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Going After High-Risk Localized Prostate Cancer

Can intense hormonal suppression before surgery keep potentially aggressive prostate cancer from coming back?

My goal in writing about prostate cancer is to offer reassurance and hope, and also a nudge or two when it’s time to take action.  I have been very excited in past posts to write about the broader window of curability for oligometastasis,  catching cancer when it first escapes the prostate and is big enough to be seen on conventional imaging.  Now, with PSMA-PET imaging, at the first sign of a rising PSA after treatment, men can see where renegade cancer may be hiding when it’s too small to be picked up by other imaging, and seek further treatment sooner than ever, still hoping for a cure.  But maybe we can be even more proactive, which brings us to the work of National Cancer Institute medical oncologist Fatima Karzai, M.D.  I interviewed her recently for the Prostate Cancer Foundation.

What does it take to make sure high-risk localized prostate cancer never comes back?  A new Phase II clinical trial aims to find out, and it is noteworthy in two ways:  One, as Karzai, the study’s principal investigator, puts it, “We’re being aggressive.”  And two, with the help of PSMA-PET imaging, the investigators can observe the effects of anti-cancer medications – three powerful forms of hormonal therapy, in addition to surgery – on the cancer in real time.

Three steps further than surgery:  This is a no-holds-barred, all-out attack on localized prostate cancer that has the potential to be aggressive and to recur after treatment.

Karzai and colleagues are taking high-risk cancer – even though it’s localized – very seriously, and rightly so:  more than half of patients diagnosed with high-risk prostate cancer have a recurrence, sometimes years later, and more than 20 percent of men with high-risk prostate cancer die of their disease within 15 years.  Note:  these numbers have not yet caught up with the use of PSMA-PET scanning, which many doctors believe is a game-changer.

What will a short-course of triple hormone therapy do?  The researchers hope this systemic (throughout the body) treatment before surgery will strike any stray cancer cells while they are most vulnerable, and reduce the risk of full-blown metastases.   A similar trial showed promising results after more than three years of follow- up.

The trial is still recruiting patients.  So far, Karzai says, the average participants are in their mid-60s, with Gleason scores of 8 or 9, but the trial is open to men of any age with high-risk or even intermediate-risk prostate cancer that has not spread to other parts of the body (up to stage N1 cancer) who are planning to be treated with prostatectomy.

For six months before surgery, men in the trial undergo “intense androgen deprivation therapy,” says Karzai, who serves as Clinic Chief and Inpatient Director of the Genitourinary Malignancies Branch of the Center for Cancer Research at the National Cancer Institute.  This includes: Goserelin (Zoladex),which shuts down testosterone, and two drugs that target the androgen receptor:  abiraterone (given with prednisone), and enzalutamide.  “We’re really driving down the male hormones as low as we can.”  The cancer is imaged with MRI and serial PSMA-PET scans – before treatment, two months after starting treatment, and again before surgery – and patients may be asked to undergo an additional prostate biopsy two months into the study.

Note:  The loss of testosterone is temporary!  As the patients are recovering from surgery, testosterone starts to come back.  “It takes six months to a year from the second shot (given midway through the study), and all the patients will recover their testosterone.  Their libido will be affected temporarily, but as they start to recover testosterone, libido will return.” 

During the six months, “we see the PSA levels become very low or undetectable,” says Karzai.  She and colleagues are also looking for corresponding changes in the tissue (in biopsy samples and in the prostate tissue itself after surgery), studying genetic mutations in the cancer and – for the first time – observing how the effects of intense hormonal therapy are manifested on PSMA-PET imaging.  “We are seeing some patients who are exquisitely sensitive to androgen deprivation, and some who aren’t; the difference really has to do with the unique biology of their cancer.”  On PSMA-PET, “usually what we see is that the area that lights up becomes less.  In some patients with disease that’s pretty aggressive, it won’t go away completely in six months,” but it does diminish.  “We’re not looking to cure them completely with this treatment, but to get them to the surgery,” and to maximize their chances of cure.

One goal of the study is to learn how to incorporate PSMA-PET scans into the treatment of men diagnosed with high-risk prostate cancer.  “Right now, these men don’t routinely get PSMA-PET scans.  We’re also trying to see, up front, if you do more androgen suppression, what does that mean for the overall outcome?”  Is it possible to hit aggressive cancer hard enough at the localized state to keep it from coming back?  “We’ll follow these patients for a long time.”

For more information about this study, please contact the study’s research nurse, Katherine O. Lee-Wisdom, R.N. at (240) 858-3525, or email: katherine.lee-wisdom@nih.gov.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

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How BAT Works

Driving Prostate Cancer “BATty”

Part Two: How BAT Works

Several years ago, medical oncologist Samuel Denmeade, M.D., Co-Director of the Johns Hopkins Prostate Cancer Program, and colleagues came up with a remarkable concept for attacking prostate cancer: alternating ADT with high-dose testosterone.  Recently, he took the time to explain to me how and why this works, in an interview for the Prostate Cancer Foundation’s website.  See part one of this interview here.

