Areas of consensus at APCCC last year … see Table 1

So your sitemaster has been looking through the full report from the APCCC meeting held in Basel last year — as he promised he would.

This was always going to be a “dense” paper, filled with nuance. Also, as carefully pointed out by Gillessan et al., it is important to understand that this conference was coordinated to garner expert consensus on the management of advanced prostate cancer in areas where there are limited high-quality data to support specific actions among patients who meet specific criteria.

To quote the authors:

… merely because experts agree does not mean that they are right. Although this paper captures what experts in the field think today [i.e., as of August 31, 2019], it should be interpreted and integrated into clinical practice with the same scrutiny that any other major paper would receive, and with the knowledge that consensus does not constitute or substitute for evidence.

After two days of discussion, on the last day of the meeting the expert panel addressed a total of 123 questions on which their opinions were sought.

From the perspective of the patient and others such as support group leaders, the greatest immediate value probably comes from having a close look at Table 1 of the paper, which appears on the fourth and fifth pages of the full PDF text of the paper itself. In that table, the authors list 50 areas of consensus related to the management of advanced prostate cancer. Consensus among the expert panel was defined as the situation when 75 percent or more of the experts agreed about a specific course of action in a specific set of patients. As just a couple of examples:

  • 92 percent of the experts agreed that, in considering the appropriate treatment of men with untreated, de novo, oligometastatic prostate cancer, it  is important to distinguish with care between patients with lymph node-only disease and patients with metastatic prostate cancer at other sites (see Question 47).
  • 76 percent of the experts agreed that, in considering the treatment of men with metastatic, castration-resistant prostate cancer, it was appropriate to extrapolate the results of efficacy data from clinical trials to patients who are older than the majority of the patients enrolled it these trials.

Of the 50 questions on which there was consensus, there were just 17 on which a strong consensus was evident. A strong consensus required that at least 90 percent of the expert panel were in agreement about an appropriate course of action. It is therefore clearly evident that the management of advanced forms or questions posed to the expert panel.

New therapeutic products have come to market (and continue to do so). The increased availability of genomic testing to identify specific subtypes of advanced prostate cancer is leading to greater application of “precision” medicine for some patients. And we are beginning to understand the best ways to “order” or “sequence” the use of the drugs available in specific patients (see this very recent commentary in Renal & Urology News).

The fourth iteration of the APCCC is currently scheduled to be held in Lugano, Switzerland, in 2021. It will be interesting to see how much has changed over the ensuing two years.

2 Responses

  1. Thanks for posting this Mike and taking time to pre-gest some of it for us.

    I have participated in several consensus conferences and have mixed feelings about the process. Opinions tend to very heavily reflect the status quo because of the logistics of selecting people who can afford to travel to the conference who are considered to be experts. Nevertheless, we collectively know more than any one individual can knowo on his/her own, so the process is helpful in bringing that group wisdom to the forefront.

    It certainly is a dense document and difficult to read from a computer screen so I will wait until I can mark up a hard copy before I comment on any specific recommendations

  2. Re: “merely because experts agree does not mean that they are right”.

    I am immediately reminded of the agreement and consensus that once existed around causes of stomach ulcers. It took an Australian GP outside the group of experts to correctly identify the role of stomach bacteria and their treatment with antibiotics to break that consensus.

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