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Managing Advanced Prostate Cancer in the Future

Panelists: Raoul S. Concepcion, MD, FACS, Comprehensive Prostate Center; Daniel George, MD, Duke Cancer Institute; Alec Koo, MD, Skyline Urology; Phillip Koo, MD, MD Anderson Cancer Center; Neal D. Shore, MD, FACS, Carolina Urologic Research Center
Published: Monday, May 14, 2018



Transcript: 

Raoul S. Concepcion, MD, FACS: I want to thank all of the panelists, because I think this has been extremely informative. But before we end this discussion, I’d like to get thoughts, from all of you, relative to what we’ve discussed. Dan, I’m going to start with you.

Daniel George, MD: OK, thanks. And thank you all for participating with me. This was a lot of fun, and it’s a great opportunity. The field now has a new option for a phenotype that we’ve never effectively treated before. I think we’re excited to see this unmet need come into focus a little bit more. We talked about the different phenotypes of prostate cancer, and I think it’s important to think of this. We’ve traditionally thought of it as a single continuum, but it’s not. There are multiple pathways in which patients develop lethal prostate cancer. The M0 space is really one of those areas that, I think, is one of the slower ones. In that space, we really need to consider who we manage, how we manage them, and what the goals of therapy are.

Imaging is overdue in this field, and we’re very excited about where it’s going. One thing to look for, in the future, is the use of image-directed therapies. We talked a lot about PSMA. PSMA, as a molecular diagnostic, as a therapeutic companion, as a directed therapy, holds a lot of promise. We’re going to see trials like that in the future. It will be interesting to see where it falls in this space. It is important to recognize that radiology is now a part of the multidisciplinary team. If it hasn’t been a part of your team, in your practice, it needs to be. We meet regularly with a multidisciplinary team, on tumor boards, that includes radiology and pathology. That’s academics. We’re all in 1 building; that’s easier. It’s harder in the community, but it’s really worth it. This can help you keep up with the changes, if you’re having that regular discourse.

Raoul S. Concepcion, MD, FACS: Yes. That’s a great point. Phil, you and I have talked about that. Again, what are your comments? May you also address Dan’s comment about this new potentially burgeoning field of theranostics?

Phillip Koo, MD: A lot of the advances that we’re doing today with PSMA-targeted PET imaging really open up the door for Lutetium-177 PSMA therapies or thorium or actinium-type of therapies, using alpha particles, which have the potential to be another therapeutic tool in our war chest. And this is just the tip of the iceberg. I think it’s so exciting to see that we’re moving past the idea of “if” we should image. Now, the questions are when, how, and what. These questions are only to be answered if we all work together. It’s an honor to be here, sitting with this distinguished panel, having the opportunity to contribute radiology as a tool to help us treat patients better. The last comment that I’d like to make just echoes what Dan has said. I encourage everyone to reach out to your radiologist, even if you’re in a community practice. There is a private-practice radiology group that can be your champion when it comes to prostate cancer imaging. Developing a working relationship with them, for prostate MRI, PET/CT imaging, CT, and everything, will do a world of wonders for your patients. I think it’s an opportunity that we have to capitalize on.

Raoul S. Concepcion, MD, FACS: Great comment. Alec?

Alec Koo, MD: From a very simplistic fashion, just by the data from PROSPER and SPARTAN, it’s incredibly meaningful to our patients. Like Dan said earlier, before, with these medications, we were talking about an extra 4 months of median survival gain. Now, we’re going to about 20 months of metastasis-free survival. That’s incredibly meaningful. It’s a very exciting time for us, as physicians who treat prostate cancer. It’s an incredibly gratifying time for the patients who have prostate cancer. Now, I can look at my patients. I can say, “There are new medications coming out, and I think we can meaningfully delay your disease onset to metastases by a couple more years.” That is exciting.

Raoul S. Concepcion, MD, FACS: Neal?

Neal D. Shore, MD, FACS: Thanks, Raoul, for organizing the panel. As Phil was saying, theranostics and the whole notion and the burgeoning field of targeted alpha therapy is incredibly exciting. We didn’t get a chance to talk too much about it. Maybe we’ll do another panel? Dan mentioned PARP inhibitors. At some point, they’re clearly going to receive approval in prostate cancer. We see them approved in breast and ovarian cancer. Oral agents will add to the armamentarium of what we already have in an advanced prostate cancer clinic. We think about all of this excitement, of 2 new agents that could be approved in the M0 Case 1 Index, whether it’s apalutamide or enzalutamide. I suspect it will be both. We also think about changing our options—metastatic tissue testing to understand somatic defects and how to personalize medicine. Plus, we consider the hereditary prostate cancer issues in germline testing.

So, why do I say all of this? I say all of this because, for our colleagues who are listening, it’s exciting. It’s getting a lot more complex and a lot more specialized. Today, advanced prostate cancer really requires a true dedicated specialist, whether it’s in a multidisciplinary fashion at an academic center or in a clinic like Alec’s or mine or Phil’s. And so, we work together. We have to specialize. That’s probably true in so much of medicine. But it is exciting. To me, it prevents the concern of burnout. How could you be burnt out if you’re following all of these incredible advances? I understand. That’s another panel, too. Anyway, thanks for having us.