Patients have asked Denmeade if this treatment, called Bipolar Androgen Therapy (BAT), could be used as initial therapy for metastatic cancer instead of androgen deprivation therapy (ADT), or even as primary therapy instead of prostatectomy or radiation.  “No and no,” he says.  “BAT was designed to work against castration-resistant prostate cancer (CRPC).”

In CRPC, the cancer’s environment is significantly different than it is in earlier- stage cancer.  As CRPC cells learn to adapt to the lack of testosterone with ADT, “they crank up the androgen receptor (AR) to high levels,” and make themselves comfortable in the new environment.  But with high levels of AR, the cancer cells are sitting ducks, vulnerable to the shotgun blast of a hefty dose of testosterone.  “Flooding the prostate cancer cell with testosterone gums up the works:  suddenly, the cancer cells have to deal with too much androgen (male hormone) bound to the receptor.   This disrupts their ability to divide.  They either stop growing or die.”

It’s all about creating chaos in the environment, so the cancer cells can’t thrive, and timing is critical.  “ADT initially works because prostate cancer cells are suddenly deprived of testosterone, and most of them can’t survive this shock.”  Cancer cells die by the thousands, PSA plummets, imaging scans show cancer shrinking, and symptoms improve.  But prostate cancer, like the Road Runner, is elusive.  Over time, the hardy band of surviving cells regroups, adapts to living in the low-testosterone environment, and begins to grow again.  “BAT is a similar type of hormone shock – just in the opposite direction,” says Denmeade.  “A key feature of BAT is the rapid change from a very high- to low-testosterone level.”  Men remain on ADT, and receive monthly shots of high-dose testosterone, which gradually fades, then bumps back up again with the next monthly shot.  That’s the bipolar part of Bipolar Androgen Therapy (Denmeade uses the illustration below to explain to his patients).  “The repeated shocks of BAT cycling don’t give the cancer cells time to adapt, “because the underlying environment is always changing.”

So far, in four clinical trials at Hopkins, Denmeade and colleagues have given BAT to about 350 men with CRPC, most of whom have also received enzalutamide (Xtandi), abiraterone (Zytiga), or both.  For men with CRPC whose disease is worsening on ADT or on AR-blocking drugs like enzalutamide or abiraterone, BAT is highly promising. In the recent TRANSFORMER study, “we compared BAT head-to-head with enzalutamide” in patients with CRPC who had progressed on ADT and abiraterone.  “It was kind of a weird study, comparing a drug to its exact opposite: an androgen vs. an anti-androgen.  I don’t know if anybody’s ever done a study like that.  To our amazement, BAT and enzalutamide were nearly identical in terms of their effect.”  PSA levels dropped in about 25 percent of men on either treatment, and for both treatments, the response lasted about six months.

However, the real difference between the treatment arms was seen after cross-over – when men on BAT were switched to enzalutamide or vice versa.  “If we gave BAT first and then enzalutamide, almost 80 percent responded, and the response lasted almost a year.  That’s quite an improvement in the rate of response and duration.”  Among patients who received enzalutamide first, followed by BAT, the response rate to enzalutamide was only 23 percent.

This begs the question:  Why stop after one round of BAT then enzalutamide?  Why not just keep going?  “We should be able to cycle back and forth over and over again,” says Denmeade.  The STEP-UP trial, of 150 patients at Johns Hopkins and eight other centers nationwide, is looking at just this, “sequencing androgen and anti-androgen.  There are two BAT treatment arms: in one, the patients just switch every two months – two months of testosterone, two months of enzalutamide.  In the other, the men stay on testosterone until their PSA goes up, and then switch to enzalutamide, and stay on that until their PSA goes up,” then repeat.  Cancer response is also monitored by regular CT and bone scans.   Patients stop treatment if scans show cancer progression.

The BAT studies thus far have been small, Denmeade says.  “We need a big phase 3 study; we’ve just been nipping at the edges.”  For now, BAT remains investigational; positive results from larger randomized trials are needed for it to be considered standard of care. While not a cure for advanced prostate cancer, BAT may become an option for extending life and, importantly, improving quality of life.

Note:  BAT is not recommended for men with symptomatic bone pain from metastatic prostate cancer, because it can make that pain worse.  “This pain increase occurs within hours of testosterone injection, and resolves as testosterone levels in the blood decline over the first cycle of BAT,” says Denmeade.  “The worsening pain is not due to rapid growth of prostate cancer, but more likely to testosterone-stimulated release of inflammatory factors.”

