Paul C. Boutros, PhD, MBA, examines germline genetics and urine characteristics of prostate cancer and how these relate to aggression.Paul C. Boutros, PhD, MBA, examines germline genetics and urine characteristics of prostate cancer and how these relate to aggression.
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In this presentation, given during the 2021 Virtual Global Summit on Precision Diagnosis and Treatment of Prostate Cancer and supported by Philips, Ilya Gipp, MD, PhD, a medical officer and oncology solutions subject matter expert with Philips in Atlanta, Georgia, discusses solutions for integrating data to personalize prostate cancer care. He first describes positive trends and challenges in prostate cancer care, noting that data silos across service lines and service providers remain a key barrier to effective and efficient treatment. Dr. Gipp describes the prostate cancer service line as beginning with early detection, progressing to diagnosis and staging, treatment selection, therapy planning and deployment, and assessment and follow-up. He then focuses on the actionability and insightfulness of information, and how to synthesize data throughout the cancer care pathway using magnetic resonance imaging (MRI). Dr. Gipp remarks that while MRI is often used in diagnosis, to benefit from the data, MRI must be the modality used at all points from screening to post-therapy assessment. For example, MRI can generate images similar to CT scans for radiation dose planning as well as guiding dose painting to offer localized, non-uniform radiation dose distribution. He summarizes by comparing the traditional approach to cancer care with a state-of-the-art model that employs biomarker imaging, image-guided multi-modality navigated fusion biopsies, digital pathology, and focal therapies.
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In this 6-minute presentation, presented during the 2021 Virtual Global Summit on Precision Diagnosis and Treatment of Prostate Cancer and supported by Blue Earth Diagnostics, Wolfgang Weber, MD, Professor and Chair of the Department of Nuclear Medicine at the Technical University of Munich in Germany (TUM), discusses 18F-rhPSMA7(.3) as a promising tracer for imaging prostate cancer for primary staging and in the case of biochemical recurrence, explaining that limited renal excretion facilitates evaluation of the prostate and the prostate bed before surgery. Dr. Weber explains that prospective registration trials have completed accrual, and the use of radiohybrid prostate-specific membrane antigen ligands (rhPSMAs) for therapy of prostate cancer is being evaluated preclinically.
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In this 14-minute program presented during the 2021 Virtual Global Summit on Precision Diagnosis and Treatment of Prostate Cancer and supported by Siemens, Michael H. Johnson, MD, FACS, Associate Professor and Vice Chair of Urology at Washington University in St. Louis, discusses why digital health solutions must revolutionize prostate cancer care. Dr. Johnson asserts that we are at an inflection point in medicine when digital medicine has the opportunity to transform and improve patient care and treatment in ways that are both instantaneous but also far-reaching.
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In this presentation, supported by Telix Pharmaceuticals, Neal D. Shore, MD, FACS, Medical Director for the Carolina Urologic Research Center in Myrtle Beach, South Carolina, presents advances in PSMA PET-CT imaging for staging, prognosis, and clinical management of prostate cancer. He first describes prostate cancer metastases before explaining prostate-specific membrane antigen (PMSA) and how it serves as an effective molecular target for metastatic prostate cancer. Dr. Shore reviews the pros and cons of conventional imaging techniques such as bone scintigraphy, computed tomography (CT), and multiparametric MRI (mpMRI). While treatment guidelines recommend conventional imaging, he notes that bone scans and CT positively identify less than 10% of men with biochemical recurrence and in particular lesions that are <1 cm with a PSA <20 ng/mL. He then compares the benefits of PSMA as an imaging target: it is upregulated in prostate cancer, the degree of expression is positively correlated with tumor state and higher risk of recurrence, there is a positive correlation between PSMA expression and Gleason score/grade, and it may be targeted with either a small molecule or antibody. Dr. Shore reviews numerous studies demonstrating the effectiveness of PSMA PET-CT in metastatic prostate cancer but indicates there is insufficient data on the use of PSMA PET-CT in patients with hormone-naïve disease. He then considers patient selection and points out several downsides including increased cost of care and the potential impact of health disparities. He concludes that PSMA PET-CT is particularly useful in detecting prostate cancer that is otherwise not identified by conventional imaging and in cases with low serum PSA.
