Conversations With Prostate Cancer Experts

Leave a comment

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.

Not a member? Join us to read more about recurrent prostate cancer.

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.

Not a member? Join us to read more about recurrent prostate cancer.


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

Leave a comment

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.

Not a member? Join us to read more about recurrent prostate cancer.

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.


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.

Leave a comment

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.

Not a member? Join us to read about prostate cancer recurrence.

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.

Leave a comment

Advances in Medical Oncology

PetrylakDr. Daniel P. Petrylak, Professor of Medicine and Urology at Yale School of Medicine, has been a pioneer in the research and development of new drugs and treatments to fight prostate, bladder, kidney, and testicular cancers.

Prostatepedia spoke with him about advances in medical oncology for prostate cancer.

Not a member? Join us.

What are the current points of controversy and/or trends in the field of medical oncology for prostate cancer?

The first controversy is over localized disease. There are really two forms of prostate cancer. There is the nonaggressive form that is not going to be lethal and that you’ll die with and not from. Then, unfortunately, there is the lethal form of the disease that kills about 30,000 men a year in the United States. The controversy is how do you treat these patients? How do you decide who to treat and who not to treat?

For advanced metastatic disease, there are controversies over the right treatments, the right sequences of treatments, when to use other hormones, and when to use other chemotherapies. There are a lot of questions that need to be answered.

Unfortunately, prostate cancer has always been behind other tumors. If you look back to the 1990s, there was about five times less funding for prostate cancer than breast cancer. We were behind in funding compared to other tumors, but have made significant strides in increasing money available for research.

We’re catching up in the area of personalized medicine. We didn’t really have markers a couple of years ago. But now we’re beginning to see markers—whether that be with BRCA mutations, BRCA-like mutations, or AR-V7—employed in the treatment of advanced metastatic disease to help select therapies. These approaches are in the advanced stages of development and have yet to be approved by the FDA. Those are the major controversies.

Subscribe to read the entire conversation.

Leave a comment

Join A Trial: Combining Xofigo + Provenge

Male, ManDr. Emmanuel Antonarakis is an Associate Professor of Oncology and Urology at the Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center.

Prostatepedia spoke with him recently about his clinical trial combining Provenge (sipuleucel-T) with Xofigo (radium-223).

What is the thinking behind your clinical trial?

Dr. Emmanuel Antonarakis: There is a lot of interest in combining immune therapies with other drugs to make immunotherapy work better.

The FDA approved Provenge (sipuleucel-T) in 2010. We’ve been using that drug for the last seven years. We’ve seen that patient survival improves by approximately three to four months on Provenge (sipuleucel-T) compared to a placebo.

However, we don’t typically see PSA levels dropping, tumors shrinking, or symptoms improving. While we recognize that Provenge (sipuleucel-T) is an immunotherapy that does have some activity in prostate cancer, the effects are fairly marginal.

We, and others, have been trying to increase its effectiveness by combining it with other medications. In this particular trial, we’re combining Provenge (sipuleucel-T) with a radiopharmaceutical drug called Xofigo (radium-223).

shutterstock_371809282 (2)




Why? We think radiation therapy can boost immunotherapy for several reasons.

One reason is that in patients who receive external beam radiotherapy, or conventional radiotherapy, healing tumor cells can release proteins called antigens from inside the cancer. Those antigens released into the circulation by radiotherapy can stimulate the immune cells that recognize and fight prostate cancer.

The second reason is that there is some preliminary evidence that these liquid radiotherapies—or radiopharmaceutical drugs that are injected into the veins, bind to the bone and then give off radiation particles at the bone—might also increase the number of antigens.

An antigen is a substance foreign to the body that elicits an immune response. These antigens are released as part of the cancer cell into the circulation and are then recognized by a stimulated immune system.

The hypothesis is that if you combine Xofigo (radium-223) with Provenge (sipuleucel-T), you would see higher immune responses against the tumor than if you used Provenge (sipuleucel-T) by itself.

What should patients expect?

Dr. Antonarakis: We’re selecting hormone-resistant prostate cancer patients with one or more bone metastases. In other words, their cancer has progressed after standard hormone therapy, but they don’t have any bone pain. Bone metastases have to be present, you have to have hormone-resistant disease, but you can’t have bone pain.

Patients will be randomized to one of two groups. Group 1 will receive Provenge (sipuleucel-T) by itself, according to the FDA dose schedule of three doses two weeks apart.

Group 2 will receive a combination of Xofigo (radium-223) plus Provenge (sipuleucel-T). The Xofigo (radium-223) will be given first according to the FDA dose schedule of intravenous injection every four weeks for six doses.

shutterstock_526769410 (1)

After the second out of six doses of Xofigo (radium-223), they will then receive the Provenge (sipuleucel-T).

After Provenge (sipuleucel-T), they will receive the third through sixth doses of Xofigo (radium-223). In other words, we give Provenge (sipuleucel-T) in between the second and third Xofigo (radium-223) doses.

Why in the middle?

Dr. Antonarakis: We are guessing when the immune system will be most stimulated by the Xofigo (radium-223). We hypothesize—and this is only a guess—that it will take at least two doses of Xofigo (radium-223) to release enough tumor antigens into the circulation to simulate the antitumor immune cells. We wanted to continue to give at least four additional doses of Xofigo (radium-223) after the immune system has been stimulated to see if we can maintain a prolonged immune stimulation period.

In a perfect world, we would have multiple different sequences, but that would require a much larger trial with at least four different study arms. We thought that was too complicated.

You said you were looking for patients with one or two bone metastases. Are you excluding those with more?

