Phillip J. Koo, MD, division chief of Diagnostic Imaging at Banner MD Anderson Cancer Center, discusses the need for next-generation imaging in prostate cancer.

Next-generation imaging has been sorely needed in the field of prostate cancer, explains Koo. Conventional imaging tools, which have been limited to bone scan and computed tomography (CT), can miss a lot of lesions. However, it’s critical to be able to identify these lesions, so the spread of disease and the type of treatment patients need can be accurately assessed.

Currently, 18F-fluciclovine (Axumin), which is a next-generation diagnostic agent, is widely used in the United States. However, the future of next-generation imaging is going to be focused on prostate-specific membrane antigen (PSMA)—based imaging agents, says Koo. Currently, the use of these agents varies across the globe. In the United States, there are no FDA-approved PSMA PET agents. However, several sites in the United States are offering these agents under new drug applications or clinical trials. The United States will see widespread use of generic 

Ga-PSMA-11 PSMA or commercialized versions of PSMA once they receive regulatory approval, concludes Koo.

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Phillip J. Koo, MD, discusses the need for next-generation imaging in prostate cancer.

Dr. Koo on the Need for Next-Generation Imaging in Prostate Cancer

Phillip J. Koo, MD, division chief of Diagnostic Imaging at Banner MD Anderson Cancer Center, discusses the actionability of next-generation imaging results in prostate cancer.

The results of next-generation imaging tests should be actionable in order to be valuable, says Koo. As such, prior to ordering a test, it should be known how the information could influence treatment decisions.

According to a trial that enrolled a SPARTAN-like population, 55% of patients with nonmetastatic castration-resistant prostate cancer (CRPC) had N1 disease when they were scanned with prostate-specific membrane antigen. Notably, those patients were included in the phase III SPARTAN trial based on conventional imaging with a bone scan and CT and still derived a 2-year improvement in metastasis-free survival.

Although next-generation imaging modalities have higher sensitivity compared with conventional imaging, it’s important to adhere to the data and use next-generation imaging where appropriate, says Koo.

Patients with CRPC have aggressive disease. Prostate-specific antigen (PSA) is an important biomarker, but patients can progress without a rise in PSA. According to data from the PREVAIL trial, 25% of patients have radiographic progression without a rise in PSA; these patients may be candidates for monitoring with next-generation imaging, concludes Koo.

Phillip J. Koo, MD, division chief of Diagnostic Imaging, Banner MD Anderson Cancer Center, discusses the actionability of next-generation imaging results in prostate cancer.

Dr. Koo on the Actionability of Next-Generation Imaging Results in Prostate Cancer

Phillip J. Koo, MD, division chief of Diagnostic Imaging, Banner MD Anderson Cancer Center, discusses the use of metastasis-directed therapy in prostate cancer.

Next-generation imaging modalities are better equipped to detect oligometastatic disease compared with conventional imaging tools, says Koo. For example, if a patient presents with biochemical recurrence and a low prostate-specific antigen of 0.5 ng/mL or 1 ng/mL, a bone scan or CT scan will likely be negative. However, if next-generation imaging is employed, there's a greater chance of detecting locally recurrent disease, local metastatic disease, or oligometastatic disease outside the pelvis, says Koo.

According to surveys and consensus meetings, such as the Advanced Prostate Cancer Consensus Conference, patients who are found to have oligometastatic disease should be treated with metastasis-directed therapy. The data supporting the impact of this approach is growing, adds Koo. For example, a study from The University of Ghent demonstrated that the time to initiation of androgen deprivation therapy was prolonged in patients who had a C11-choline PET/CT and then received radiation or surgery on identified lesions, concludes Koo.

Dr. Koo on Metastasis-Directed Therapy in Prostate Cancer

Phillip J. Koo, MD, division chief of Diagnostic Imaging, Banner MD Anderson Cancer Center in Arizona, discusses new management strategies for patients with prostate cancer.

If a patient presents with biochemical recurrence and a low prostate-specific antigen of 0.5 or 1, conventional imaging will likely show the bone scan or CT as negative, explains Koo. However, if a next-generation imaging agent is used, there is a high likelihood that locally recurrent disease or local metastatic disease will be detected, potentially even detecting oligometastatic disease outside of the pelvis, says Koo.

The next step is to determine how to manage the patient once the test results are received. According to surveys and consensus meetings, such as the Advanced Prostate Cancer Consensus Conference, many providers are treating patients with oligometastatic disease with metastasis-directed therapy and the data regarding this approach are growing, according to Koo. A study from Ghent University showed that the time to initiation of androgen deprivation therapy was longer in patients who had a C11-choline PET/CT scan and then received radiation or surgery on those identified lesions, concludes Koo.

Phillip J. Koo, MD, discusses new management strategies for patients with prostate cancer.

Dr. Koo on New Management Strategies for Prostate Cancer

Phillip J. Koo, MD, division chief of Diagnostic Imaging, Banner MD Anderson Cancer Center in Arizona, discusses next-generation imaging tools in prostate cancer.

18F-fluciclovine (Axumin) is the next-generation imaging tool that is widely available and best performing, explains Koo. The performance of 18F-fluciclovine thus far has been as good or better than choline C-11, which was the first novel radiopharmaceutical PET agent that was approved in the United States, says Koo.

Conventional imaging tools have focused on bone and CT scan, but many lesions were missing on these scans, according to Koo. This is important because when looking at salvage therapies or potential curative interventions, physicians should be aware if the disease is metastatic and where it might be confined, concludes Koo.

Phillip J. Koo, MD, discusses next-generation imaging tools in prostate cancer.

Phillip J. Koo, MD

Articles

Dr. Koo on the Need for Next-Generation Imaging in Prostate Cancer

Dr. Koo on the Actionability of Next-Generation Imaging Results in Prostate Cancer

Dr. Koo on Metastasis-Directed Therapy in Prostate Cancer

Dr. Koo on New Management Strategies for Prostate Cancer

Dr. Koo on Next-Generation Imaging in Prostate Cancer