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Robert Princenthal, MD, describes the transurethral ultrasound ablation (TULSA) procedure, highlighting its flexibility, effectiveness, and histological benefits.
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Phillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses the expansion of the role and utility of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in the management of prostate cancer. He highlights the fact that this next-generation imaging (NGI) technology will lead to changes to diagnostic approach and management, explaining that a landscape change is imminent as NGI is poised to fundamentally change the medical management of prostate cancer.
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Faina Shtern, MD, President and CEO of the AdMeTech Foundation, presents key highlights from the 5th Global Summit on Precision Diagnosis and Treatment of Prostate Cancer, a virtual event organized by the AdMeTech Foundation and held from September 23 through September 25, 2021. After introducing the AdMeTech Foundation, Dr. Shtern goes over the rationale for the annual summit and brain trust, explaining that the goal is for multi-disciplinary key opinion leaders to address fundamental challenges in patient care by: developing accurate diagnostic tools; integrating anatomic, biologic, and histologic diagnostics; and integrating precision diagnosis with precision treatment. She discusses the AdMeTech Foundation’s approach, which includes reaching consensus on the best emerging clinical practices, identifying clinical needs and related research priorities, educating the medical community and general public, and expediting the transfer of promising diagnostics and therapeutics to patients. Dr. Shtern then considers the 5th Global Summit specifically, noting that it focused on integrating precision diagnostics and therapies and addressing fundamental problems in prostate cancer care. She summarizes key points from the four meeting sessions, which focused on: the population of men prior to diagnosis with prostate cancer (Session I); the population of men with newly diagnosed localized disease (Session II); precision oncology of advanced prostate cancer (Session III); and image-targeted, minimally-invasive focal procedures. Dr. Shtern concludes by summarizing the key findings of the 2021 meeting’s Panel on Health Disparities and Panel on Bioinformatics, Machine & Deep Learning, and Artificial Intelligence.
Read MoreMukesh Harisinghani, MD, Director of Abdominal MRI at Massachusetts General Hospital and Professor of Radiology at Harvard Medical School in Boston, Massachusetts, discusses how deep learning algorithms can improve the efficiency and accuracy of prostate cancer imaging. He highlights the importance of widespread prostate cancer screening, observing that every 3 minutes, a man is diagnosed with prostate cancer, and every 17 minutes, a man dies of prostate cancer. Dr. Harisinghani notes that patients want to get a multiparametric (mp)MRI if there is a clinical suspicion of prostate cancer and, if negative, avoid a biopsy in order to prevent unnecessary intervention and avoid cost. Because this is such a widespread need and mpMRIs are relatively time-consuming, he argues there is a need to figure out how to reduce scan time and not lose accuracy. Dr. Harisinghani explains that the two main time sinks in prostate mpMRI are T2-weighted imaging and diffusion-weighted imaging (DWI). He then demonstrates how deep learning reconstruction using software like AIR Recon DL in all 3 planes leads to significant time gain for T2-weighted imaging. Dr. Harisinghani says that many might be hesitant to ‘skimp’ on DWI, since higher b value (which takes a longer time to attain) leads to better image quality. However, he argues that deep learning can reduce scan time without reducing scan quality in DWI, and presents images comparing standard DWI and Air Recon DL to show the improved quality of the latter. Dr. Harisinghani concludes that a scan time of less than 10 minutes is not necessarily just a dream if you can apply Air Recon DL to both T2 and DWI.
