An Interview With Professor Nicholas James: Part 2

Professor Nicholas James is Chief Investigator on the STAMPEDE trial that I think has changed the path of prostate cancer treatments, especially advanced stage prostate cancer.

This is the 2nd part of an interview that I conducted with him. Read Part 1.

Our interview

Frustrating to see

Tony: It has been hugely frustrating to see the National Institute for Health and Care Excellence (NICE) consistently refuse to approve Abiraterone as first line treatment for men newly diagnosed with advanced stage prostate cancer. That means the treatments available were ADT for those men who were not chemofit and ADT + Docetaxel chemotherapy for men who could tolerate chemo. I know that you were an expert commentator at the NICE appeal. Could you tell us what your views were on approving Abiraterone as first line treatment and, assuming that you were in favor of the approval, why do you think NICE chose not to take account of your expert views?

Prof. James: I believe that it was all down to the price negotiations between Janssen, the manufacturer, and NHSE (National Health Service England) – no one doubts the efficacy. They couldn’t agree a price in essence.

A non-chemo option

Tony: It was very heartening to see Enzalutamide approved in the first line setting recently, and at least we now have a treatment option for men who couldn’t tolerate chemo. Do you think that this approval sounds the death knell for Abiraterone being approved, or is there still a strong case for having both available to give more patient choice, and what arguments do you believe support that case?

Prof. James: Not directly connected, but at least this gives us a non-chemo option!

Why people react differently to treatments

Tony: In the 4 years since my diagnosis, I’ve seen men be diagnosed and sadly pass away with treatments only seeming to buy them a short time, whereas the combination of Prostap and Abiraterone for me drove my PSA down to unrecordable levels. It has stayed there for over 3 years. I may be talking rubbish, but it seems that some men are super-responders to certain treatments, while other men barely respond at all. Is there a reason for this, and how can we go about identifying which men will respond to which treatment combination best?

Prof. James: This is a focus of much research, including a lot linked to STAMPEDE. Right now we have no good predictors of response/failure to respond that can guide upfront therapy.

Potentially exciting developments

Tony: There are many developments in treatments that you are looking at as part of the STAMPEDE trial, such as different drug combinations, and radiotherapy to the prostate for men diagnosed with advanced stage prostate cancer. Which development excites you most and why?

Prof. James: To be honest, I’m most excited by stuff that works. Our next 3 arms will be SABR (Stereotactic Ablative Radiotherapy) for oligomet (small number of tumors) disease, a PARP inhibitor for men with DNA damage repair mutations and PSMA Lu for men with high volume disease. I think it likely that at least one of these will have a big impact.

Tony: NHS first line treatment norm for advanced stage prostate cancer has, until very recently, been ADT combined with chemotherapy. Since the start of the STAMPEDE trial, there have been many significant developments. What do you think that the standard treatment will look like in the short, medium, and long terms?

Prof. James: It’s hard to say and depends on trial results. The most key thing is to use the stuff we know works but, sadly, that frequently does not happen!

PSA testing

Tony:What are your views on using PSA testing in a screening program in conjunction with the Best Timed Prostate Pathway?

Prof. James: I’m not convinced that screening per se is a good idea. We need better ways to risk stratify.

Searching for a cure

Tony: Do you think we will ever see a cure for prostate cancer and, if yes, what are the barriers to getting there?

Prof. James: We cure a lot of prostate cancer. Will we cure metastatic disease? It’s possible in a proportion of cases by combining RT with ADT etc. Will we cure polymetastatic disease? That’s much harder to say.