BAT and the Immune System

Some men are exceptional responders to BAT.  Denmeade has a few patients who have remained on BAT alone for several years.  But for many men, the response is temporary; just a few months.  Why?  Could it have something to do with mutated genes?  What about the immune system?

“One of the things observed in the lab by our colleague, Dr. Sushant Kachhap, is that when we give testosterone, the prostate cancer cells get stressed and turn on all these immune factors,” says Denmeade. “Testosterone activates immune pathways.”  When three men who had participated in BAT trials later had “dramatic” responses to immunotherapy – 100-percent decreases in PSA, and one man remains in long-term remission – “we thought that might be the secret: androgen plus immunotherapy.”

COMBAT, a small, phase 2 study supported by PCF, co-led by Hopkins investigators Mark Markowski, M.D., Ph.D., and Emmanuel Antonarakis, M.D., (now Director of Genitourinary Oncology at the University of Minnesota) tested the combination of BAT and immunotherapy in 45 men with metastatic castration-resistant prostate cancer (mCRPC).  The men were treated with BAT in combination with nivolumab (an immunotherapy agent).  “We saw an impressive clinical response rate of 40 percent,” says Markowski.  “We also observed a durable benefit, lasting over a year, in a few patients who had received extensive prior therapies.”  The results suggested that BAT alone has significant efficacy, while nivolumab improves responses in some patients.  The combination of BAT with nivolumab was safe and well tolerated by the participants.  Markowski and Antonarakis are designing a randomized Phase 3 study to compare combined BAT plus nivolumab versus standard treatments for patients with mCRPC.

In the COMBAT trial, “we treated a group of incredible men who agreed to have tumor biopsies before and after three cycles of BAT,” says Denmeade.  “We are studying the heck out of these biopsies,” looking for specific biomarkers or gene mutations that might help predict who will have the deepest and longest-lasting responses.  The team is also performing additional studies of the interactions between BAT and the immune system to discover how this treatment can be improved.

 

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In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

 

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Driving Prostate Cancer “BATty”

BAT: The Opposite of Conventional Wisdom

Could the flat-out opposite of conventional wisdom prove to be effective against metastatic prostate cancer?

 Androgen deprivation therapy (ADT) has been the bedrock of treatment for advanced prostate cancer for more than half a century.  But investigators at Johns Hopkins are rethinking it – in a way that sounds counterintuitive – and driving new approaches to tackle treatment resistance.  They’re discovering that shaking up prostate cancer with high-dose testosterone makes it more vulnerable to other treatments. 

ADT slows prostate cancer’s progress by shutting off testosterone.  Eventually, however, cancer adapts to this new environment and PSA levels start to rise; this stage is called castrate-resistant prostate cancer (CRPC).  ADT is not a curative treatment, and long-term ADT causes significant side effects, including fatigue, hot flashes, weight gain, and loss of sexual function.

Several years ago, medical oncologist Samuel Denmeade, M.D., Co-Director of the Johns Hopkins Prostate Cancer Program, and colleagues came up with a remarkable concept for attacking prostate cancer: alternating ADT with high-dose testosterone.  I have interviewed Denmeade several times over the years for Johns Hopkins publications, and recently I was lucky enough to talk to him in-depth for the Prostate Cancer Foundation’s website.

“It had been known for a long time that something weird happens when you give testosterone to prostate cancer cells,” says Denmeade.  “With low doses you can get the cancer cells to grow,” which nobody wants.  “But plenty of reports said that paradoxically, at high doses the cancer cells don’t grow as well, or they die.  Even Charles Huggins, who won the Nobel Prize for discovering hormonal therapy, said in his Nobel acceptance speech (see below) that another way to kill cancer would be to give too much hormone.  I was always interested in that idea.”

About 10 years ago, Denmeade conducted a small study at Hopkins to test the concept of using testosterone against prostate cancer.  “At the time, it seemed like all the data and literature suggested that the dose was really important; it had to be a high dose.”  The hypothesis:  Prostate cancer cells adjust to a very low-testosterone environment (created by ADT) by making very high levels of the androgen receptor (AR).  And here, as he says, “too much of a bad thing can be a good thing.”  These high levels of the AR now make cancer vulnerable to very high levels of testosterone.  Cancer cells that survive this respond to high-dose testosterone by turning the AR back down – and making the cancer once again susceptible to very low testosterone.”

The idea is “to screw up the cancer cell’s ability to adapt.”  Denmeade and colleagues coined the term, Bipolar Androgen Therapy (BAT), “to capture these polar extremes of very high and very low.  Not just making the testosterone high, but cycling between high and low.”  It’s this cycling that seems to be the key to keeping the cancer off-balance, slowing its ability to flourish.  In BAT, men experience high testosterone levels that decrease over a 28-day period, then bounce back up with the next testosterone injection.