Read MoreJohn F. Feller, MD, Founding Partner of Desert Medical Imaging, Chief Medical Officer for HALO Diagnostics, Assistant Clinical Professor in the Departments of Radiology at Loma Linda University and at Riverside School of Medicine, and Chief of Radiology and Partner of the American Medical Center in China, discusses the emerging role of radiogenomics in prostate cancer in the context of risk stratification for focal therapy. He explains that he and his colleagues at HALO Diagnostics are interested in finding “Whack-a-Mole” patients whose cancer tends to recur in a way that makes them difficult to manage with focal therapy. Dr. Feller asks whether risk stratification for focal therapy can be done using radiogenomics and whether responders to focal therapy for prostate cancer can prospectively be distinguished from non-responders using biomarkers. He defines responders as those with a negative MR guided biopsy of the treatment site(s) 6 months following focal therapy who do not develop in-field or out-of-field clinically significant recurrences over time. Dr. Feller then lists the biomarkers and other criteria used in risk stratification with radiogenomics, including age, initial serum PSA, initial PSA density, mpMRI, index lesion mpMRI volume, index lesion quantitative ADC, systematic biopsy, Gleason score, tissue-based genomics, liquid biopsy, molecular imaging. He goes into depth about results from the tissue-based genomics PTEN and ERG (ProstaVysion), Decipher for biopsy (Decipher Score), and Decipher GRID. He also further explores liquid biopsy options, including urine (ExoDx) and blood (Biocept). Dr. Feller concludes: that mpMRI followed by genomics and other biomarkers show promise for risk stratification for focal therapy of prostate cancer; that a biomarker ensemble approach to prostate cancer helps mitigate the blind spots of individual biomarkers, as well as the heterogeneity of the disease; that research of radiogenomics in the setting of focal therapy for prostate cancer may help develop novel combination therapies such as focal therapy combined with checkpoint inhibitors; and that multiple biomarker complex data sources present an artificial intelligence/machine learning opportunity.
Read MoreLaurence Klotz, MD, Professor of Surgery at the University of Toronto and the Sunnybrook Chair of Prostate Cancer Research, discusses the Sentinel PCC4 assay for prostate cancer in detail and reviews data on its performance characteristics. He gives an overview of the Sentinel Prostate Disease Management Platform, explaining that it is based on an analysis of a large number of urinary exosomal small non-coding (snc)RNAs that have been found to be predictive of cancer and cancer stage. Dr. Klotz shows an electron microscopy of urinary microvesicles and overviews research that looked at the independent predictive value of around 10,000 different microRNA sequences and ranked them according to the likelihood of being associated with cancer being present or not. 442 of the sequences were selected for further analysis and are used as part of the Sentinel PCC4 assay. He then discusses initial Sentinel Assay data published in the Journal of Urology showing 98% specificity for detecting the presence or absence of cancer and 96% specificity for differentiating low-grade vs. high-grade cancer. This data raised the question of how Sentinel could predict the results of biopsy so well when biopsy does not correlate as closely with the extent and grade of cancer present. Dr. Klotz reviews a summary of the key validation data to date that reveals a specificity rate of 66%, with a 34% rate of false positives, and found that 52% of positive Sentinel assays for any cancer were followed by a negative biopsy. He suggests that this liquid biomarker test is superior to others and that the data is compelling. Dr. Klotz concludes that the Sentinel PCC4 sncRNA assay has high specificity and sensitivity, relatively speaking, and that further validation studies are ongoing.
Read MorePhillip J. Koo, MD, Division Chief of Diagnostic Imaging and Northwest Region Oncology Physician Executive at the Banner MD Anderson Cancer Center in Phoenix, Arizona, discusses current and possible future applications for prostate-specific membrane antigen (PSMA) as both a diagnostic and a theranostic radiopharmaceutical for prostate cancer. He begins by considering PSMA in the diagnostic setting and explains that its current state-of-the art use is in the area of detection of metastatic disease. Dr. Koo particularly highlights its role in detecting oligometastatic disease in cases of biochemical recurrence. He also notes that PSMA currently has a role in initial staging, and that this role is likely to expand in the future. He predicts that other future diagnostic applications of PSMA will include restaging/treatment response, primary lesion characterization, and potentially prognosis. Dr. Koo then moves to discussing PSMA in the theranostic setting, mentioning the current role of Lu-177 PSMA on the “thera-” side and looking at PSMA, FDG, and PSMA plus FDG on the “-nostic” patient selection side. He also considers the question of whether imaging is even needed considering the large percentage of patients who are PSMA-positive, though he argues for the benefits of imaging. Dr. Koo lists some potential future therapeutic applications of PSMA, such as in earlier treatment, retreatment, combination therapy, dosimetry, and with alpha particles. He concludes that there are many unanswered questions, that conventional wisdom and anecdotes are not evidence-based, and that there is a need for more clinical trials and more disease site specialization within nuclear medicine.
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