.”

He also called for attention to penile structural changes that take place due to hypo-oxygenation, which, as has been shown in several preliminary studies, might be prevented by timely penile rehabilitation and the chronic use of PDE5 inhibitors.

New hormone therapy strategies for the treatment of PCa were discussed by Prof. Vincent Ravery from Bichat Hospital in Paris, France. “I would like the delegates to go home with the message that the hormone therapy era is not over, that we have new information about the way hormones work in the context of prostate cancer, and that this new knowledge has led to the development of novel agents, for example MDV 3100, which target androgen receptors,” he told EUT.

Bladder cancer: from diagnosis to follow-up
Various aspects related to the diagnosis, prognosis and treatment of bladder cancer were dealt with in the framework of several sections. Recent advances and challenges in the research on gene profiling and urine biomarkers were discussed in much detail, offering an essential update for those attending the meeting.

In his lecture on neo-bladder reconstruction, Prof. Urs Studer from University Hospital of Bern, Switzerland, discussed several techniques that are in use today, underscoring, however, that post-operative active patient management is the key success factor. According to Prof. Studer, surgeons must ensure voiding without residual urine, compensation of metabolic acidosis with Na-bicarbonate, as well as an increase in the functional capacity to 400-500 mL. This, in turn, must be coupled with a systematic life-long follow-up.

Dr. Maria De Santis, from Kaiser Franz Joseph-spital in Vienna, Austria, presented a lecture on the currently standard as well as novel systemic treatment modalities in advanced bladder cancer, including chemotherapeutics and targeted agents. “Many more clinical trials are needed to assess the potential benefit of these agents and their combinations,” said Dr. De Santis, “We have to have more data from Phase I trials, as there might be more toxicity than expected, but most importantly we need more overall survival and progression-free survival data, at least as long as no surrogate end-points are available.”

Much-anticipated were the debates on the future of robotic surgery in radical cystectomy (Profs. P. Wiklund and A. Alcaraz), the usefulness of urine biomarkers in the screening for bladder cancer (Profs. M. Droller and J. Witjes) and on the optimal treatment for patients over 75 (Profs. M. Babjuk and A. Bossi).

Renal cell carcinoma
Novel treatment modalities were the main focus of discussions dedicated to the treatment of kidney cancer. While the issue of minimally invasive procedures for small renal tumours was tackled during expert case discussions, active surveillance strategies, targeted agents and systemic treatment of RCC were dealt with in a series of state-of-the-art lectures.

Another state-of-the-art presentation by Prof. Didier Jacqmin from NHC HUS Strasbourg, France, discussed the need for nephrectomy in metastatic RCC in the modern era of targeted agents. Summarising the arguments in favour of surgery he pointed to the mean size reduction in volume of only 20% and the presence of such symptoms as pain and haematuria. He also reminded that substantial benefit of immunotherapy can only be seen in low and medium risk patients.

Other lectures in this section included “The role of neoadjuvant and adjuvant therapy in metastatic RCC” by Prof. Peter Mulders, from Radbound University Nijmegen Medical Centre, “Are active surveillance strategies viable options in the treatment of renal cell cancer?” by Prof. Michael Stöckle, from University Clinic of Saarland in Hamburg, Germany, “Sequential and intermittent systemic treatment in RCC” by Prof. Jennifer Knox, from Princess Margaret Hospital, Toronto, Canada, and “Do costs and benefits justify the use of new targeted agents in metastatic RCC?” by Prof. Paul Nathan, from Mount Vernon Cancer Centre in UK.

In conclusion of the meeting, awards for excellence in urology and radiation oncology were handed to Prof. Fritz Schröder and Michel Bolla, who then presented their inspiring lectures on the controversies and the future of prostate cancer treatment.

“There is no doubt that in the future EMUC is going to attract more experts across the board of uro-oncological speciality,” commented Prof. Bob Djavan from New York University of Medicine “Not because there is more information out there, but because we all need a different perspective on our own practice and experience.”