Video Archives

The Role of Molecular Imaging to Improve Cancer Control Post-Prostatectomy

Posted by Peter J. Rossi, MD | Jun 2021

Peter J. Rossi, MD, a board-certified radiation oncologist affiliated with Calaway Young Cancer Center at Valley View Hospital in Glenwood Springs, Colorado, considers the evidence for using molecular imaging to improve prostate cancer control post-prostatectomy, focusing on the results of the EMPIRE-1 study comparing 18F-fluciclovine-PET/CT imaging versus conventional imaging alone to guide post-prostatectomy salvage radiotherapy for prostate cancer. Dr. Rossi explains that while doctors may offer postoperative radiotherapy to patients experiencing a PSA rise or biochemical failure, the decision to do so can be complex and failure rates are high. He notes that improving adjuvant therapy is therefore imperative, and investigators have looked to molecular imaging as the means to do so. Dr. Rossi then describes the aims and methods of the EMPIRE-1 trial, noting that the investigators sought to expand the role of 18F-fluciclovine-PET/CT imaging beyond diagnostics and into cancer control by studying how radiotherapy decisions and planning changed based on molecular scans as compared to standard imaging. The results showed that radiotherapy plans were changed in 35.4% of patients based on PET uptake, and that using PET imaging resulted in a significantly improved and significantly more durable failure-free survival rate compared to using standard imaging alone, suggesting that PET is a viable tool for improving adjuvant radiotherapy. Dr. Rossi concludes by looking at future directions for molecular imaging and adjuvant care, highlighting a new study comparing 18F-fluciclovine-PET/CT to PSMA.

Screening and Prevention of Prostate Cancer 2021 (Part 2): Who Needs a Biopsy?

Posted by Sigrid V. Carlsson, MD, PhD, MPH | Jun 2021

In part 2 of a 3-part series, Sigrid V. Carlsson, MD, PhD, MPH, Assistant Attending Epidemiologist at Memorial Sloan Kettering Cancer Center, goes over her 5 Golden Rules for prostate cancer testing, which are intended to minimize overdiagnosis and overtreatment while also making sure that significant disease is not missed. Rule 1 is to get consent and engage in shared decision-making with patients. Dr. Carlsson notes that this can sometimes be difficult since the numerous decision aids available are often difficult to use and understand. The second rule is not to screen men who will not benefit, for instance, older men with multiple comorbidities and short life expectancies. Dr. Carlsson does observe, however, that instituting an age cutoff does not necessarily make sense, and that physiologic assessment of life expectancy may be a more useful metric. In rule 3, Dr. Carlsson advises clinicians not to biopsy patients without a compelling reason, since prostate biopsies may lead to infectious complications and hospitalization. She then lays out the options for risk stratification, such as risk calculators, biomarker tests, and MRI. Rule 4 recommends against treating low-risk disease since, as Dr. Carlsson explains, active surveillance is a safe strategy over longer follow-up for appropriately selected patients with Grade Group 1 prostate cancer when following a well-defined monitoring plan. Finally, rule 5 exhorts clinicians to send patients who require treatment to a high-volume provider. This is key, Dr. Carlsson argues, since evidence shows that there is a large degree of heterogeneity among surgeons regarding functional and oncological outcomes after prostatectomy, and it takes approximately 250 surgeries for a surgeon to really master the procedure.

Current and Emerging Imaging Tools for Improving Risk Assessment and Selection of Patients for Biopsy

Posted by Clare Tempany, MB, BCh, BAO | Jun 2021

Clare Tempany, MD, the Ferenc A. Jolesz Professor of Radiology at Harvard Medical School in Boston, Massachusetts, summarizes evidence for multiparametric magnetic resonance imaging’s (mpMRI) utility in prostate cancer diagnosis, and goes over recent developments in its use. She first looks at selection criteria for biopsy and biopsy type, including history, digital rectal examination (DRE), prostate specific antigen (PSA), and imaging, arguing that mpMRI is particularly helpful in allowing patients to avoid unnecessary biopsies. Dr. Tempany then defines state-of-the art mpMRI as featuring diffusion/apparent diffusion coefficient, being T2-weighted, being IV contrast/dynamic contrast enhanced, and as being reported using the PI-RADS v2.1 assessment. She goes over the PI-RADS assessment categories, considers the findings of multiple publications backing up the value of mpMRI as compared to transurethral ultrasound (TRUS), and looks at evidence supporting guidance indicating patients with PI-RADS 3 lesions should get a biopsy. Dr. Tempany follows this up by summarizing a paper from the PI-RADS steering committee on how PI-RADS and mpMRI should be used. Suggestions include performing mpMRI in most men suspected of having clinically-significant disease, providing a safety net of monitoring for patients who decline immediate biopsy after low-likelihood MRI findings, and using a combination of systematic and targeted biopsies in biopsy-naive patients while only using targeted biopsies for patients with prior negative findings on TRUS. Dr. Tempany then notes that the AUA, EAU, and NICE guidelines all now recommend MRI before biopsy, and also observes that MRI is cost-effective if it leads to the avoidance of biopsy. She concludes by listing areas for future development, including multi-omics, molecular pathology, germline mutations, CTC/blood biomarkers, and mass spectrometry.

Androgen Society 3rd Annual Meeting Review (Day 3)

Posted by Abraham Morgentaler, MD, FACS | Jun 2021

Abraham Morgentaler, MD, FACS, Associate Clinical Professor of Urologic Surgery at Harvard University, reviews day three of the 3rd annual meeting of the Androgen Society, an international organization consisting of healthcare professionals interested in testosterone deficiency and its treatment. The day began when Martin Miner, MD, and Jean-Paul Deslypere, MD, PhD, debated the correct threshold for diagnosing testosterone deficiency, ultimately concluding that the lower the T level, the better. Dr. Desylpere then discussed the role of active metabolites of testosterone in manhood, specifically the importance of testosterone in developing structural and functional characteristics of the sex. Hugh Jones, MD, followed with an analysis of androgen receptor sensitivity and its implications for clinical disorders and mortality. Abdulmaged Traish, PhD, then presented on whether or not age-related testosterone deficiency should be treated, respectfully disagreeing with the FDA’s position on not treating men with age-related hypogonadism. Martin Miner, MD, then looked at the relationship between testosterone and mood, depression, and dementia. Next, David Sullivan, MS, PhD, shared information about the preventative effect of androgens on dry eyes. Ernani Rhoden, MD, spoke on testosterone and gynecomastia before engaging in a debate on whether testosterone therapy may be used as monotherapy treatment of erectile dysfunction. The day concluded with a discussion by Dr. Morgentaler on testosterone, science, and human dignity that stemmed from his experiences with patients wanting testosterone therapy despite the impact on their life expectancies out of a desire to improve their quality of life.

Screening and Prevention of Prostate Cancer 2021 (Part 1): Evidence for PSA Screening

Posted by Sigrid V. Carlsson, MD, PhD, MPH | Jun 2021

In part 1 of a 3-part series, Sigrid V. Carlsson, MD, PhD, MPH, Assistant Attending Epidemiologist at Memorial Sloan Kettering Cancer Center, looks at the evidence supporting widespread prostate specific antigen (PSA) screening. She looks at a range of large studies with long follow-up that demonstrate a reduction in prostate cancer mortality of approximately 30% as a result of widespread PSA screening. Dr. Carlsson also looks at how PSA screening decisions can be made by taking other risk factors into account in order to minimize unnecessary testing. She also notes that the loss in quality-adjusted life years somewhat offsets the benefits of widespread screening. She concludes by introducing her 5 Golden Rules of testing to keep the benefits and reduce the harms.