Conversations With Prostate Cancer Experts

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Imaging Metastatic Prostate Cancer

Dr. Eric Rohren is the chair of the department of radiology at Baylor College of Medicine.

Prostatepedia spoke with him about imaging metastatic prostate cancer.

Subscribe to read Dr. Rohren’s comments on radium therapy + imaging. Members can read the interview in their March 2018 issue of Prostatepedia.

In terms of imaging, what kinds of scans can determine if a man has metastases (mets) anywhere in his body?

Dr. Eric Rohren: X-ray has been around for a long time and still has a role to play. It’s easy to obtain, it’s cheap, and it has low radiation exposure. We still rely on a good old-fashioned chest or bone X-ray, depending on the patient’s symptoms.

These days, most patients with any type of malignancy, and specifically prostate cancer, are managed in a couple of ways.

One way is a CAT scan. CAT scan is a 3-D imaging technique that uses X-rays that can take images of the body, chest, abdomen, and pelvis. Most patients with newly diagnosed prostate cancer or treated prostate carcinoma have undergone a CAT scan at some point in the course of their disease. CAT scans can show us the prostate gland, lymph nodes, liver, and many of the different organs where cancer may be hidden.

To supplement that, patients with prostate cancer often get a bone scan, which is a nuclear medicine technique. In a bone scan, we inject radioactive material that goes to the skeleton, and most strongly so in areas where there’s increased skeletal turnover, where something in the bone is inciting a reaction. It may go to benign things like healing fractures, arthritis, and various areas of injury. But the radioactive material also goes to areas of metastatic disease in the skeleton, and it localizes most particularly in those areas, lighting up on these bone scans.

Rather than just a particular region of the body, a bone scan shows us from the top of the head all the way down to the feet, which is nice. We get a look at the entire skeleton, and we can look for the little spots that are lighting up that may indicate the presence of metastatic disease in the skeleton.

CAT scans and bone scans are very widely used. A bone scan is a little bit better than a CAT scan in looking for these bone metastases, so the two really augment each other in detection of the disease.

Beyond these, we do have some newer imaging techniques coming into play. There’s a way of doing a bone scan with PET scanner. A PET scanner is another nuclear medicine technique that is more sensitive than a standard nuclear medicine camera, and it acquires a CAT scan at the same time. You can look at the images on the nuclear medicine technique overlaid on the CT scan to see where exactly the activity is and what it’s due to.

We can also use some agents with PET scanning to look at the skeleton. A so-called fluoride PET/CT bone scan seems to have many advantages over a conventional bone scan in terms of detecting smaller disease, more sites of disease, and things like that. MRI is also used in some cases.

Traditionally, MRI is used to evaluate specific areas, so if there’s pain in a particular area such as the skeleton,

MRI is a great way to do that. MRI is also used to look directly at the prostate gland and at the prostate bed after prostate surgery or after other therapy in the pelvis. It can be very good at detecting small volumes of disease. The problem with PET scanning and MRI scanning is that they are less accessible, although MRI is in most places now, and most major areas have access to a PET scanner.

Then there’s the issue of cost. Both techniques are costly. We need to determine if the added cost is justified by the additional information that those scans provide.

Beyond these techniques, the exciting thing for nuclear medicine is the new developments on the horizon. As we discover more about the molecular nature of disease, why cancer forms, and what makes and defines a cancer cell, those molecular discoveries can be translated into imaging studies that we can then use with PET scanning to be even more sensitive for detection of disease.

For example, there are several new molecular tracers in the United States that are approved for imaging of prostate cancer. Choline and Axumin (FACBC) are both agents approved in the United States for use with PET/CT.

Internationally, people are moving to a compound called prostate surface membrane antigen (PSMA) that can image prostate carcinoma. It seems to be even better than Choline or Axumin. The data is still a little bit undetermined at this point, but there’s a lot of excitement around these newer agents being able to seek out cancer in very small volumes anywhere it occurs in the body.

Then I guess the question becomes: when do you treat?

