Phillip Koo: Hello, my name is Phillip Koo. And welcome back to your today's exclusive coverage of the 13th International Neuro-Oncology Conference in Sao Paulo, Brazil. If you've never been to Sao Paulo, I recommend you put it on your bucket list, because it's an amazing city. Anyway, we have with us today, Dr. Andre Soares, who's a medical oncologist at Albert Einstein and one of the thought leaders, especially in Latin America, when it comes to GU malignancy. So thank you very much for joining us.

Andre Soares: Thank you for the invitation. It's a pleasure.

Phillip Koo: So one of the hot topics globally, and especially in Latin America and Brazil, seems to be the management of patients with high risk localized disease. Can you talk to us about some of the challenges and opportunities you see in that space?

Andre Soares:  Yeah, it's very challenging in Brazil because we don't have a very good screening program here in Brazil. So we have a lot of patients diagnosed in a locally advanced disease. So I believe that the most important thing here is discuss about how the surgeon, the urologist and the medical oncologist discuss this kind of patients. So we know that the best evidence that we have to treat patients with high risk or local advanced disease is probably radiotherapy plus ADT for a long time, at least 18 months.

So in the past, we are moving this kind of therapy to surgery for this kind of patients, and maybe in some subsets of patients to perform a radiotherapy as an adjuvant therapy with or without ADT. I believe that the major challenge is to discuss with urologists the benefit of adding not only ADT and radiotherapy for this kind of patient, but abiraterone. We saw the data from Stumpe that's showing a very benefit for this kind of patients. So it's very hard to convince the urologists to not operate these patients and send to us to treat with radiotherapy ADT plus two years of abiraterone.

Phillip Koo: So, PSMA PET is very available in Brazil and in Latin America, and in the US it was just approved a year ago or so. And one of the indications is for use in patients pre definitive therapy. So are you getting a PSMA PET in all your patients with high risk disease? And how is that [inaudible 00:02:12]?

Andre Soares: The very important point here that we are using a lot of PSMA PET here, but we don't have for all patients. Three quarter of the population depend off the public setting and we don't have PSMA PET for this kind of patients. So at least 25% that has some reimbursement with the insurance. But the majority of this 25% of patients does not have this reimbursement. So, but in my practice, the urologist usually to see these patients before the medical oncologist and they order up a PET PSMA for this kind of patients. Usually we tend to discuss different way or different strategy to treat these patients. But it's very hard to convince the urologists that patients with metastatic disease or even lymph node disease in the PSMA PET has to change the practice. Another point is the discussion that not only in Brazil, but worldwide, about how biologic active are this metastasis just as seen in the PSMA PET.

Personally, I believe that this is really, really biologic active. The Oriole trial, that test the possibility of ADT plus radiotherapy in patients who fail at prostatectomy and treat one to five metastase with SABR. We have the retrospective analysis in 36 of patients that did it PSMA PET, and the patients who had image in PSMA PET that was negative in the conventional image, but it wasn't treated, they going very badly comparing with the other patients who treat all the lesions. So because this data and some other datas, I believe that this kind of image in PSMA PET are biologically active.

Phillip Koo:  So I think high risk local disease is clearly a multidisciplinary space, more than some other spaces, and requires that collaboration. So let's move forward a little. So, Brazil doesn't have a formal screening program. I imagine your population of metastatic hormone sensitive patients is higher than we're seeing in other countries. We spoke with Dr. Tombal earlier about ARASENS. Can you talk to us about some of the challenges that you see with implementation of something like ARASENS with access and whatnot?

Andre Soares: Yeah. This is another very important point in a country like Brazil. So in the mCSPC setting, we have some public data showing that this kind of patient, at least in the public setting, it's almost 35% of the population. So we are saying that one third of the population open the prostate cancer diagnosis with M1 disease. And on the other side, we have only ADT for this kind of patient in the public setting. In the private setting, we have only the approval for abiraterone for this kind of patients. We don't have the other drugs. And even with this approval for the private setting, there's no good reimbursement for the majority of insurance for this kind of patient. So we have the same problem from other countries outside of Brazil, like US, like some European countries, that we have probably 40-50% of patients that have to receive, that should receive at least a double therapy, receive a double therapy.

This is one point. So to move for triple therapy, we have to improve the double therapy. Personally, I like the data from ARASENS. I believe that we have to think for all high volume patients, not only for patients that have de novo disease. And I believe that for one side it's easier because docetaxel, it's easier to provide for patients. But on the other side would be very challenging to associate darolutamide for this kind of patients. So I believe that in Brazil, we have still work to start to use double therapy with a new hormone agent before go to the triple therapy.

Phillip Koo: That's interesting. So let's get to double first, get comfortable using double. Then we move the triplet. And I think that's a great piece of advice, because there are so many challenges and in all these challenges, there are local influences that it's discouraging at times. Because you have the data that shows that patients who can get this triplet have a better outcome. But I think the realistic aspects of how we have to practice does play a role in this. Any closing thoughts you have for our viewers as we kick off this wonderful meeting here in Brazil?

Andre Soares: Yeah. I believe that is a very wonderful meeting. We have to congratulate Dr. Fernando Malufi to perform this 13th meeting. It's one of the biggest worldwide. And we have a lot of colleagues from Brazil, Latin America, and US and Europe discuss with us. So I hope that UroToday comes next year to join with us.

Phillip Koo: Great. Thank you very much.

Andre Soares: Thank you.