Raoul S. Concepcion, MD, FACS: Those are great points. Again, as we said, it keeps changing every 3 or 4 months. Hopefully, we will sort of move away from this traditional organ-based cancer-driven consideration to something that’s more based upon molecular drivers. And hopefully, we will treat people more often based upon what their tumors are expressing. Thank you, all, for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity 

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Transcript: 

Raoul S. Concepcion, MD, FACS: I want to thank all of the panelists, because I think this has been extremely informative. But before we end this discussion, I’d like to get thoughts, from all of you, relative to what we’ve discussed. Dan, I’m going to start with you.

Daniel George, MD: OK, thanks. And thank you all for participating with me. This was a lot of fun, and it’s a great opportunity. The field now has a new option for a phenotype that we’ve never effectively treated before. I think we’re excited to see this unmet need come into focus a little bit more. We talked about the different phenotypes of prostate cancer, and I think it’s important to think of this. We’ve traditionally thought of it as a single continuum, but it’s not. There are multiple pathways in which patients develop lethal prostate cancer. The M0 space is really one of those areas that, I think, is one of the slower ones. In that space, we really need to consider who we manage, how we manage them, and what the goals of therapy are.

Imaging is overdue in this field, and we’re very excited about where it’s going. One thing to look for, in the future, is the use of image-directed therapies. We talked a lot about PSMA. PSMA, as a molecular diagnostic, as a therapeutic companion, as a directed therapy, holds a lot of promise. We’re going to see trials like that in the future. It will be interesting to see where it falls in this space. It is important to recognize that radiology is now a part of the multidisciplinary team. If it hasn’t been a part of your team, in your practice, it needs to be. We meet regularly with a multidisciplinary team, on tumor boards, that includes radiology and pathology. That’s academics. We’re all in 1 building; that’s easier. It’s harder in the community, but it’s really worth it. This can help you keep up with the changes, if you’re having that regular discourse.

Raoul S. Concepcion, MD, FACS: Yes. That’s a great point. Phil, you and I have talked about that. Again, what are your comments? May you also address Dan’s comment about this new potentially burgeoning field of theranostics?

Phillip Koo, MD: A lot of the advances that we’re doing today with PSMA-targeted PET imaging really open up the door for Lutetium-177 PSMA therapies or thorium or actinium-type of therapies, using alpha particles, which have the potential to be another therapeutic tool in our war chest. And this is just the tip of the iceberg. I think it’s so exciting to see that we’re moving past the idea of “if” we should image. Now, the questions are when, how, and what. These questions are only to be answered if we all work together. It’s an honor to be here, sitting with this distinguished panel, having the opportunity to contribute radiology as a tool to help us treat patients better. The last comment that I’d like to make just echoes what Dan has said. I encourage everyone to reach out to your radiologist, even if you’re in a community practice. There is a private-practice radiology group that can be your champion when it comes to prostate cancer imaging. Developing a working relationship with them, for prostate MRI, PET/CT imaging, CT, and everything, will do a world of wonders for your patients. I think it’s an opportunity that we have to capitalize on.

Raoul S. Concepcion, MD, FACS: Great comment. Alec?

Alec Koo, MD: From a very simplistic fashion, just by the data from PROSPER and SPARTAN, it’s incredibly meaningful to our patients. Like Dan said earlier, before, with these medications, we were talking about an extra 4 months of median survival gain. Now, we’re going to about 20 months of metastasis-free survival. That’s incredibly meaningful. It’s a very exciting time for us, as physicians who treat prostate cancer. It’s an incredibly gratifying time for the patients who have prostate cancer. Now, I can look at my patients. I can say, “There are new medications coming out, and I think we can meaningfully delay your disease onset to metastases by a couple more years.” That is exciting.

Raoul S. Concepcion, MD, FACS: Neal?

Neal D. Shore, MD, FACS: Thanks, Raoul, for organizing the panel. As Phil was saying, theranostics and the whole notion and the burgeoning field of targeted alpha therapy is incredibly exciting. We didn’t get a chance to talk too much about it. Maybe we’ll do another panel? Dan mentioned PARP inhibitors. At some point, they’re clearly going to receive approval in prostate cancer. We see them approved in breast and ovarian cancer. Oral agents will add to the armamentarium of what we already have in an advanced prostate cancer clinic. We think about all of this excitement, of 2 new agents that could be approved in the M0 Case 1 Index, whether it’s apalutamide or enzalutamide. I suspect it will be both. We also think about changing our options—metastatic tissue testing to understand somatic defects and how to personalize medicine. Plus, we consider the hereditary prostate cancer issues in germline testing.

So, why do I say all of this? I say all of this because, for our colleagues who are listening, it’s exciting. It’s getting a lot more complex and a lot more specialized. Today, advanced prostate cancer really requires a true dedicated specialist, whether it’s in a multidisciplinary fashion at an academic center or in a clinic like Alec’s or mine or Phil’s. And so, we work together. We have to specialize. That’s probably true in so much of medicine. But it is exciting. To me, it prevents the concern of burnout. How could you be burnt out if you’re following all of these incredible advances? I understand. That’s another panel, too. Anyway, thanks for having us.

Raoul S. Concepcion, MD, FACS: Those are great points. Again, as we said, it keeps changing every 3 or 4 months. Hopefully, we will sort of move away from this traditional organ-based cancer-driven consideration to something that’s more based upon molecular drivers. And hopefully, we will treat people more often based upon what their tumors are expressing. Thank you, all, for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity 
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