In that early study, of just a handful of patients, “we were very cautious, because we didn’t want to make the disease worse.  We built in all these safety parameters.  But we were surprised:  it didn’t seem we made anybody worse.  It seemed very safe.  The patients did very well, and some of them stayed on the testosterone for a year or more.  Most of them felt really good.  A number of them did not want to come off of it when it seemed they were progressing:  they were just so happy to have more energy, and some of them could have sex again.”

Armed with this initial clinical data to show that BAT was safe and to show some response, Denmeade received funding for additional proof-of-concept studies from PCF, among other sources. Larger studies at Johns Hopkins have followed, including RESTORE, TRANSFORMER, and COMBAT.  Other trials testing this concept have been completed or are under way at the University of Washington, University of Colorado, and in Australia, Brazil, and the Netherlands.

Next:  How BAT Works

“Certain cancers are hormone-dependent and these cells die when supporting hormones are eliminated.  Certain cancers succumb when large amounts of hormones are administered.”–Urologist Charles Huggins, M.D., whose discoveries led to hormonal therapy for cancer and earned him the 1966 Nobel Prize for Physiology and Medicine, shared jointly with virologist Peyton Rous.

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In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

 

 

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MRI’s Future Role in Prostate Cancer Treatment

Prostate MRI’s ability to show what’s happening in the prostate is already transforming how prostate biopsies are done.  Will it change treatment for prostate cancer, as well?

Radiologist Peter Choyke, M.D., believes it will.  He is Senior Investigator and Director of the National Cancer Institute’s Molecular Imaging Branch, and I recently interviewed him for the Prostate Cancer Foundation’s website.  He gave me some good examples of what MRI is already doing, and what’s on the horizon:

 Active surveillance:  “You can monitor patients on active surveillance with MRI,” says Choyke, but there’s a caveat:  “What you’ll typically see is not much change over two to three years.  But if you do biopsies over time, it’s not uncommon to see grade migrations, like Gleason 6 to Gleason 7, with no visible change on the MRI.”  Is that a significant change for the patient?  Does that mean that active surveillance has to stop and the man needs treatment right away?  “As far as I can see, there’s no right answer.  A lot of people are trying to substitute MRI for biopsies.  The danger there is that you will miss patients who are converting from Gleason 6 to 7.  Just because the MRI is unchanged doesn’t mean the histology (what’s happening within the cancer) is unchanged; that’s not a good assumption.”  Choyke suspects that MRI changes actually reflect growth of the tumor, “and are related to the number of cancer cells that are present – which is a really good index of how aggressive the tumor is.  If there are more cells, that’s a bad sign.  But if the cells are about the same in number, that’s not such a bad sign.”

One important role for MRI is before a man starts on active surveillance.  “You want an MRI to see what the extent of the disease is, to make sure you get a targeted biopsy of the lesion or lesions, and to make sure that you’re not putting someone on active surveillance who needs treatment instead.  By doing this, you get the patients who really should be on active surveillance, and can stay on it for much longer.”

 On the horizon:  Local treatment for prostate cancer:  MRI-guided treatments are being tested in clinical trials at the NIH and elsewhere.  The idea here is that MRI is getting so good, it may be able to provide a roadmap for treatment within the prostate.  Instead of removing or irradiating the entire gland, “we have a few protocols where we are trying to treat the lesions that we see on MRI.”  One approach is focal therapy, with MR-guided laser ablation “just to the lesion.”  If this works, there are some big advantages:  “We could significantly reduce the side effects from surgery and radiation,” says Choyke.  “We’re also very interested in, and are about to open enrollment for a trial of, local deposition of anti-androgen therapy – essentially putting androgen deprivation therapy (ADT) directly into the spot of cancer seen on the MRI – so the patient doesn’t have to undergo systemic ADT while receiving radiation therapy.”  Unlike, say, taking Bicalutimide by mouth, which affects the entire body, a micro-dose of Bicalutimide within the prostate tumor “only goes a certain distance before it’s washed away, and it’s in such a low concentration that the systemic effect is negligible.”   This will be tested in men with localized, intermediate-grade cancer, “where ADT is useful but not mandatory,” Choyke adds.  “There may come a time when this can be advanced to higher-grade tumors.”

Another trial in the works will test MR-targeted focal radiation.  “We’re very excited about this because with radiation, you can really do dose painting.  With a laser, you either kill or you don’t kill; you either burn it or you don’t burn it.  But with radiation, you can taper the dose around the edges of a tumor, where there’s a large expectation of cancer.  That’s good for the patient, because you’re not giving the same dose throughout and irradiating things that don’t need to be irradiated, like the rectum, urethra, or bladder base.”  This trial is “awaiting good planning software,” to help plot precisely where and how much the dose should be.

But much more testing is needed.  “First, do no harm.”  If it turns out that “we can treat the cancer successfully without a lot of side effects, that’s a good outcome.  All of that is enabled by the MRI providing the spatial information to direct these therapies.”

