Breakthroughs in Imaging Modalities for Prostate Cancer


Five expert panelists in prostate cancer consider how recent advances in imaging, particularly PSMA-PET, have impacted the field, and highlight guidelines that may aid clinicians in selecting amongst the available imaging modalities.


Alan Bryce, MD: Hello and welcome to this OncLive® Peer Exchange titled, “Key Updates in Nonmetastatic and Metastatic Prostate Cancer Treatment.” I’m Alan Bryce from the Mayo Clinic in Arizona, a professor of medicine, medical oncologist, and director of the Mayo Clinic Comprehensive Cancer Center here [in Phoenix,] Arizona. I’d like to welcome my esteemed fellow panelists to introduce themselves. We’ll start with Dr Elizabeth Heath.

Elisabeth Heath, MD, FACP: Hi everyone. Thanks for joining. My name is Dr Elizabeth Heath, I’m a professor of oncology at the Karmanos Cancer Institute in Detroit, Michigan. I’m also the associate center director for translational sciences. Thanks for having me.

Alan Bryce, MD: Dr Benjamin Lowentritt.

Benjamin Lowentritt, MD, FACS: Hi, my name’s Ben Lowentritt, I’m a urologist practicing at Chesapeake Urology in [Baltimore,] Maryland, and the director of our comprehensive prostate cancer program. Thanks for having me.

Alan Bryce, MD: Dr Edwin Posadas.

Edwin Posadas, MD: Hi, everyone. I’m Ed Posadas, I am the codirector of the experimental therapeutics program at Cedars-Sinai [Samuel Oschin Cancer Center] and the medical director of the urologic oncology disease research group for the Center for Urologic Research Excellence at Cedars-Sinai [in Los Angeles, California]. I’m happy to be here.

Alan Bryce, MD: Dr Tian Zhang.

Tian Zhang, MD, MHS: Hi, it’s great to be here with everyone. I’m Dr Tian Zhang, I’m chief medical oncologist and associate professor at UT Southwestern Medical Center in the Harold C. [Simmons] Comprehensive Cancer Center in Dallas, Texas.

Alan Bryce, MD: Excellent. Welcome everyone, and thank you for joining me. Today we’re going to discuss several recent updates in the treatment of patients with nonmetastatic and metastatic prostate cancer that were presented at key conferences within the past couple of years. We’ll discuss the data in the context of guidelines, the existing treatment landscape, and potential impact on clinical practice. Let’s get started on our first topic. In the first module, we’re going to talk about recent paradigm shifts in prostate cancer. We’ll go around the panel here and start with Dr Heath. What do you think some of the most significant advances are in imaging for prostate cancer?

Elisabeth Heath, MD, FACP: I think we could start this conversation with PSMA [prostate-specific membrane antigen]. Those 4 letters have changed our landscape, whether it’s for imaging or for treatment. That’s a recent development. As many of us remember, it’s the start of something, and when the initial Gallium 68 PSMA was announced in December of 2020, it was then followed by Pylarify [piflufolastat F 18], and then again with the actual indication with the lutetium-177 compound. With the advent of that, all of our conversations shifted quite dramatically.

Alan Bryce, MD: Fair enough, absolutely. Considering how it’s impacting our daily practice, Dr Lowentritt, from a urology perspective, how about at initial diagnosis? How can clinicians use PSMA PET [positron emission tomography] in the initial setting now?

Benjamin Lowentritt, MD, FACS: There’s been a rapid acceptance among clinicians that we have superior staging imaging now. For those patients who are high risk, and select unfavorable/intermediate-risk patients, it makes sense for any patient you would consider imaging to consider one of the novel PSMA PET agents. We see more entrants coming every month, and another one likely coming with a radio-hybrid PSMA. Some of the results were shared at the recent ASCO GU [American Society of Clinical Oncology Genitourinary Cancers Symposium] meeting that suggested we can get good true detection rates out of these PET scans with patients who otherwise we’d be considering for imaging prior to therapy. It’s becoming an essential part in helping us adequately stage our patients and cater the treatment as needed.

Alan Bryce, MD: What are the difficulties with using PSMA PET in that initial setting?

Benjamin Lowentritt, MD, FACS: The first and foremost hurdle is the insurance coverage, which we unfortunately still must deal with. Otherwise, you must make sure you have imaging readers that are comfortable. You must make sure you know what you’re looking for and where you’re looking for the most likely yield for finding disease. We still see some strange findings that are unlikely cancer-related but lead to some handwringing. I think we’re introducing some uncertainty with a new agent, but in general, the information we get is helpful in patients that can alter therapy and maybe save them some degree of adverse effects or potentially increase their chance of long-term response. I think we’re getting there with our ability to finding out who we can most benefit early.

Alan Bryce, MD: Dr Posadas, what about the guidelines, are they helpful at this point? And where can clinicians look when trying to decide whether to use conventional imaging or next-generation imaging in prostate cancer?

Edwin Posadas, MD: This is a good question, and it rolls into what Dr Lowentritt was speaking to, which is that there’s now incorporation of PSMA-based imaging into guidelines like the NCCN [National Comprehensive Cancer Network]. There are additional guidelines like RADAR [Radiographic Assessments for Detection of Advanced Recurrence] VI that have come out. The payers have not always taken these to heart because they ask a question about how this is impacting survival, and they may put up a fuss, which is a bit frustrating because we as clinicians have seen value. But until certain things read out with end points, it’s going to become more difficult. It’s exciting to see this move forward. It opens up new opportunities for patients. Hopefully those of us involved in the guideline formation can further push the importance of this type of imaging for our patients, both with metastatic and nonmetastatic prostate cancer, to get further insight into both the staging and the molecular nature of their disease, which helps guide important decision-making.

Transcript edited for clarity.

Related Videos
Video 14 - "Key Takeaways in HER2-Mutated NSCLC"
Video 13 - "Treatment Considerations in HER2-Mutated NSCLC"
Timothy Yap, MBBS, PhD, FRCP
Kara N. Maxwell, MD, PhD
A panel of 5 experts on lung cancer
A panel of 5 experts on lung cancer
Mike Lattanzi, MD, medical oncologist, Texas Oncology
Video 18 - "Reflecting on Differentiated Thyroid Cancer: Final Insights"
Video 17 - "Phase 2 ATLEP Trial Results"
Rohan Garje, MD