Initial Risk Stratification of Localized Prostate Cancer


Tanya Dorff, MD, reviews guidelines for initial risk stratification of patients with localized prostate cancer, and the choices in imaging strategies.

Alicia Morgans, MD, MPH: Hi, and thank you for joining us for this Targeted Oncology Virtual Tumor Board©, which is focused on the use of PSMA targeted therapies in prostate cancer. In today's presentation, my colleagues and I will review clinical cases, discuss approaches to treating patients with prostate cancer, and share our perspectives on key clinical trial data that may impact our treatment decisions. My name is Alicia Morgans, and I am a genitourinary medical oncologist and the medical director of the survivorship program at Dana-Farber Cancer Institute. Today, I am joined by 3 wonderful friends and colleagues; Dr Tanya Dorff, who is a medical oncologist and the section chief of the genitourinary disease program, as well as an associate professor in the department of medical oncology and therapeutics research at City of Hope. We also have Dr Phillip Koo, who is a division chief of diagnostic imaging and the northwest region oncology physician executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona. Last but not least, we have Dr Ulka Vaishampayan, who is a professor of oncology and the leader of the translational clinical research team, as well as being the director of the phase 1 program at the Rogel Cancer Center at the University of Michigan. Thank you so much for joining us.

Let's get started by reviewing the NCCN [National Comprehensive Cancer Network] guidelines that help us think through how to really risk-stratify patients who have localized disease and choose imaging strategies that make the most sense for them. Dr. Dorff, can you please get us started?

Tanya Dorff, MD: Yes, thank you. This is an area that's definitely emerging and evolving. Traditionally we restricted imaging as part of staging to higher risk, newly diagnosed patients. That was especially in the setting of having just traditional CT and bone scans that aren't very sensitive. Over time we included some of the maybe unfavorable, intermediate-risk, certainly anyone with any symptoms but now we're faced with the availability of PSMA PET imaging, which is much, much more sensitive. Yet though it's available, there are still not as many data as we might like that show us how to use the results. All of our classifications in all of our older clinical trials were really based on conventional imaging rather than PSMA PET findings.

The NCCN, in thinking about how to position PSMA PET imaging versus conventional imaging, is grappling with both trying to minimize what the patient goes through, be most efficient, less radiation exposure, less cost and so it is appealing to use a PSMA PET scan as the main imaging modality since that will provide both bone and soft tissue in a single exam. It's probably not necessary to have a CT or bone scan first and then do a PSMA PET. It could be helpful if there are equivocal findings, but at lower PSA ranges and in these newly diagnosed localized patients, it's unlikely that we're going to see much that's informative. Understanding that these aren't available everywhere and that there are some issues with insurance coverage, of course, traditional imaging remains a reasonable option for many of these patients. Then MRI sometimes to give some more anatomic detail down in the pelvis or to also investigate an equivocal finding further.

Alicia Morgans, MD, MPH: Thank you for that. I think this is an area that's absolutely evolving, and I'm really grateful that the NCCN team members have commented on this because it certainly helps us when we're in practice, trying to figure out what to do and then to get coverage to perform these kinds of tests.

Transcript edited for clarity.

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