Artificial intelligence and MRI:  “We have a very good correlation between what’s on the MRI and the actual pathology of the radical prostatectomy specimen,” says Choyke.  “We have thousands of cases where we’ve compared the pathology to the MRI.  So now, with pretty good accuracy, we can predict the pathology from the MRI.”

But sometimes, MRI can’t see every bit of a tumor.  Sometimes normal tissue is interspersed with cancer, “at the resolution that MRI can’t detect; cancer is sort of hidden in all that normal tissue.”  Sometimes, tumors have stroma (noncancerous connective tissue cells), that masks the cancer cells.  And then there are some higher-grade tumors that simply don’t show up on MRI.  “In our studies, it’s 5 percent, but I’ve seen it as high as 15 percent of patients with intermediate or high-grade disease who have negative MRIs.  We’re looking to see whether artificial intelligence (AI) can pull out these lesions that the human eye can’t detect.”  No one knows why this is; under the microscope, “the pathology of those lesions doesn’t look that different.

“You’d think by now we would understand this very well,” but because the vast majority of tumors do show up on MRI, “it’s hard to accumulate enough cases to make bold statements about what’s going on.  We are continuing to look at it – so stand by for more information!”

This is part3 of 3 stories on MRI, MRI’s role in cancer screening, and MRI’s potential use in treatment.

In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

 

 

 

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MRI: No More “Hit-or-Miss” Biopsy!

Can MRI really make a difference in diagnosing prostate cancer?  Just ask Rob Gray.  It took nine years for his cancer to be diagnosed.  He felt like a human pincushion after going through numerous tests, exams, and five prostate biopsies – some of them saturation biopsies (each involving 20 or more needle samples!).  Doctors couldn’t find cancer, but they couldn’t rule it out, either.  The inconclusive “TRUS” (transrectal ultrasound) biopsies took their toll, as well: scar tissue developed in his prostate, making cancer even more difficult to detect with TRUS.   Rob is firmly convinced that, had it not been for an MRI-guided fusion biopsy, his cancer, which turned out to be Gleason 3 + 4, still might not have been found.  Today he is cancer-free.

Out with the “Hit-or-Miss” Biopsy!

With TRUS, unfortunately, Rob’s story is all too common, says radiologist Peter Choyke, M.D., Senior Investigator and Director of the National Cancer Institute’s Molecular Imaging Branch, and a pioneer in the rapidly evolving use of MRI to evaluate prostate cancer.  He is at the top of the MRI-prostate cancer field, and I was privileged to interview him recently for the Prostate Cancer Foundation’s website.

Why have so many men, like Rob, endured multiple inconclusive biopsies?  Choyke explains: “Let’s look at what until very recently was state of the art: 12 biopsies performed by the urologist under TRUS, six on one side and six on the other.  It really wasn’t targeted to anything in particular.”  The basic biopsy sampled the upper, mid and lower part of each side of the prostate (this, by the way, was an improvement over the old biopsies of 20 years ago, which took only six samples!).  Even with 12 samples, “there are a lot of opportunities to miss lesions.  And, because urologists don’t want to injure the urethra, which is in the center of the prostate, they tend to put the needles more towards the back of the gland, so the front part of the gland was relatively unsampled in a traditional TRUS biopsy.”

In other words, the traditional biopsy is largely hit or miss.  “Once we started doing MRIs,” says Choyke, “we realized that a lot of tumors are above where the needles usually went in; in fact, those lesions are more amenable to transperineal biopsy.  That was important in helping us detect the cancers in men who had multiple negative TRUS-guided biopsies.”

A targeted biopsy – done with TRUS, but using the MRI as a roadmap – can direct the needle to specific areas that look suspicious.  “Also, once you have the MRI, you realize how big the lesion is.  With TRUS, you just had a specimen that was positive.  You didn’t know if it came from a 3mm- or a 5 cm-sized lesion!  It was just ‘positive.’  Now with MRI, we have a much better feel: is this a big lesion, has it been there a long time, has it grown outside the prostate, possibly to the lymph nodes?  Are the seminal vesicles involved, is the bladder involved?  There’s a lot of anatomy that you can get from the MRI that you just don’t get from the biopsy information.  Was the needle in the center of the lesion, or the periphery – or did it biopsy something completely different than the main lesion?  Is this cancer caught very early, so it’s hard to see, or is it large and obvious?  That influences the discussion of treatment options, and allows the patient to make a much more informed decision.  With MRI, you’re way far ahead of the game.”

And this is why Choyke believes that “in the best of all possible worlds, every man with suspected prostate cancer would get an MRI.”  MRI is of even more benefit, he adds, as a man’s PSA rises.  “We did a study where we compared men with a PSA less than 5 with men with a PSA greater than 5.”  For men with a lower PSA, “the advantage of MRI was much smaller compared to a traditional TRUS biopsy.  But for those with PSA greater than 5, it was clearly superior to have an MRI.”

