Alicia Morgans: I am so excited to wrap up the APCCC, Advanced Prostate Cancer Consensus Conference, 2022 in Lugano, Switzerland. We have a wonderful group of people together tonight to talk about the highlights of that conference. Let's start with the overall impression by Dr. Silke Gillessen, who has worked in this conference, actually, partnered with Dr. Aurelius Omlin to put it together in the first place. I'd love to hear from your perspective, Silke. What's it like to be back together again in person after such a period away?

Silke Gillessen: Yeah. First of all, can only say very, very positive, because when we planned it, we weren't really sure what happened with COVID, so we did everything hybrid. We were hoping, obviously, that we could get together. And I guess it was really fantastic, because one part of this meeting is really the networking, the interaction, and it is so much easier in person than by Zoom. I think we all are also a bit Zoomed out. We have all enough of Zoom meetings. You don't concentrate. And here, it's really very active, you see the people in the audience, not with their iPhones, but really listening and making remarks, making comments, and asking questions. I think this is really, first of all, a very positive, nice experience again. And it's also a bit of a trademark of this conference, because the networking here is very intense and really important for the conference.

Alicia Morgans: I think that's great. It has been such an exciting time to get together, see old friends and to talk through some of these very complicated questions. Dr. Omlin, I'd love to hear from you. Let's think about day one. Really, we were thinking about high-risk localized disease, we were thinking about biochemical recurrence, and even some thoughts on metastatic hormone-sensitive prostate cancer. There was a lot of information that we discussed. What were some of the highlights or take-home messages that were most impactful to you?

Aurelius Omlin: Thank you, Alicia, for this question. Day one, as you mentioned, mHSPC is very close to what we do in daily practice. We see these patients with metastatic hormone-sensitive prostate cancer, and we've seen a lot of updates, ASCO last year, ESMO with the PEACE-1 data, and now at GU ASCO, ARASENS, and it was very nice to have questions around these topics and to see how people integrate the new findings and how we can use it in daily clinical practice. We had also a lot of discussions on high-risk localized prostate cancer, mainly around imaging, the new imaging technologies, especially PSMA PET. And it was also nice to see here, how we best use it, maybe, in which patient populations, and what conclusions we take from these scans.

Alicia Morgans: Yes. A lot to cover it there and we somehow packed it all into day one. In day two, Dr. Shore, what are your thoughts on the conversations around non-metastatic and metastatic castration-resistant prostate cancer? I know you gave a fantastic discussion and participated in conversations about how we really think about radiopharmaceuticals among all of the other treatments that we have and how we think about choosing therapies for our patients.

Neal Shore: Well, if I could just begin by saying there were two things, for me, at the conference that were a hundred percent consensus, and the first was, all of the speakers, all of the faculty, everyone just adores Silke and Aurelius. What they've done now, their fourth meeting to do this, especially in with the interlude of COVID in a pandemic, was absolutely astounding. Everyone just has the greatest amount of appreciation and respect for what they've done. So, that's number one. And then number two is the meeting itself. Everyone constantly would say over and over, this is a phenomenal meeting. There's an intimacy, there's an intellectual vigor, there's the debate, and there's some things that we don't reach consensus on, but many things I actually thought was fascinating at this meeting compared to some earlier ones where we came close to, and had actually reached, a lot of consensus.

Regarding your question, it's such a fascinating time, particularly for the nmCRPC journey for prostate cancer patients. We incorporated, thanks to Silke and Aurelius, bringing in the patient voice in a much clearer way throughout the meeting and really getting that patient centered voice, which I think for a long time we haven't accomplished, which was a real tribute to this particular meeting. But for nmCRPC in particular, is how do we best use PSMA PET, then all the different various modalities for PSMA PET that are coming across, as well as the current data, what additional data we need, and will eventually conventional imaging become anachronistic. And I thought the conversation around that and how do we use our approved therapeutics and additional therapeutics, for example, the PSMA RLTs, where they'll fit in, was a really robust discussion.

Alicia Morgans: I could not agree more. And I think it's been such a rich discussion, not just about therapeutics, but also on how we take care of the whole patient and complications of survivorship that we must address and support for our patients. Dr. Ryan, I know you were in a session that really focused on so many aspects of survivorship. Can you tell us a little bit about your thoughts, your take home messages from there?

Charles Ryan: Well, first of all, it is a great conference and I will agree with everything Neal Shore said. The issue of survivorship, a couple of important things. One is that it's held up on the agenda as important as every other aspect of consensus development and therapeutic choice, and so survivorship clearly has a seat at the table in the prostate cancer conversation. That's not entirely new, but it's really highly validated here, so that's really important. And number two is that prostate cancer is unique in a few perspectives with regards to survivorship because of how we manipulate a man's physiology to treat the disease and how we do that, not just for the short run, we do that for, in some cases, a decade or 15 years. And we see so much of the toxicities of the therapy be really the inverse of the healthy patient. In other words, cognitive decline with androgen deprivation therapy highlights how normal hormonal status helps preserve cognition. And so I find that to be quite fascinating.

