TAKING STOCK - Taking Stock
EAPM Director Dialogues - Hendrik van Poppel
Professor Hendrik van Poppel is chairman of the Department of Urology at the University Hospital Gasthuisberg, Katholieke Universiteit Leuven.
He is the Admin. Secretary General of the European Association of Urology (EAU) with responsibilities for education and was the Director of the European Society of Surgical Oncology, while also being chairman of the Educational Office of the EAU, director of the European School of Urology and holding several other urological and oncological posts.
Prof Van Poppel graduated in general surgery in 1980, in urology three years later, and joined the Academic Unit at KU Leuven after his postgraduate training in London, Barcelona, Copenhagen, Mainz and Rotterdam. In 1988, he obtained a PhD in Medical Sciences.
An expert on prostate cancer, he was in Vienna for the ECCO/ESMO assembly and said of his profession: “When it comes to personalised medicine, this has been around for many years. We had a much more individualised way (even before) having all the tools that we have today on genomics and stratification.
“We have always looked at a patient as an individual. This is personalised medicine, not just using novel biomarkers, but looking at his age, his family situation, his social situation…Is he married? Does he have children? Does he want children? Does he want to be sexually active? How is he going to react to the consequences of radiation therapy? We have already been doing that, just based on the interaction between the expert and the patient. So the patient has not been ‘a number’ for many, many years.”
”Of course,” he adds, “personalised medicine is an evolving area where we now come across individual parameters that can direct which type of treatment we can give. When we just had radiotherapy, hormones and chemotherapy, it was very easy because it was straightforward that a normal patient had the one after the other. You did not need to individualise.
“Today, with the different drugs we have, with the different treatment strategies, you have to look further at really choosing the ideal for a given patient - and this is not only about drugs. Because when it comes to personalised medicine, I often get the impression that this is what they are talking about - is this drug going to work in that patient?”
“But,” Van Poppel continues, “it’s also about the primary treatment delivered. Are you going to treat a patient with surgery, for instance, or with radiotherapy for prostate cancer? What are the choices to be made? His willingness to suffer the consequences of the treatment – which are incontinence and impotence - how important is that? So there are different parameters that we need to take into account.”
“When it comes to drugs”, he continues, “there are a lot around now. We are more-and-more able to predict that a person may not respond to a certain drug, so it’s no use to give it to him. There is a completely different spectrum with all the biomarkers we have today. Prostate cancer is now so diversified that there are no two patients the same.”
But are professionals keeping up with the pace of the fast-moving world of medicine? Van Poppel says: “Everything has become more complicate and sophisticated. You really need to be in the game because, if you do not follow everything that’s ongoing, then you will not be aware of it. If you don’t go to congresses you will not be educated. And you are ill-treating your patients if you don’t know the correct treatments.”
He adds: “I don’t think that everybody today is really aware of the changes that are occurring. There is absolutely a training-and-skills gap.”
Access is always a big issue in personalised medicine and Van Poppel can clearly see the gaps there, too. He says: “If you look at countries like Belgium and The Netherlands, just speaking about diagnosis, and planning the primary treatment, not yet the advanced treatment, we see the availability of MRIs. In the UK it is terrible, you have waiting lists for half-a-year.
“There are huge differences already just for diagnostic tools, it is very different in the EU’s 28 countries. How easily can you get into an access programme, at an early stage? In France, Germany, Belgium, The Netherlands, you have that. It is easily available but, when you go to Slovenia or Slovakia, I can imagine that they do not have these things, so you cannot offer the optimal treatment in every country.”
So what does the modern-day patient need to know? “The first thing is that they have the right to a second or a third opinion,” insists Van Poppel. “They need to go to specialised centres with multi-disciplinary teams. This is what needs to be advocated to patients today. If you go with your prostate cancer to a surgeon, it is very likely that he will propose that you be operated on – telling you that this is the best possible treatment you can get. If you go to a radiation oncologist he will say (radiotherapy) is exactly the same, and maybe better in this case. So, second opinion, third opinion, multi-disciplinary teams…that’s the most important.”
And do men know enough about prostate cancer and their own risks? It appears not. “If you are 54-years-old then you are probably already too late for early diagnosis. EAU recommendations say you need to have your prostate-specific antigen (PSA) drawn at age 40, then again at 45, and again at 50. And you will see with the slope of your PSA and whether you can then stop being screened, because you will not develop prostate cancer – or whether it’s going too fast…”
”We know today that if you take a guy who’s 54, he may have a prostate already of 60 grammes. He may have a high PSA but you do not know (what to compare it to), so you need to start testing at age 40. So, the patient who does not want to die from prostate cancer, should be well informed and know that when he starts doing the PSA test at 40, he might develop prostate cancer, but that the team will be there early enough to treat it adequately.
”It’s all about information for the GPs, information for the population. This is a task for the European Union, the Commission…they have to take responsibility.”
Very little is happening, however, because according to Van Poppel: “they are maybe not interested enough in prostate cancer, they are not interested in men’s health”.
He says the Commission has to show “much more awareness,” adding: “This is about preventable death. You cannot prevent getting cancer but you can prevent dying from it.”
Van Poppel spells out this message to the health commissioner: “If you do not want any man in your population, in your country, to die from prostate cancer, you could achieve this. But you need good information, and you need to have awareness and, if you are not aware that prostate cancer (as a percentage of cancers) kills the highest number of men in Europe, there’s some work to do there.Author: Denis Horgan