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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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.


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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Anxiety, Depression + Prostate Cancer

Mr. Chuck Strand is the CEO of Us TOO International Prostate Cancer Education and Support Network. He discusses the anxiety and depression often associated with prostate cancer.

A cancer diagnosis of any type triggers a wide range of initial reactions and emotions. While in some instances it might provide a sense of resolution, a more typical response may include sadness, loss, fear, guilt, stigmatization, embarrassment, anger, or disappointment.

Many aspects of living with a prostate cancer diagnosis can be sources of anxiety and depression— everything from anticipating the next PSA (prostate-specific antigen) blood test results to dealing with the post-treatment impact of common side effects like incontinence and erectile dysfunction (ED).

Unfortunately, men and their partners are not always fully informed about the likely side effects when selecting a treatment. In addition to managing the anxiety resulting from ED and/ or incontinence, an unexpected decrease in a man’s sexual virility can lead to a sense of betrayal or reduced trust in his medical provider or in the medical community in general. Recognizing and learning to cope with anxiety and depression can be critically important for effectively managing life with prostate cancer.

In a recent collaborative survey conducted by Us TOO International and CancerCare, 94 percent of men who were diagnosed with prostate cancer indicated that experiencing anxiety and/or depression is to be expected. Anxiety and depression can interfere with a person’s day-today activities, responsibilities, and relationships and can impact not only the person with cancer, but also the caregiver. Helping family members manage their distress may have a beneficial effect on the distress level of the person with cancer.

The stress and anxiety associated with a prostate cancer diagnosis can be significant enough to influence a man on active surveillance to opt for treatment earlier than necessary, resulting in what is often referred to as over-treatment.

Treatment decisions must address whatever aspect of disease management is a priority for each man, after he has sufficient information on all treatment options, possible or probable side effects, and management of side effects.

One man’s priority could be to do everything he can to minimize the possibility that prostate cancer will metastasize, while another man’s priority could be to do everything possible to maintain and maximize his quality of life. It is important for a man to recognize that once diagnosed with prostate cancer, the disease will unfortunately be a perpetual issue of concern and a potential source of anxiety due to ongoing monitoring of PSA test results at a minimum, regardless of the course of action he takes. While active surveillance can be emotionally exhausting, over-treatment can result in decreased quality of life with ED, incontinence, and the potential emotional and psychological impact of having second thoughts about his treatment choice.

Symptoms of Anxiety and Depression

Anxiety and depression not only affect the quality of a man’s life, but can also keep the body’s immune system from functioning at its full capacity. Additionally, it can have a negative impact on adherence to treatment regimens. Therefore, it’s important to recognize these conditions and attempt to address them accordingly.

Anxiety is a feeling of nervousness, fear, apprehension, and worrying—typically about an imminent event or something with an uncertain outcome. Symptoms include: feelings of fatigue or weakness, sweating (for no reason), chest pains, headaches, gastrointestinal problems, or inability to rest.

Depression is a feeling of severe despondency and dejection. Symptoms include: sleeping more or less (as compared with regular sleeping habits), loss of interest in daily activities, an unusual increase or decrease in energy, changes in appetite (eating either more or less as compared with regular eating habits), increased irritability or impatience, or difficulty concentrating.

Action Items to Help

Take action rather than passively accepting anxiety and depression as a given. Begin by acknowledging the very real relationship between anxiety, depression, and prostate cancer. Take stock of your own emotions. Talk to your doctor about your concerns. Make sure your diet is heart-healthy/prostate-healthy. Exercise even if you do not feel like it. Especially if you do not feel like it! Exercise releases endorphins and neurotransmitters that promote relaxation and eliminate excess cortisol, a hormone released during stress and associated with anxiety. Get mindful and try to incorporate yoga, meditation, acupuncture, or other holistic practices into your life. These lift the body, mind, and spirit. Try to keep a positive attitude when possible, but understand that ups and downs are normal and expected during prostate cancer treatment.

If appropriate, your doctor might be able to provide a referral to a counselor who can help. Some common techniques to effectively manage anxiety include talk therapy (especially Cognitive Behavioral Therapy [CBT]) and antianxiety medications. Depression can be managed though lifestyle changes to establish more connections and support, psychotherapy (including Cognitive Behavioral Therapy), pharmacological treatment and, in advanced situations, Electroconvulsive Therapy (ECT).

Reach Out!

If you are dealing with prostate cancer and experiencing anxiety and/or depression, know that you’re not alone. Educational resources and support services are available to help cope with anxiety and/or depression.

Many men with prostate cancer and their wives/partners have dealt with anxiety and depression. It can be helpful to attend an Us TOO prostate cancer support group to share experiences and gather information and strength from those who have successfully managed these challenges.

To find an Us TOO prostate cancer support group near you, visit, call 800-808-7866, or email

To join a prostate cancer support group via telephone, visit

For individual counseling on anxiety or depression by telephone and online group counseling, contact CancerCare at 800-813-4673 or

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Living A Normal Life After Prostate Cancer

Dr. Stephen Freedland is a urologist at Cedars-Sinai in Los Angeles, California and the Director of the Center for Integrated Research in Cancer and Lifestyle, Co-director of the Cancer Genetics and Prevention Program and Associate Director for Faculty Development at the Samuel Oschin Comprehensive Cancer Institute.

Dr. Freedland treats the whole patient and not just a man’s prostate cancer.

He frames this month’s conversations about stress, depression, and prostate cancer.