Dr. Rohren: Yes. That is very much the question. As we discover more and more sites of disease and smaller sites of disease, the question becomes: do we need to treat those aggressively or conservatively? We’re discovering new things about tumor biology, and we need to understand how that gets translated into the best appropriate therapy for patients.

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Dr. Eric Rohren: Why Radiology?

Dr. Eric Rohren is the chair of the department of radiology at Baylor College of Medicine.

Prostatepedia spoke with him about the path that led him to radiology.

Subscribe to read Dr. Rohren’s comments on radium therapy + imaging.

Why did you become a doctor?

Dr. Eric Rohren: I actually tried my best not to become a doctor initially. My father was a doctor. I grew up in the shadow of the Mayo Clinic up in Minnesota. I knew I was interested in science, but for a long time, I thought I wanted to pursue a career as a research scientist and not a physician.

As I made my way through college and looked at what I really enjoyed and what a career would look like, I wanted to focus on patient care and do things that impacted people. I looked for a career that could combine the science that I enjoyed with the ability to directly interact with people, to hopefully make their lives better. I came full circle, landing back in a career in medicine.

How did you end up in radiology and nuclear medicine?

Dr. Rohren: That was also a little bit indirect. Most medical students aren’t introduced to radiology until very late in their medical training.

A lot of people make the decision to do medicine or surgery well ahead of time, but radiology is often a latecomer. Nuclear medicine is even more so. It’s a subspecialty of imaging, its own medical specialty, but it can also be considered a part of radiology. Medical students often make it through their entire medical training without learning about nuclear medicine at all.

I was fortunate to have a mentor in the radiology department at the Mayo Clinic who taught me what he loved about radiology and how impactful it was on patient care. He got me further plugged in to nuclear medicine.

As I went into my residency and pursued it further, I decided that the science that I loved and the ability to do new things were most focused in radiology, and particularly in nuclear medicine. That’s the career I ended up with.

Many people assume radiology is just imaging. Is that the case? Where does it branch off into nuclear medicine? What kinds of therapies would a radiologist administer?

Dr. Rohren: A big part of being a radiologist is reading images. We also oversee the acquiring of the images, so we monitor the acquisition of the scans and the technologist performing the scans. Many of the people reading this article will have had X-rays, CTs, and MRIs. While technologists and nurses take them into the scanner and get them positioned, ultimately, the radiologists are the ones who oversee the program and make sure that the scans are acquired in the right way. They’re responsible for patient safety, the patient’s experience, and things like that.

At the back end, once the scan is complete, radiologists interpret the scans and look for the findings that may be used to guide medical decisions. Whereas many radiologists can go through their day and not see a patient, they do see the patient’s images. However, there are components of radiology that are directly related to therapy and directly patient-facing.

In interventional radiology, we do biopsies and endovascular procedures, catheter-based procedures, embolizations, administering treatment, and things like that. In women’s imaging such as mammography and breast cancer screenings, those radiologists spend a lot of their time talking to patients and counseling them about their diagnosis and procedures.

One area of radiology where we do meet with a patient face-to-face and interview or talk with them is in nuclear medicine. In that role, we act as “real doctors,” where we walk in, interview the patient, review their labs, go over the plan, do a consent process if it’s for a therapy that has some risks associated with it, and then we administer the therapy directly there in the clinic. When I serve in that role, I feel much more like a patient-facing physician than I do a traditional radiologist. It’s one of the most enjoyable things about it for me.

People tend not to be familiar with specialists until they need them. They might not really understand what you do until they’re at the point where they need your services.

Dr. Rohren: Generally, that is the impression, that the radiologist sits in a dark room, reads scans, and that’s the end of it. The national societies for radiology really encourage us to interface with patients and physicians to make our presence known. Radiologists need to do a better job of that. We have a critical role to play in the management of patients and the diseases that they’re dealing with, so the more we can be out there, share our professional knowledge, act as consultants, and act as physicians for the patients, that’s a positive thing.

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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.


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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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.