Defining Hormone-Sensitive Prostate Cancer, and When to Consider PSMA PET Scans

In this roundtable discussion, Irbaz Riaz, MBBS, PhD, of Mayo Clinic Arizona, and panelists Roopesh Kantala, MD, James Ewing, MD, and Chad Cherington, MD, of Ironwood Cancer and Research Centers, delve into current approaches for managing metastatic prostate cancer. The team begins by defining metastatic hormone-sensitive prostate cancer (mHSPC) and contrasts it with castration-resistant prostate cancer (mCRPC), providing insights into diagnosis, staging, and risk stratification. They discuss preferred imaging methods, such as PSMA PET scans, and explore how disease volume impacts treatment decisions.

Watch the next part of this roundtable: Novel Hormonal Therapy Approaches in Prostate Cancer

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Dr. Riaz:
Hi, my name is Irbaz Riaz. I’m a GU medical oncologist at Mayo Clinic in Arizona.

Dr. Kantala:
Hi, I am Roopesh Kantala. I’m a medical oncologist at Ironwood Cancer and Research Centers in Mesa, GU oncology as well.

Dr. James Ewing:
James Ewing. I’m a medical oncologist with a GU subspecialty, also with Ironwood in the Phoenix-Scottsdale area.

Dr. Cherington:
And I’m Chad Cherington, also with Ironwood Cancer and Research Center, particularly focusing in genitourinary oncology in Chandler, Arizona.

Dr. Riaz:
Thank you gentlemen, we are going to start our discussion with metastatic hormone-sensitive prostate cancer and then transition to metastatic castration-resistant prostate cancer. So maybe we should start with the basics. How do we define metastatic hormone-sensitive prostate cancer in our practices?

Dr. Kantala:
Usually patients who have not seen androgen deprivation therapy yet and who have presented with signs and symptoms of metastatic disease or have asymptomatic metastatic disease, primarily born disease in where I practice in and that those are the patients, I define them as hormone-sensitive metastatic prostate cancer.

Dr. Cherington:
I think the other way to think about it is those who are castrate-resistant and those that have a rising PSA, despite androgen deprivation therapy in a castrate-level, testosterone level less than 50.

Dr. Riaz:
So when a patient presents with hormone-sensitive disease, what is your usual practice in terms of initial metastatic workup? Are we still doing conventional scans? Are we doing PSMA PET scans for the staging of prostate cancer?

Dr. Kantala:
Preferred is PSMA PET scan. Depends on, I guess certain financial factors where certain carriers don’t cover that. So in such situations I still rely, a bit not a lot, but a bit on the conventional CAT scans and bone scan.

Dr. Ewing:
Concurrently with conventional imaging such as a CAT scan, PSMA PET scan is preferred in this setting for my practice.

Dr. Riaz:
Do you have any different thoughts?

Dr. Cherington:
No, I usually will first think of the PET PSMA scan, particularly if the PSA is greater than 0.5 or I think they’re going to qualify under insurance and I think they’re high risk to have metastatic disease, so.

Dr. Riaz:
So in addition to conventional risk stratification, when we do the scans and we try to think about, let’s say in the conventional scans era, if you’re not doing PSMA PET scans, if you’re just doing CT scan and nuclear medicine bone scans. The way I think about these patients is usually by chartered criteria. Is it high volume disease, is it low volume disease? And that kind of helps me guide in addition to synchronous or metachronous presentation helps me guide how aggressive we be in the treatment of initial metastatic prostate cancer. When you do a PET scan in the initial staging of prostate cancer, do you still think about this concept of high volume, low volume disease?

Dr. Ewing:
I think so. You’re still thinking about what the volume of disease is, the location of metastasis, for instance metastasis versus bone or lymph node only, but it is going to be more sensitive than conventional imaging. So you’re going to have some stage migration certainly, using the PET PSMA up front.