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Conversations With Prostate Cancer Experts


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Advanced Imaging + Prostate Cancer

Dr. Phillip Koo is Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center.

Prostatepedia spoke with him about advanced imaging + recurrent prostate cancer.

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Do you have any advice for men considering advanced imaging for prostate cancer?

Dr. Koo: We’ve been talking about better imaging tools for prostate cancer for years. When it comes to other cancers, we moved forward a great deal when FDG PET/CT became available. With prostate cancer, we’ve been stuck with CT and bone scans since the 1970s. They’re great tools. I don’t want to devalue what they’ve done for our patients since then, but we knew we could do better. Urologists and oncologists knew patients had metastatic disease, but our imaging tools limited detection.

We have new tools available to us in 2018. There is no question that costs are going to be higher, but that shouldn’t stop us from exploring and pushing the envelope. The whole purpose is to improve overall survival and treatment for our patients. An ounce of diagnosis could be a pound of cure. If we could identify disease sooner, identify the right patient for these exams, and use them at the right time, then we could probably create treatment plans more appropriate for patients with better outcomes. It’s something that I firmly believe. There is so much potential here.

When radiology is practiced in a vacuum, it’s not as powerful as when it’s integrated into patient histories and treatment plans. Radiology is a very powerful tool. But we often think of it as a commodity, something that does not have any distinguishing value. That is a huge under-estimation of radiology.

When performed correctly in a multidisciplinary setting, with access to the medical record and physicians who are taking care of the patient, radiology unlocks information that can really impact care for patients with prostate cancer. And we are currently only scratching the surface. This will change as analytic tools continue to analyze bigger data sets that include imaging and clinical data. If a urologist determines that their patient needs imaging, they’re going to write a request for imaging that describes what type of test they want and why they need it.

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Patients often go to the closest facility. Convenience is important, but when it comes to certain tests or exams, I urge patients to seek out subspecialized radiology experts and facilities with the experience and expertise in the performance and


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Imaging + Prostate Cancer Recurrence

Dr. Phillip Koo is Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center.

Prostatepedia spoke with him about imaging recurrent prostate cancer.

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Prostatepedi:Some imaging occurs when men are first diagnosed. When, after treatment, do they encounter these newer imaging techniques? After a high PSA reading? Or just a part of routine follow-up?

Dr. Philip Koo: That’s a really tough question because imaging has a role throughout the continuum of care for any prostate cancer patient. Screening currently isn’t done with imaging, but there are a lot of research studies looking at it.

Prostate MRI is most often used for the detection of local disease. Oftentimes, patients with a rising PSA and a negative standard biopsy might get an MRI or an MRI-guided biopsy.

Bone scans and CT scans are used to help detect metastatic disease. There are many different scenarios, but usually after patients are diagnosed with cancer, most will visit radiology if there is a suspicion for metastatic disease. If we refer back to the RADAR 1 paper published in 2014 by Dr. Dave Crawford in Urology (see Urology 2014 Mar; 83(3): 664-9), we talk about imaging patients at initial diagnosis and imaging those who are intermediate or high-risk. In those patients, we recommended a bone scan and a CT scan.

Patients who are biochemically recurrent may also be imaged. Again, MRI will often be used to look for locally recurrent disease. Bone scans and CT scans are used to look for metastatic disease.

What about some of the newer imaging techniques?

Dr. Koo: The newer techniques are exciting. In both the patient community and the scientific community, we’ve heard a lot about these tools over the past decade. They weren’t widely available, especially in the United States. These newer imaging tools are simply better, which is why there is so much excitement. They will pick up more sites of disease at lower PSA levels.

When we do detect sites of disease, they’re more specific. Our confidence that these sites are actually disease is higher than our confidence when we’re using traditional bone and CT scans. These tests perform at a higher level compared to standard imaging.

Another benefit to these new tools is that in one single exam, we’ll be able to detect soft tissue and bony disease.

How do these newer techniques change treatment? If you can pick up the disease at a lower PSA is that going to change how a doctor treats a man?

Dr. Koo: Yes. We will be able to detect disease sooner. Currently, these newer imaging techniques are used mostly in patients with biochemical recurrence. When a patient has biochemical recurrence and we see the PSA rise, our standard imaging techniques are often not good enough to detect metastatic disease. The problem is that the radiation oncologist or the urologist needs to decide how they want to treat the patient.

Using these newer tools, we can provide the urologist or radiation oncologist with better information about whether or not the disease has spread at the time of biochemical recurrence. If it has not, and the urologist can perform salvage cryotherapy or a radiation oncologist does salvage radiotherapy, we could potentially cure the patient.

Really?

Dr. Koo: You’re hitting the disease before it spreads, so theoretically yes. These newe imaging techniques do better, but we really need to prove why this is important and how this impacts care. The answers to these questions will solidify the utility and value of these imaging techniques for prostate cancer patients.

If a patient gets the Gallium-68 PSMA or Axumin scans will his local urologist or oncologist know what to do with that information?

Dr. Koo: Maybe. The problem is that all of this sounds great: we have a tool that can detect disease sooner, better, and more accurately. But then the more important question is what to do with that information and does it impact outcomes. If we don’t know, then what is the value of that imaging tool? We operate under the assumption that earlier detection is always better, but we’re learning that in a lot of diseases that is not always true.

We could be over-diagnosing and over-treating certain diseases. Whether it’s imaging, urology, radiation oncology, or oncology, it really is a team effort because we all bring something unique to the table. We really need to work together to make sure we come up with the best plan and the best answers.

Join us to read the rest of Dr. Koo’s comments on imaging recurrent prostate cancer.


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Dr. Philip Koo: Why Medicine?

Koo-WEBDr. Phillip Koo is Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center.

