The several new therapies recently approved for the treatment of metastatic castrate resistant prostate cancer patients have altered the roles of various healthcare providers practicing in this space. For example, urologists have become more actively involved in the management of castrate resistant prostate cancer patients. With regards to imaging, the advances in therapy have created an urgent need to develop better technologies to detect and monitor metastatic disease. Radiology and nuclear medicine practices are also changing as we expand beyond diagnostic imaging to include more longitudinal therapeutic care to our patients through the administration of radium 223 to our castrate resistant patients with symptomatic bone metastases.
One of the main goals for radiology and nuclear medicine in diagnosis is to provide the patients with the right test, at the right time. By serving as the stewards for imaging, we must strive to perform quality imaging by ensuring accuracy, timeliness, and patient safety throughout the entire process. We must also make every attempt to maximize the information obtained from imaging to lead to improved clinical outcomes.
The search for the right test is still underway, but there is much hope with new radiopharmaceuticals for prostate cancer such as F-ACBC (Axumin), which was recently approved by the FDA, and new PET based PSMA radiopharmaceuticals. The improved sensitivity and specificity of these exams at lower and lower PSA levels are very exciting, but this alone is not enough. It will be up to the imaging community, in close collaboration with our colleagues in urology and oncology, to design robust studies to demonstrate the clinical benefit and impact of imaging on outcomes. The utility of imaging will also extend beyond just disease detection to include the use of imaging as a prognostic tool and biomarker for treatment response/progression.
The radiologist/nuclear medicine physician also needs to become more involved in the development of more comprehensive and up to date appropriateness criteria for imaging prostate cancer patients in different stages of disease. Current guidelines and recommendations often focus solely on imaging at diagnosis and biochemical recurrence, but we know that the biology of disease in the castrate resistant setting is completely different. This gap was addressed by the RADAR Group recommendations in 2014, and it is clear we need better tools and better data through clinical trials to fully realize the potential of diagnostic imaging in advanced prostate cancer.
With regards to therapy, FDA approval of radium 223 significantly changes the treatment landscape for radiologists/nuclear medicine physicians for two reasons: 1. Unsealed sources of radiation therapy in prostate cancer are no longer just palliative, but they have been proven to improve overall survival. 2. Radium 223 is administered in a longitudinal fashion over 20 weeks rather than a single visit. This change in paradigm requires several changes to the traditional practice of radiology and nuclear medicine.
First, we need to create more patient friendly clinics. Most radiology/nuclear medicine practices were not designed to accommodate physician-patient interactions. Dedicated clinic space is required to allow for patient interviews and exams. Though radium 223 has a very good safety profile, radiology/nuclear medicine practices still need to develop the infrastructure to communicate with patients and manage adverse events. Radiology/nuclear medicine practices also need to actively manage the financial aspects of high cost therapies to help patients understand the costs involved, provide access to financial assistance, if possible, and manage the financial implications/risks for our respective practices.
Secondly, our practices need to become more “provider friendly.” Whether over the phone, through email, or the electronic medical record, radiologists/nuclear medicine physicians need to be available to provide consultative services with regards to the appropriateness of the therapies, risks/benefits, and radiation safety. Additionally, we should be active participants in tumor boards and multidisciplinary clinics to establish ourselves as valued contributors in the management of advanced prostate cancer patients. This will require more learning about many of the other therapies in prostate cancer which will allow us to dialogue with colleagues to identify the optimal patients for these life prolonging treatments. Radiologists/nuclear medicine physicians need to expand their consultative responsibilities beyond standard dictated reports.
Third, radiology/nuclear medicine must become more involved in therapeutic clinical trials. The inability to recruit patients into trials is often cited as the main factor why this is not possible. I believe this can be overcome through strong relationships and communication with the entire care team. Contributions to the design, implementation, and analysis of clinical trials will be important ways in which we can meaningfully contribute to the advancement of patient care.
In conclusion, it is a very exciting era in advanced prostate care for all healthcare providers involved. Whether we are dealing with imaging technologies or therapeutic agents, the radiologist/nuclear medicine physician must continue to engage all of the members of the care team and establish themselves as a vital and valued contributor. As roles change, I am constantly reminded that our ultimate goal is to create a better experience and a better outcome for our patients. With this guiding principle, I have no doubt that we can all continue to adapt and improve our practices accordingly.
“Opportunities multiply as they are seized.” – Sun Tzu
Written by: Phillip J. Koo, MD