Redefining Advanced Prostate Cancer with Novel Imaging - Episode 8

Guidelines for Early Detection of Metastasis in CRPC


Raoul S. Concepcion, MD, FACS: I think the problem that we see in the community, especially, is that as we know, these patients continue to be followed in the urologist’s office. They’re coming in. Suddenly, there’s a little bit of a bump in the patient’s prostate-specific antigen. The busy urologist is thinking, “Oh, I’ve got 30 more minutes. I’ve got 10 more patients to see. It’s OK, I’ll just see you back in 6 months.” Unfortunately, they don’t recognize that they’re on androgen deprivation therapy, and they’re used to seeing these small blips in their normal patients who are not on hormonal therapy. These patients are asymptomatic. So, unfortunately, the urologist sort of forgets about them. Phil, you were part of a committee that published some recommendations on when to start looking for metastatic disease in this particular patient population. Would you mind going over that for us?

Phillip Koo, MD: Sure. This was done by the RADAR Working Group. I was honored to be a part of it, along with Raoul, Neal, and many other distinguished physicians. We met in 2013, and we published the recommendations in 2014, in Urology. It was developed to meet an unmet need in the community, with regard to when you should image patients to detect metastatic disease. A large part of it was the fact that patients were considered to have M0 castration-resistant prostate cancer for a long time, and we knew that these patients did have metastatic disease. Data show that a lot of these patients, when you screened them or did bone scans and CTs, actually had metastatic disease. We just weren’t looking for that.

As a group, we created 3 separate buckets. We looked at patients with initial diagnosis, biochemical recurrence, and M0 CRPC. For patients with an initial diagnosis, we recommended that they get a bone scan and CT if they had a Gleason grade that was greater than or equal to 7, palpable disease, or a PSA level greater than 10. You needed 2 of the 3 before you would get imaging. The whole point was to discourage imaging for patients with low-risk disease. For patients that had a biochemical recurrence, we recommended bone scan and CT when their PSA levels reached 5. We now know that this isn’t true because we have next-generation imaging. But for the time being, we recommended testing at a number of 5. And if it was negative, we recommended it, again, at a PSA level of 10.

I think the M0 CRPC recommendations were really where we’ve made a big impact. From there, we recommended a bone scan and CT when patients’ PSA levels reached greater than or equal to 2. Then, we recommended the next one at 5 and at every doubling of PSA. And after that, it was based on PSA checks every 3 months. I think these guidelines have been helpful for a lot of people in the community, to really detect metastatic disease and make patients eligible for a lot of these therapies that are now approved for M1 CPRC only.

Raoul S. Concepcion, MD, FACS: Alec, you’ve got, again, a very highly evolved group. Again, these are just recommendations. This was a consensus statement. So, how has your partnership sort of evolved, relative to looking at and scanning these patients, using the guideline?

Alec Koo, MD: We created an Advanced Prostate Cancer Center, along with navigators and pathways. We also understand that in order to properly identify these patients, we really need to monitor them in a systemized fashion. So, we put all patients on ADT in a database, and our navigators are systematically making sure that they actually have routine PSA and testosterone obtained. In the past, studies showed that patients, in your general community urology groups, often did not have routine testing for PSA and testosterone. So, first, we just made sure that those were obtained. And then they’re reduced, in a systemized fashion by our navigator, so they can identify patients who need imaging based exactly on the RADAR criteria that Phil spoke about.

Raoul S. Concepcion, MD, FACS: Do you empower your navigators? Obviously, this is a huge problem in many large community practices. If they see that they’ve reached some criteria, as Neal spelled out, and that they meet the definition of CRPC and haven’t had a scan within a year, are they empowered to go ahead and order the scan? Or do you have to route that through the treating physician?

Alec Koo, MD: The navigators always email or text, within our electronic medical records, the treating physician. They say, “Mr. so-and-so has been noted to have ‘this.’ You probably should consider obtaining some imaging studies.” And most of the time, the urologists sign off on that. They say that it’s fine to navigate and go ahead and order those tests.

Transcript Edited for Clarity