Closing out his review of imaging modalities in the setting of prostate cancer, Brian Helfand, MD, PhD, looks toward future evolutions in detection and treatment.
Brian Helfand, MD, PhD: Where we have come and where we are going; I do think that we have really made a lot of strides in PET [positron emission tomography] scan imaging. Next-generation imaging has really just scratched the surface. I think we have a lot farther to go. Compared to where we were with conventional imaging in terms of CT, bone scans, and even MRI, I think we have really changed the landscape. These PET/CT imaging modalities, whether it be fluciclovine, PSMA [prostate-specific membrane antigen], choline, etc., these have all been able to identify prostate tumor recurrence at earlier and earlier time points and really help make treatment plans that are right for that patient. These personalized treatment plans have really [helped us avoid] overtreatment for certain patients and have really intensified therapies for other patients. I think that that really, if we believe the prospective studies with fluciclovine, have really improved the management and even potential for recurrence of these patients and time to recurrence. So I think they are clinically making a difference.
As we look at the problems that we are facing, we have a lot of different tools now and there are even more tools coming to the market. Once we have a lot of tools in our toolbox the question is which tool do we use for the right patient? Whether it’s a low PSA [prostate-specific antigen] level, whether it’s a patient who has had exposure to hormone therapy or has become hormone refractory or has seen chemotherapy, I think we are going to see differences in the sensitivity, specificity, and overall performance of these imaging modalities. We need to do prospective studies that are comparing these for these different populations.
I think understanding the true biology of what the type of imaging modalities can detect is imperative. We have this ability to look at the actual tumor subtypes, again maybe it’s influenced by hormones, maybe not. Whether it’s a neural endocrine or small cell variant or whether it’s genetic mutation variant, kind of BRCA2 or ATM mutation carrier, how does that impact our ability to detect recurrences? I think that all of these are great questions. As we move forward and we have more and more tools in our toolbox whether it’s PSMA [or another] agent, the question is, is there going to be an ultimate winner that is uniform all of these? I don’t know. Is it ultimately going to be a combination of different radio tracers that we use at once? Is it going to be a combination of fluciclovine and PSMA, or even some newer thing that comes into play? These [questions] keep me excited and keep me investigating and asking these type of questions because I think that the answer will come into play.
I can only say that right now we have certainly moved the bar. It appears to make a clinically significant difference for patients, for precision making and, most importantly, for outcomes. I think that keeps it exciting. If I was going to give advice on who should use these, I really think that urologist, radiation oncologist, and medical oncologist should be very comfortable using next-generation imaging. Sometimes we get held up when new technology or imaging modality comes to the market, but I think formally talking to most urologist and even radiation and medical oncologist, we all feel very comfortable with these modalities because it’s just looking at an image. It’s not like a Rorschach image or difficult to interpret. They actually light up and tell you exactly where that signal is. And yes, there are subtle differences in the actual reading of the PET/CT imaging radiographs, but uniformly they are really easy to use and interpret and make a plan. I really encourage urologist in our community who are treating prostate cancer to engage and use next-generation imaging modalities.
Transcript edited for clarity.