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Historically, the goal was to cure cancer. We don’t really cure other major medical problems like heart disease, diabetes, high blood pressure, or high cholesterol: we manage them. Cancer, in general, and prostate cancer, in particular, are becoming chronic diseases. Occasionally, we need to do something more aggressive, but we really just need a management strategy so that people can live normal, healthy lives even after being diagnosed with cancer.

With this shift from quantity of life to quality of life comes an opportunity for us to have conversations about how prostate cancer and its treatments affect daily life. People are now younger at diagnosis than ever before. They’re still active. They’re still working. They’re still productive members of their families and of society.

How do we help them maintain that while providing the best cancer care? The challenge is how to marry those two. It’s not enough to focus on Gleason score, PSA, and stage. The focus is on the patient. On the person. It’s not just about the numbers.

I applaud Prostatepedia for delving into this subject matter with some very engaging conversations with some of the world leaders on the topic. I work very closely with Dr. Arash Asher at Cedars-Sinai Medical Center. We focus now on nutrition, exercise, and psychosocial health. It’s really spectacular to see. Men are able to maintain much of their quality of life and sometimes feel better than ever.

At the same time, we’re realizing that what works for one patient will not necessarily work for another. There is no shortcut to sitting down with a patient, understanding his needs, goals, and desires, and then working together to come up with a care plan that manages his cancer and his side effects. We want to keep you psychologically strong and able to fight your cancer–but also to live your lives.

Subscribe to read our February conversations about stress, depression, and prostate cancer.

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State Prostate Cancer Advocacy Groups Meet

This October 13-15, the 13th Annual Meeting of the National Alliance of State Prostate Cancer Coalitions (NASPCC) met in Washington, DC on Capitol Hill. State prostate cancer organizations, including state coalitions, associations, foundations, and consortia were represented by at least one leader. Invited guests and sponsors also attended.

The first panel on advanced prostate cancer covered new treatments for advanced prostate cancer and appropriate clinical trials. After a detailed Q & A session, a second panel on genomics and genomic testing met. The presentations included information on markers.

Then Dr. James Gulley, lead Prostate Cancer Researcher at Building 10 of NIH spoke about immunotherapy. Dr. Gulley will return at next year’s meeting.

In the third panel of the day, the prostate cancer coalitions of Georgia, Arkansas, New Mexico, South Carolina, and California presented. Mr. Tom Kirk, an invited member of the Executive

Committee of NASPCC and Vice President of the California Prostate Cancer Coalition, moderated the panel. The five state leaders discussed awareness and education programs in their states and expressed a willingness to help other state coalitions as needed.

At lunch, Dr. Michael Zaragoza, President of the Delaware Prostate Cancer Coalition, talked about the current proposed United States Preventive Services Task Force guidelines for PSA testing.

The group later heard Dr. Ashley Ross, a Urologist/Oncologist from Dallas and formerly of Johns Hopkins, discuss important advances in diagnosis and treatment. Dr. Ross’s discussion included genomic testing, early and advanced prostate cancer, and the 2017 results of clinical trials.

Attendees also heard from Mark D. Vieth, Coordinator for the Defense Health Research Consortium (DHRC), who spoke about the urgent need to keep the Congressional Directed Medical Research Program (CDMRP) in place. NASPCC is a signatory of the letter asking that the CDMRP remain in place, and NASPCC joined the DHRC by vote after this year’s Annual Meeting.

The group then heard from panelists who discussed new products and advances benefiting patients with prostate cancer. These included CyberKnife and hydrogel spacer for men undergoing radiation therapy for prostate cancer. A company offering free genetic testing at various centers in the US also spoke.

The group elected its 2017-2018 officers: Merel Nissenberg of California, President; Johnny Payne of South Carolina, Vice-President; Donald Lynam of Kentucky, Treasurer; and Jan Marfyak of New Mexico, Secretary. LaTanya Patton of Missouri is again Director-at-Large. These five officers comprise the Executive Committee, along with Tom Kirk as Invited Member.

The 2017-2018 Board of Directors are the officers named above along with Robert Johnson (Wyoming), Alvin Chin (Virginia), Paul Kradel (West Virginia), Mary Anderson (North Carolina), Dave Hulbert (Minnesota), Ira Baxter (Tennessee), Michael Zaragoza, M.D. (Delaware), and Sanford Jeames (Texas).

Saturday evening NASPCC held a cocktail awards reception. Robert Johnson of Wyoming gave a talk entitled “Why We Are Here,” and then Dave Hulbert of Minnesota talked about his journey as an advanced prostate cancer patient. The group presented two awards: the Georgia Prostate Cancer Coalition won Most Outstanding State Prostate Cancer Coalition of 2017, and Kathy Meade of Virginia received a service award. Guests included the Chief Counsel for Senator Roy Blunt (Missouri) and the Executive Director of the Vietnam Veterans of America. Merel Nissenberg received a surprise crystal award of appreciation.

On the last morning of the meeting, Tom Kirk gave a detailed discussion on “The New Workplan” adopted by the Board on July 18. Andrew Chesler of CancerCare also spoke about a number of emotional and physical issues facing prostate cancer patients and caregivers, which was very helpful in addressing a topic often overlooked at prostate cancer meetings.

The meeting concluded with an open discussion on participating state prostate cancer organizations, co-branding issues, and goals. The group is especially grateful to Tiffany Razzo, who served as staff during the meeting. Next year, the group will meet October 12-14.

Learn more about the NASPCC.