That said, there are some qualifiers:  Not every insurance policy pays for MRI, and good-quality MRI is not universally available.  The power of the MRI machine itself used to matter more, with 3 Tesla strength preferred.  But today, the major determinants are, “how old is the MRI unit, and is there a radiologist who is focused on prostate MRI, who has been to courses learning how to interpret it properly?  Or, is the radiologist a generalist without specific expertise?”  If you’re paying for part or all of the cost out-of-pocket, Choyke notes, “these scans are very expensive.  I don’t think it’s unreasonable to ask good questions.”

Another bonus to today’s prostate MRI:  With more sophisticated machines, very few men require the endorectal coil, a latex-covered probe, inserted in the rectum, that helped provide better-quality images of the prostate with earlier-generation equipment.  “We advocated for endorectal coils universally five years ago; but once we bought a new scanner, we now reserve coils for cases in which the patient’s already been treated and we’re looking for recurrent disease in the pelvis, which can be very subtle.”  With the recent approval of 18F DCFPyl PSMA-PET, which uses a highly specific molecular tracer to find prostate cancer cells anywhere in the body, “we’re using the coil less and less.  That’s associated with lower cost, better patient appreciation, and faster scans.  Nobody regrets to see the passing of the endorectal coil.”

This is part 1 of 3 stories on MRI, precision cancer screening, and MRI’s potential use in treatment.

In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

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Do You Need Prostate MRI?

Prostate MRI is on the upswing in cancer diagnosis.  Should it play a role in screening, too?  

Many men with suspected prostate cancer are getting MRI, because the information it provides is so good:  MRI can show the size and location of tumors and guide a personalized, targeted biopsy aimed at suspicious areas – instead of a best-guess biopsy that tries to sample tissue from each part of the prostate.

Traditionally, if a man’s doctor suspects he has prostate cancer, the next step has been a biopsy.  But that’s changing:  Today, ideally, the next step should be an MRI, says radiologist Peter Choyke, M.D., Senior Investigator and Director of the National Cancer Institute’s Molecular Imaging Branch.  And even more ideally, maybe MRI should be part of regular screening.  I recently interviewed Choyke for the Prostate Cancer Foundation’s website.

“Prostate cancer is not one disease: it’s a broad spectrum ranging from cancer that is slow-growing, indolent and probably will never bother the man, to cancer that is very aggressive, as bad as pancreatic cancer in its severity,” Choyke explains. “It’s important to pick out who has that really aggressive type, and who has the indolent type.”  In large, multicenter studies in the United Kingdom, prostate MRI is part of regular screening.  If the MRI is negative, “men go back in the screening pool and are monitored with regular PSA tests.  If the PSA goes up, they repeat the MRI,” and undergo biopsy only if anything suspicious shows up on the MRI.  “The virtue of this approach is that in the UK, almost one-third of men avoid biopsy, which is very significant.  If you don’t do the biopsy, you don’t detect incidental Gleason 6 disease,” which does not always require treatment. “But in the U.S., biopsies continue to be done even when the MRI is normal or equivocal.”

Do higher-risk men need MRI sooner than others?  Choyke is investigating this question in studies of targeted populations, including men with a family history of prostate cancer, men of African descent, and men identified with “genetic predispositions to prostate cancer,” he says.  “We’re doing a study now of men who come from families with known genetic abnormalities that predispose to cancer.”  Eligible for the study are men without prostate cancer, ages 30 to 70, who have tested positive for mutations in one or more of these genes:  BRCA1, BRCA2, HOXB13, ATM, NBN, TP53, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, PALB2, RAD51D, and FANCA.

Already, Choyke says, “We are finding cancers in younger men from those families.”  This is important:  Many family doctors don’t recommend prostate cancer screening until men are in their fifties.  Men at higher risk should start screening earlier, in their early forties.  Men with a family history of prostate cancer, or of other types of cancer (such as colon, breast, or ovarian) tend to develop prostate cancer at a younger age.  Some men can develop prostate cancer in their thirties and even younger.  MRI, Choyke hopes, may one day play a role in diagnosing higher-risk men sooner.  “It may be that if you have one of these predisposing genetic conditions, you would get an early MRI, way earlier than it’s now recommended and catch the disease at a curable state,” as part of a precision medicine approach to screening and diagnosis.

Also at higher risk of developing prostate cancer at an earlier age are men of African descent.  “African American men have a greater predisposition to prostate cancer, and are much more likely to die of it,” says Choyke.  “Many of these men live in medically underserved communities, so this is a population I would think well worth targeting for MRI.”