Prostatepedia spoke with him about imaging recurrent prostate cancer. But first we asked him why he became a doctor.

Dr. Philip Koo: I became a doctor in large part because I couldn’t imagine anything better than spending my life learning about the human body and using that knowledge to improve human health. Given that I tended to do better in science and math, medicine provided a nice fit.

Why radiology?

Dr. Koo: During medical school rotations, you try a variety of specialties. A common theme in all my rotations was the central value or importance of imaging within the care of a patient. That piqued my interest in radiology. When I learned about radiology, I was captivated by looking at images or different techniques to capture a certain body process anatomically or physiologically and by being able to use that information combined with the clinical scenario in order to come up with a diagnosis.

Did you ever study engineering? I’ve been reading a lot about how radiology and imaging are becoming incorporated into the tech world, such as with IBM Watson.

Dr. Koo: I’m not much of a techie. Before I switched to one of those flat screens, my friends used to joke that I was the last person in the United States to have a tube TV.

To me, it’s not necessarily a disconnect with radiology because radiology is the practice of medicine. It is an art. No matter how much technology we implement, there still is an art to the way you practice the science of radiology.

There is no question that technology has caused a tremendous growth in our field over the past 10 to 20 years. These technologies were disruptive and beneficial to our specialty. Artificial intelligence and machine learning are the newest technologies poised to disrupt the specialty. As a specialty, we are embracing these tools and finding ways that they can be utilized to improve patient care.

Join us to read Dr. Koo’s comments on imaging + prostate cancer.


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Prostate Cancer Recurrence

Dr. Alicia K. Morgans is a medical oncologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois. She specializes in treating advanced prostate cancer and is particularly interested in addressing treatment side effects.

She frames Prostatepedia’s March conversations about prostate cancer recurrence.

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One of the most common questions I’m asked as a doctor who treats prostate cancer is: what happens to me if my cancer comes back? This is always a difficult conversation, especially because people often ask it in the presence of their family members. A man’s wife or child is also really interested in knowing the answer to the question. The question is often driven by anxiety and fear in men who have already undergone what can be a life-altering treatment experience. They’re trying to look ahead and plan for their future. But there are many parts to any possible answer.

First: what do you go through to monitor before the cancer comes back? After treatment, we follow a man’s health, watch his PSA intermittently over time, and often do imaging studies.

If the cancer comes back, the first sign is often that a man’s PSA starts to rise. At this point, we typically use imaging studies to understand what the disease is doing. Even when the PSA is really low, our new imaging technologies can show us where the cancer is and help us determine how a man’s recurrence may be ultimately treated—whether that is with local or systemic treatment. Again, this is a really anxiety-laden situation. We’re fortunate to have these new exciting imaging technologies for patients and their clinicians, which Prostatepedia discusses at length in this edition.

We use these imaging technologies in men with biochemical or PSA-only recurrence to help us understand where the cancer is located. For some men, these new imaging techniques might show us that there is a cancer recurrence in the pelvis where radiation can be given to potentially cure them of recurrent prostate cancer. That is a huge win, progress for our patients, and of course, wonderful news for the men and their families.

For other men, it is possible that we will not necessarily find recurrence, even with new imaging techniques. In those cases, we often continue to wait and watch. Biochemical recurrence can be challenging psychologically because knowing that your PSA is rising can be stressful, and the data explaining the best approach to treatment is not complete.

For men who have a single area of prostate cancer that has come back, whether as a single bone lesion or a few locations, advances in therapy for oligometastatic disease have come fast and furious. In this issue, Dr. Piet Ost talks about oligometastatic prostate cancer and how we might use radiation or surgery to treat a small amount of recurrent prostate cancer. Several clinical trials are working hard to figure out if treating this low volume of prostate cancer in single areas will potentially cure men of recurrent cancer.

It’s really important that we have new treatments we can use for men with hormone-sensitive metastatic prostate cancer, too. Over the last few years, we’ve seen men with metastatic hormone-sensitive prostate cancer live well for many years with several options for treatment. New data describing chemo-hormonal therapy or androgen deprivation therapy (ADT) with Zytiga (abiraterone acetate) have been incorporated quickly into clinical practice and are being widely used to help men with metastatic hormone-sensitive prostate cancer live longer.

Unfortunately, sometimes a man’s prostate cancer comes back more broadly, as a rising PSA only, or with sites of metastatic disease. This can be challenging physically, because sometimes it’s coupled with fatigue or pain as well as emotional difficulty. The cancer that a man thought was gone has now come back. To address this, there are many scientists and physicians working to try to help men with prostate cancer live better by using therapeutic advances as well as psychosocial and pain support teams that can improve patient-reported as well as disease outcomes. By incorporating social work and psychiatrists, centers are able to support men and their families, helping patients cope with PSA anxiety, which is an issue that can be anxiety-provoking and potentially go on for years at a time.

In terms of therapies, we as a field are very excited about new data that offers new therapies to men with biochemical recurrence who develop castration resistance before they have radiographic evidence of metastatic disease. Two clinical trials presented last month in San Francisco at the annual ASCO Genitourinary Oncology Symposium suggest that using either Xtandi (enzalutamide) or Erleada (apalutamide)—both androgen receptor-directed therapies—can prolong metastasis-free survival for men with castration-resistant non-metastatic disease.

This is a valuable advancement because any day spent without metastasis is a day spent feeling stronger and with less pain. We are also excited because both of these oral drugs have relatively low toxicities. Both clinicians and patients win when we add a significant amount of metastases-free time with a few pills and minimal side effects.

As a clinician, I understand the anxiety that drives the question: what if my cancer comes back? But this is a time of incredible hope. Medical advances are helping men live longer and live better, even if their cancers do come back.

Join us to read this month’s conversations about prostate cancer recurrence.