But there's also this tremendous ground swell of interest in muscle tone and exercise and bone health and cardiovascular health, and it's now just part of the conversation and this is critically important and I applaud you for putting it on the agenda and I'm happy to have been part of that panel.

Alicia Morgans: I could not agree more. I think that elevating the complications of survivorship related to treatment of patients with systemic therapy absolutely should be part of the conversation and kudos to the organizing committee for ensuring that it is something that we talk about and continue to think about in our daily practice.

The final day, I think, was also so exciting, an area of innovation and really very gray data here, talking about oligometastatic and oligoprogressive disease, and imaging, metastasis-directed therapy. It's just all new and all quite gray, as is appropriate for the APCCC. So, Silke, what was your take-home from those conversations?

Silke Gillessen: One thing is that we had already, in 2017, some questions about oligoprogressive. And at that time, everyone was like, oligoprogressive? What are they speaking about? And this time it's very different. So this kind of concept of oligoprogressive is much more popular obviously, and I thought that is interesting. So we have made a step and it's sometimes also interesting to look back how we voted maybe 2015, 2017 to very similar questions. And you see, we did this also development. We are changing, we are learning more, and that's always a very nice thing to see.

The other thing is, I guess it's still oligometastatic, seems to be some topic where there is a lot of enthusiasm, there is a lot done. We were very surprised of the number of panelists who are doing MDD in mCRPC, so metastasis-directed therapy, and without having really good evidence. And I think this is really something interesting. So, not a lot of evidence, not a lot of consensus. So let's see maybe 2024 or '26, we'll have more data for this really fascinating topic.

Alicia Morgans: Well, I am sure that we all look forward to that, because it is happening out there. Lots of different treatment approaches. So coming to consensus will absolutely be important in that area. Let's go down the line and I'd love to hear final comments from each of us on the panel here today. Just final take-home message from the APCCC 2022, we'll start with you, Aurelius.

Aurelius Omlin: Thank you, Alicia. After APCCC, I always want to go back to clinic because I really feel inspired. I heard so many new, interesting aspects of probably treatments that I thought I understood, but obviously I can still learn. And that's a good thing. I also had so many inspiring conversations, so it makes me proud to be working in this job and I'm happy to go back to work.

Alicia Morgans: Beautiful. Go ahead, Silke.

Silke Gillessen: Yeah, same here. I think it's really so stimulating to discuss things, and I guess also to find out where we have no consensus. Chuck said that, right? So for me, it's still, this one is fascinating in this conference that the questions where we don't find consensus were really like you have a third, a third, a third of answer options, of panelists choosing different answer options. So there's really, and this is all experts and now it's 105, so it's a pretty big basis. So that means that we need to do research in these topics and this is really stimulating me to do a lot of new trials. This is what we should do.

One thing that I found really also fascinating is that we have now done a lot of work in intensifying treatment for metastatic hormone-sensitive disease. And now we are starting, like the lymphoma people, like the testicular cancer people, to say, there may be also patients where we can deescalate. So I think it's kind of a natural, probably, wave that from all this intensification, we may be now trying to find the subgroups where we can deintensify. And I think this is a very interesting direction.

Alicia Morgans: I could not agree more. Dr. Ryan?

Charles Ryan: I would say, most meetings are about the data. This meeting is sort of about the anti-data, right? Where are the gaps? There's two important points there. One is that it's actually really comforting to sit in a room with really brilliant people from around the world and for us to agree that we don't know what to do in certain circumstances. And so, this is just part of being a physician, which is keeping in pace with what is not known and that comfort that you get from your colleagues from knowing that this is not knowable. It's just not known.

And so you can take that back to clinic, because that vagueness is actually somewhat useful for helping us to design future trials, et cetera. And so, I would argue that, yes, Silke, the gaps do point to where we need to do research, but we can't do all of that research. We can't answer every question. And so that's why this meeting is going to be even more necessary as things evolve, because we simply can't answer every question with a randomized control trial, as many of the debates showed.

Alicia Morgans: And, Dr. Shore?

Neal Shore: Well, I would echo Aurelius' comment. There's so much to, that comes out of this meeting. It's a treasure trove of pearls. Pearls that you can take to the clinic as soon as you download the presentations, if you weren't fortunate enough to be here or you watched it virtually. I know everyone looks forward to the publication. It's amazing how quickly Aurelius and Silke are able to get it out. It's the most downloaded publication, typically, in European urology where it's been submitted over the years. And the fact that they are able to, with the Scientific Committee, come up with these questions, which are just so inspiring, so interesting, as Chuck said, we can't always get the answers, but it's remarkably compelling to hear some of the most brilliant minds, in a multidisciplinary way, debate these questions and how we vote on it, and I think it leaves everybody so excited for the meeting to come in 2 years time. So, great for community physicians, great for academic physicians, great for researchers, and it really embodies the multidisciplinary team that we all need to aspire to.

Alicia Morgans: Well, I'll add one thing to that. Great for patients. And I think that's ultimately the goal of this meeting. So, I will wrap up and say, ciao from Lugano, Switzerland, 2022 APCCC.

Silke Gillessen: And hello in 2024, again in Lugano.

Charles Ryan: Yes.