What if you want an MRI but your insurance won’t pay for it?  “We see this problem all the time,” says Choyke.  His advice:  get your urologist to help!  For many doctors in the U.S., trying to get past an insurance company gatekeeper is a daily occurrence – which means, you’re not the first person this has happened to.  Your doctor is used to it, and may be able to cut through the bureaucracy.  Here’s a battle plan suggested by Choyke:  “First, discuss the need for MRI with your urologist and make sure you’re on the same page.”  Then, if your urologist agrees that an MRI would be beneficial, team up:  “The patient and urologist working together have a better shot at convincing the insurance company than either alone.”

Another issue: prostate MRI is not available everywhere.  “MRI scanners are difficult enough to access, and centers with expertise in prostate MRI are even less common.”  You may need to travel to a bigger medical center in another city.  Even if you’re in a major city, this doesn’t guarantee easy access, Choyke adds:  “I know of patients and urologists in Washington, D.C., who can’t get MRIs.  We will be conducting a study with patients from underserved parts of Washington to determine if we can make earlier diagnoses and have better outcomes.  If we can show that patients in this community benefit – and I think they will! – then maybe those communities can argue for more resources based on data.  In contrast, in the UK, every patient gets an MRI, no questions asked, because of their more socialized system of medical care.”

This is part 2 of 3 stories on MRI, precision cancer screening, and MRI’s potential use in treatment.

In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

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PSMA-Targeted Treatment:  Why Side Effects Matter

This new form of treatment for metastatic prostate cancer is being used in Europe, Australia and elsewhere, and being tested in clinical trials in the U.S.  As part of my series on PSMA-targeting, here’s more of the story:

We have talked a lot about the amazing results in some men with metastatic prostate cancer of PSMA-targeting radionuclides, being used in Europe, Australia, and elsewhere, but still in clinical trials here in the U.S.  Now, I’m all for moving drugs right along, damn the torpedoes, and giving anyone who wants to take the risk a chance to beat a terrible disease.  But there’s a good reason that the U.S. is taking this cautiously:  because some of these PSMA-targeting treatments – not all – can harm the salivary glands and tear ducts.  When these treatments become FDA-approved in this country, I believe the side effects will not be so severe.  Scientists like Neil Bander and Martin Pomper are developing agents that have much milder side effects.

The whole time I’ve been writing about PSMA, I have been thinking of Nathan (I changed his name to protect his privacy), a remarkable, tough and courageous man I interviewed in 2018.  He is one of the pioneer patients of PSMA-targeting treatment.  I want to tell you his story now.

On a dark day in 2013, Nathan was diagnosed at age 57, with stage 4 prostate cancer that had spread to his lymph nodes, his spine and hip.   His cancer was very aggressive: Gleason 9.  The prognosis was grim, and Nathan had a choice to make:  do what his initial urologist suggested, start on androgen deprivation therapy (ADT), hope it works for a long time and wait until the cancer gets worse, or go into “high-gear mode.”  He chose option B.  “If I have an aggressive cancer, I want to deal with it aggressively.”

So, in addition to starting on ADT and an androgen receptor blocker, abiraterone (Zytiga), plus prednisone – a combination that is now FDA-approved, but was about five years ahead of its time in 2013 – Nathan underwent a radical prostatectomy.  The surgery did not cure him, but eliminating the primary tumor dealt the cancer a severe blow and bought him more time.  “The plan all along was, kick the can down the road until science can catch up,” he says.  He assembled a team of doctors who had the same philosophy.

Next, Nathan got radiation:  high-intensity radiation to the spots of cancer in his spine, followed by 40 radiation treatments over two months to his pelvis and prostate bed.  Despite a change to a different androgen receptor blocker, enzalutamide (Xtandi), his cancer picked up steam.   Soon, his PSA was doubling every three weeks.  A PET scan showed new metastases, including a big one in his elbow.  In 2016, Nathan learned about the PSMA-targeted radionuclide treatment being done in Heidelberg, Germany.  He talked to his oncologist, who expressed concern about the side effects.  Nathan decided to go to Heidelberg.

The most worrisome side effect of this treatment was damage to the salivary gland.  As it turns out, PSMA doesn’t quite live up to its name; it is not entirely “prostate-specific.”  This molecule normally exists in small amounts in the salivary glands and a few other places of the body.  The drugs that target the PSMA-containing cancer cells don’t know the difference, and they can kill or damage these normal cells, too; there is also a risk of kidney toxicity.  “The salivary gland problem happens right away,” Nathan says.  “But the treatment also works right away.  They give you an infusion and the cancer cells are dying within hours.”

Despite the risks and the unknowns, Nathan wanted to go ahead – sooner, rather than later.  “I knew they had done this treatment on no more than 30 to 40 patients.  But I also didn’t want to get to a point where I was going to be in bad shape,” before the cancer burden grew bigger and began causing pain, “and then get the treatment.”