Dr. Antonarakis: Patients have to have a minimum of one bone metastasis, but there is no maximum. If a patient has a hundred bone metastases, he is eligible.

Patients cannot have liver or lung metastases larger than one centimeter in diameter.


Xofigo (radium-223) does not get into the liver or the lung. It only targets the bone. And we have never seen liver or lung metastases shrink with Provenge (sipuleucel-T) by itself. We wanted to exclude patients who wouldn’t benefit from Xofigo (radium-223), so we decided to exclude liver or lung metastases more than one centimeter.

We also exclude patients with lymph node metastases more than three centimeters. We allow small liver or lung metastases less than one centimeter and modest lymph node metastases less than three centimeters.

shutterstock_314852276 (1)

Is the trial being conducted only in Baltimore, Maryland?

Dr. Antonarakis: The trial is being conducted at four sites across the United States: John Hopkins University in Baltimore, Maryland is the lead site. The other sites are Tulane University in Louisiana; Duke University in North Carolina; and Cedars-Sinai Cancer Center in Los Angeles, California.

For more information, contact Dr. Emmanuel Antonarakis by emailing or calling 410-955-8964.

1 Comment

A Urologist’s View Of Bone Metastases


Dr. Raoul Concepcion is the Director of The Comprehensive Prostate Center in Nashville, Tennessee and the past President of the Large Urology Group Practice Association (LUGPA.)

Prostatepedia spoke with him about approaches to bone metastases within urology groups.

To read the rest of the article, subscribe or download the issue.

How does a urologist know when a man has developed metastases?

Dr. Raoul Concepcion: Fortunately, the majority of prostate cancer diagnosed today tends to be low-risk and associated with lower Gleason grades. For those men, active surveillance may be an appropriate treatment option. The challenge now is not to just identify prostate cancer, but to identify significant prostate cancer: those at risk for dying of their disease if left untreated. If you have Gleason -3 + 3, what we are now calling Group Pattern 1, or Gleason 3 + 4 (Group Pattern 2), the recommendation is not to do a staging work up. The likelihood of finding metastatic disease is very low. But if you do pick up a higher-grade clone on biopsy in a Gleason 4 or 5 prostate cancer, that man should definitely undergo a staging workup—usually a CT scan and bone scan—to look for metastatic disease.

Bony metastases can be detected in a couple different phases of prostate cancer. Sometimes, bone metastases are found at initial diagnosis during staging work-up. This usually happens with higher-grade tumors. The second phase is when men progress past definitive therapy and adjuvant treatment to we now call metastatic castration resistant prostate cancer (mCRPC). After diagnosis, both low-grade and high-grade patients decide on prostate cancer management.

Lower-grade patients can choose active surveillance, radiation therapy, radical prostatectomy, or even focal therapies like cryotherapy.

shutterstock_183834947 (1)

Options for higher-grade patients could include multi-modality therapy of surgery, radiation therapy, and hormones. These patients are really the people at risk.

After an individual has been treated definitively for prostate cancer, we measure his PSA after therapy. If his PSA starts to go up again, he is said to have a biochemeical recurrence.

For the most part, these patients do not have symptoms. They’re not in pain. They don’t have significant fatigue. Again, these are patients who have been definitively treated and are currently not on therapy.

Once his PSA starts to go up, we start to look at the rapidity with which it goes up. We call this PSA kinetics, or doubling time. If there is a rapid doubling time in a man who had a higher grade Gleason Pattern at diagnosis, we know he has a higher risk of developing metastatic disease. We usually go ahead and get a scan when his PSA goes above 10. If that scan is still negative in a high-grade patient with a rapid doubling time, most urologists initiate androgen deprivation therapy.

Androgen deprivation therapy, or hormonal therapy, tries to drive down testosterone levels into castration range. If his PSA then starts to go up again, he now has, by definition, mCRPC. Again, these are patients with prostate cancer that has been definitively treated.

shutterstock_328192013 (1)

They have then gone on androgen deprivation therapy until their testosterone levels got to less than 50, and then their PSAs started to go up again.

What is the trigger for the urologist to start looking again for bone metastases?

That has never been really well defined. I participated in a consortium of academic and community urologists, medical oncologists, and radiation oncologists called the RADAR (Radiographic Assessments for the Diagnosis of Advanced Recurrence) working group chaired by Dr. E. David Crawford to answer just that question.

We recommended that in such patients we should go ahead and look for metastases with a bone scan, a CT scan, or some of the new advanced imaging techniques when the PSA gets to 2.

Why would you hesitate to look for bony metastases earlier?

Dr. Concepcion: I think most urologists, unfortunately, extrapolate what they know about PSA in the early stages when patients aren’t on hormones to the castration resistant prostate cancer space.

If a patient had never been on hormones and his PSA is low, usually it means they don’t have a lot of disease. It’s become a real hurdle, an educational challenge, to get urologists to start thinking about that and not to wait until patients are symptomatic.


Do you think it would make sense for such a patient reading this to ask his urologist to scan him earlier?

Dr. Concepcion: Yes, I think that would be very appropriate. Unless you’re being treated by a urologist with a lot of expertise… A lot of general urologists aren’t going to know about the RADAR recommendations.

Are these scans usually done at the urologist’s office or does the urologist refer the patient to someone else?

Dr. Concepcion: It depends. Most urologists in community practices, especially in bigger groups, have their own CT scans. That part of the workup can be done in the urology office.

Technetium-based bone scans usually require a nuclear medicine department and are done in a hospital.

A lot of times, we’ll get a CT scan in our office and then coordinate with a freestanding imaging center or a hospital-based imaging center to get a nuclear medicine scan.

To read more about bone + prostate cancer, subscribe or download our April issue.