Daniel George, MD

Daniel J. George, MD, professor of medicine, medical oncology, and surgery at Duke Cancer Institute, discusses why he considers using prostate-specific membrane antigen (PSMA) imaging early in treatment of patients with castration-resistant prostate cancer (CRPC).

A PSMA PET scan can detect distant metastases of prostate cancer early and is required before treating patients with the radioligand 

Lutetium-PSMA-617 (Pluvicto), which showed strong efficacy in the VISION trial (NCT03511664).

George says now that PSMA-targeted therapy is available, he considers PSMA imaging before patients receive chemotherapy for CRPC. Knowing whether he can give 

Lutetium-PSMA-617 next will inform his decision to continue chemotherapy if patients have difficulty tolerating it.

Otherwise, he recommends a PSMA PET scan after chemotherapy so patients can receive radioligand therapy if necessary, though he may not do imaging immediately if patients have a positive response to therapy with no rise in prostate-specific antigen (PSA) or other signs of clinical progression. When there is a rise in PSA after prior therapy, he recommends starting the process to receive 

Lutetium-PSMA-617 since it can take time for insurance to approve treatment.

 When I'm thinking about the castration-resistant population, patients who might be good candidates for radioligand therapy or particular for Pluvicto therapy, PSMA-targeted therapy, I want to think about doing my imaging in those patients a little bit earlier. I actually like to do that imaging before they go on to chemotherapy, because then I know this is going to be someone who I'm going to sequence, and it affects how I use my chemotherapy. I may not push that chemotherapy to the very last cycle, cycle 10 or cycle 9 if they're struggling; I'll stop a little bit early because I know I have this other therapy to follow. Or, if their PSA response seems to have really flattened out and it's not clear how much additional benefit they're getting, I'll stop a little bit earlier. I like to do my PSMA imaging before, now. Of course, this is an evolving time. We didn't have that available 6 months ago, so it's a little kind of in the future here.

But the other time is when to do the imaging right after chemotherapy. Sometimes those patients, if they've responded, may not have the best images. So if I have a patient that's on docetaxel chemotherapy or cabazitaxel, and they've had a really good response to therapy and I'm taking a treatment break, I'm not going to immediately image them until I start to see that PSA rise or some other clinical signs of progression. Then I'm going to do my PSA imaging and then I'm going to think about treatment with Pluvicto.

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Daniel J. George, MD, discusses why he considers using prostate-specific membrane antigen imaging early in treatment of patients with castration-resistant prostate cancer.

Expert Discusses When to Perform PSMA PET Imaging for Metastatic CRPC

Daniel J. George, MD, professor of medicine and surgery, member, Duke Cancer Institute, discusses how cabazitaxel (Jevtana) can impact the sequencing approaches physicians use to treat patients with metastatic castration-resistant prostate cancer.

According to George, there are 2 things to think about when using cabazitaxel in this treatment landscape that may make this agent ideal for sequencing. First is the tolerability of the agent. When it was first developed in clinical trials, it showed survival benefit at a dose of 25 mg/m2. However, there was also an association between the drug and significant neutropenia and diarrhea in some patients. In a head to head comparison study of a 20 mg/m2 dose versus the 25 mg/m2 dose, cabazitaxel demonstrated no decrease in efficacy but a decrease in the rates of these common toxicities, particularly neutropenia, George says.

The second strategy George highlights is that this is a novel taxane that has demonstrated survival benefit and efficacy after treatment with docetaxel. We know there are some differences in these drugs, George says, and it is possible that the tolerance and efficacy may prove to be optimal for this type of sequencing.

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Daniel J. George, MD, discusses how cabazitaxel can impact the sequencing approaches physicians use to treat patients with metastatic castration-resistant prostate cancer.

Daniel George, MD | Authors

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Expert Discusses When to Perform PSMA PET Imaging for Metastatic CRPC

Cabazitaxel Impacts Sequencing Strategies in Prostate Cancer