Before he could undergo the treatment in Germany, Nathan had to have a PSMA-PET scan.  “My body lit up like a Christmas tree with PSMA-PET: it showed cancer in my ribs, sternum, manubrium, scapulas, upper extremities, femur, and numerous places on my spine.”

Nathan weighed the risks of side effects against the possibility of getting a true remission of his cancer.  The hope of remission won.

What’s it like?  The treatment itself is given by infusion and only takes 10 minutes – and in 10 minutes, prostate cancer cells throughout Nathan’s body started to die.  Before and after his treatment, he drank “tremendous amounts of electrolyte fluids,” to minimize the risk of kidney damage:  “The more you drink, the more you can flush out the radioactive materials.” Nathan was given ice packs to put around his neck to help protect the salivary glands.  He was supposed to use them for six hours; he kept icing his neck for 12 hours, and also drank as much water as he could.  “I think in those two days, I drank between 10 and 12 liters of electrolyte water.

“This treatment was only approved by the German government on a humanitarian basis,” he notes, “basically, to treat people in extensive pain, who were far along in the disease, and who didn’t have much time to live.”  Nathan was the only man on the ward who was not taking morphine.  “One guy came in in a wheelchair, in bad shape.  He got discharged before me.  He walked out – didn’t use the wheelchair.  That’s how quickly it alleviated his pain and was killing the cancer cells.”  The man in the next room had an exceptional response, as well:  “He was from the Netherlands.  He told me he came in when his PSA was 964, got his first treatment, and his PSA went down to 11, then his second treatment was two months later, and his PSA was down to 3.5, and now he was there for his third treatment.”

Two weeks later, when Nathan went to see his oncologist back in New York, his PSA was undetectable.  A second treatment was scheduled.  “I was already experiencing significant salivary gland problems,” Nathan says, “and we thought he might reduce the dosage.”  However, he doesn’t know whether the dosage was reduced for the second round.

Going Off Enzalutamide

Enzalutamide may have helped make the treatment more effective:  some studies have suggested that enzalutamide enhances PSMA.  Otherwise, Nathan wasn’t sure how helpful it was.  Six months after his second treatment in Germany, he asked his doctor: “What do you think about me getting off enzalutamide, and staying on Lupron?  He said, ‘I don’t know if it ever really worked on you; it only lowered the PSA for a few weeks.’”  So Nathan tapered off, then stopped taking it altogether – which led him to another milestone:  “I said, ‘So, am I still castrate-resistant?”  His doctor told him, “’From a scientific standpoint, once you’re castrate-resistant, that’s it.  They don’t change that.’  But I don’t think they’ve ever come across a situation where people start dialing back their medicines.”

“Not for the Faint of Heart”

About a year after the treatment in Germany, Nathan got a PET scan.  “There was no evidence of cancer, which is great news,” he says.  However, “they said I had a compression fracture in my spine.”  Previously, when he had the high-dose radiation to his spine, he asked about side effects.  The radiation oncologist told him, “In rare cases, people can get compression fractures.  Don’t jump out of any planes.”  But back then, this was a new treatment, and there was no long-term follow-up.  To treat the fracture, he underwent a procedure called kyphoplasty, done by an interventional radiologist.  It involves a balloon – like angioplasty – that restores space in the collapsed vertebra, which then is filled in with glue and cement to restore the bone and relieve pain.

In 2018, Nathan got another PSMA-PET scan at Weill Cornell.  “Thankfully, I was PSMA negative.”  But Nathan cautions that the radionuclide treatment he received is “not for the faint of heart.”  The loss of salivary gland function “has not been pleasant.  It encompasses many things.  I can swallow, and I can taste, but I get a tremendous amount of dry mouth.”  A CT scan showed esophagitis – inflammation of his esophagus from lack of salivation, and thyroiditis.  “I have to constantly keep lubrication going.  It has gotten slightly better, and they told me it’s possible that if the treatment didn’t burn off all my salivary glands and there were some cells left, they could possibly regenerate, but it would take a long time.   I think I’ve gotten about 20 percent back over the two years.”  Nathan uses gels in his mouth every night.  “Otherwise, I wake up choking.”  He also uses prescription toothpaste and extra fluoride to protect the enamel on his teeth.

He is trying to limit scans that will subject his body to more radiation (MRI, for example, has no radiation; CT does).  “Over the last couple months, my creatine level (reflecting kidney function) has slowly increased.   It’s not out of the range of normal, but at the high end.  I’m conscious that these radioligand therapies can produce kidney damage.”

“It’s an amazing age we’re living in,” Nathan says.  “I’m happy to be here, grateful that I was able to kick the can long enough to have gotten this treatment.”  Whenever he sees his oncologist, the conversation ends with the doctor saying, “Grow old.”  And Nathan says:  “I plan to.”

Note:  If you are seeing this as a solo story, click here for more.

 

In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

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