Phillip Koo: Hi, my name is Phillip Koo, and welcome back to our exclusive coverage of the 13th International Uro-Oncology Conference here in beautiful São Paulo, Brazil. We're very fortunate to have with us today, Dr. Fabio Schutz, who's a medical oncologist at the Portuguese Beneficence Hospital of São Paulo. I've known Dr. Schutz several years now, and he's always a very thought provoking thinker and practitioner. He's giving two plenary lectures at this meeting. The first one is talking about hormonal blockade and biochemical recurrence. So, can you give us some of the highlights of that lecture?

Fabio Schutz: Well, thank you Dr. Koo for inviting me. Actually, I think the two main trials I am showing in my presentation, and the ones that I base my decisions when I'm treating my patients, is PAR trial and GETUG 16 trial. Both trials, they just fight to use the short term, like six months of ADT, together with radiotherapy, for patients with biochemical recurrence.

There is some controversy if we need to include, for example, the pelvic lymph nodes in the radiotherapy fields. Usually, I leave this discussion to the radiotherapist. But, usually, overall, I just give six months of hormonal therapy for patients together with radiotherapy. I also show some data about the new STAMPEDE data that was just recently presented in the patient with nonmetastatic prostate cancer. But, we have to remember that, for example, only 2% to 5% of the patient population included in the STAMPEDE non-metastatic are actually patients with recurrent disease, such as biochemical reoccurrence. All of them had high risk biochemical recurrence with PSA more than four, doubling time, less than six months. So usually, I would say, that it's not very common for us to give abiraterone, for example, for patients with biochemical recurrence, at all.

Phillip Koo: So in your opinion, I know some trials have been designed with the idea of delaying initiation of ADT, especially when you're looking at an oligometastatic disease type patient. In your opinion, are we past that? Do you feel like, all right, every patient does need ADT, especially if they're metastatic?

Fabio Schutz: That's an excellent question. And, for this, we are fortunate enough, and I think we have, I would say, perhaps good experience using the PSMA PET. We are doing that for our private patients since 2017 now. For all patients with biochemical recurrence, we usually indicate to do the PET CT PSMA. And if we found oligometastatic disease, or just small mets around the bones or the lymph nodes, and we can discuss for those patients to give SBRT, or stereo body radiotherapy, to try to delay the initiation of ADT for those patients.

But, and at the same time, if we don't show the metastatic disease, and there is issue, the possibility of local recurrence, and then we go back and give localize radiotherapy to the perfect bed. But I agree, I think there is the STAMP trial, the OReO trial, but we have to remember that on those trials, the PET CT PSMA was not done. Usually, they just, CT scans and bone scans. And I think, there are future trials that they are looking at in the stereo body radiotherapy with PET CT PSMA, but those trials did not use that.

Phillip Koo: Yeah, it's definitely an evolving area. And I think, there's a lot more exciting data to come.

So shifting gears a little, your second lecture is going to be focusing on targets and biomarkers in advanced prostate cancer. So can you give us some of those highlights?

Fabio Schutz: Well, for those, for that talk, I usually discuss, I do a deep discussion, the BRCA1/2, but I also do some discussion about the ParB B2, the JAK2, the CDK12 and the differences in responses with PARP inhibitors, according to the different trials that we have, for example, the PROfound study, the TRITON2, the TALAPRO, and we try to show the differences. And the biggest group that usually have the highest response rates are the BRCA2 and ParB B2 patients, that they seem to have higher response rates. And at the same time, patients with ATM mutations, or patients with the androgen receptor mutation, they usually don't do well with PARP inhibitors.

So besides, for example, being approved in our country for the cohort A, olaparib, for the cohort A, being BRCA1/2, or ATM, I think the ATM patients, for example, they don't do well with olaparib. So I usually discuss all that. I also go with, in the discussion, with the PTEN patients mutated with the ipatasertib, the potential trial, but since we don't have that available in our practice, and I don't know that we have available in any other country. So I think there isn't much things to discuss about that.

Phillip Koo:  So you discussed a lot of these genetic mutations in Brazil and Latin America. How accessible are those genetic testing services?

Fabio Schutz: Well, they are not very accessible. Usually, they cost some money, and that's out of the pocket for patients. Usually, the healthcare insurances don't cover that in Brazil, and I believe that they don't cover that, as well, in Latin America countries. But at the same time, we are fortunate, because the company that are involved with the olaparib, for example, they pay for those exams for patients overall. So usually, use that program from AstraZeneca, actually, to try to request the test for patients in the tumor T-cell somatic mutations.

The germline mutations, that's much more accessible. And overall, I would say, that most patients in the private practice, actually, they can do that tests. And we unfortunately, in the public healthcare system, we don't do that at all, because patients usually, don't have access to almost anything in the public healthcare system. So unfortunately, in the public healthcare system, we don't request that.

Phillip Koo: Yeah. I mean, as a radiologist, a lot of these genetic mutations, whatnot, are new to me. But I can clearly see that this is a huge area. And I hope the payers and the government starts recognizing that, and covers this, and provides more of these services for the patients, because it seems like such a strong driver of treatment decisions.

Fabio Schutz: Yeah, for sure. That's an unmet need. And I think, we are just starting to use the PARP inhibitors and other targeted therapies in prostate cancer, and I think, we are going to. Olaparib is the first and only one that's approved here in Brazil. But we know that we have more PARP inhibitors that are going to be probably, positive and probably going to be approved, as you have, for example, in the United States, to rucaparib, that's also approved there, but we don't have that approved here in Brazil yet.

Phillip Koo:  Well, thank you very much for your time. We enjoyed talking with you, and we'll see you next year.

Fabio Schutz: Okay. Thank you very much.