Dr Koo on Treating Various Stages of Prostate Cancer

Philip J. Koo, MD, division chief, Diagnostic Imaging, Northwest Region Oncology, physician executive, Banner MD Anderson Cancer Center, discusses the treatment of patients with prostate cancer throughout the different stages of their disease.

Recommendations for treating patients with prostate cancer align closely across various published guidelines, Koo begins. Before initiating definitive therapy, oncologists should consider employing prostate-specific membrane antigen (PSMA) PET scans, particularly in cases where there's a heightened suspicion of metastatic disease, he says. The focus of PSMA PET scans isn't primarily on identifying the primary disease but rather on detecting metastatic sites, particularly in patients with unfavorable intermediate-, high-, or very high-risk disease; biomarker indications of heightened metastatic risk; or elevated risk as indicated by nomograms, Koo elucidates. Utilizing PSMA PET can aid in treatment planning before proceeding with procedures such as prostatectomy or radiation therapy, he shares.

Transitioning to the biochemical recurrence (BCR) stage, there's a need for a more nuanced approach to using PSMA PET scans, Koo expands. Although the prostate cancer field initially used these scans aggressively in patients with BCR, now it's advisable to consider their use more thoughtfully, especially in cases where metastasis-directed therapy is being contemplated, he adds. The necessity for PSMA PET is clearer in such scenarios, whereas its utility in other contexts remains subject to debate, Koo notes.

Evidence from trials such as the phase 3 EMBARK trial (NCT02319837) indicate that patients with high-risk biochemical recurrences can benefit from systemic therapies such as enzalutamide (Xtandi) alone or in combination with androgen deprivation therapy (ADT), he continues. This raises questions regarding the timing as well as the appropriateness of PSMA PET scans in such cases, he adds. For patients who present with castration-resistant disease, PSMA PET scans play a pivotal role in identifying candidates for radioligand therapy, representing a significant advancement in treatment optimization for this population, Koo concludes.