David J. Einstein, MD, instructor of medicine, Harvard Medical School, attending physician, Beth Israel Deaconess Medical Center, discusses treatment approaches for patients with early evidence of oligometastatic prostate cancer.

There’s a question of whether oligometastatic recurrences can be detected early and treated with metastasis-directed therapy with radiation or surgery, says Einstein. That approach was tested in the phase II STOMP trial and showed that metastasis-directed therapy could delay the need for systemic androgen deprivation therapy, an approach that is associated with many toxicities and is not curative. However, further validation is required, adds Einstein.

Another related strategy is to use metastasis-directed therapy plus intensified systemic therapy to eradicate the disease at first recurrence. Only time will tell which approach is superior. In the meantime, there are 2 other trials being conducted in this area—the phase II ORIOLE trial and the phase II METACURE trial&mdash;which are testing different methods in the early oligometastatic recurrent setting.

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Dr. Einstein on Treatment Approaches in Early Oligometastatic Prostate Cancer

David J. Einstein, MD, genitourinary medical oncologist, Beth Israel Deaconess Medical Center, discusses novel imaging tools used in prostate cancer.

Many investigators have developed various imaging strategies to improve upon the sensitivity of available modalities, says Einstein. These approaches range from choline C-11 PET scan, to the 18F sodium fluoride PET/CT scan, to the newly FDA-approved fluciclovine PET/CT scan, to prostate-specific membrane antigen scans. Many of these technologies are various PET modalities that differ from conventional PET scans. The goal of these modalities is to pick up disease at lower levels than what was previously possible with traditional methods. Whether that helps patients has yet to be determined, says Einstein.

However, being able to detect small amounts of disease may help guide a patient’s intended course of treatment. For example, if postoperative patients are scheduled to receive salvage radiation to the prostate area, physicians may opt for sensitive imaging to guide that beam rather than radiating blindly, explains Einstein.

Another potential application for these modalities could be in patients who have already been through all of the standard local therapies, have rising prostate-specific antigen, and don't have anything on a conventional scan. Whether oligometastatic recurrences can be identified early and receive metastasis-directed therapy remains of debate. However, data from the phase II STOMP trial seemed to suggest a delayed time to ADT when metastasis-directed therapy was employed.

Dr. Einstein on Novel Imaging Tools in Prostate Cancer

David J. Einstein, MD, instructor of medicine at Harvard Medical School, and attending physician of medicine at Beth Israel Deaconess Medical Center, discusses research with immunotherapy in prostate cancer.

There is a lot of interest with immunotherapy in prostate cancer, specifically in patients with micrometastatic disease, says Einstein. There are several reasons why investigators believe micrometastatic disease may be particularly susceptible to this approach. Research is focused on testing vaccines and checkpoint inhibitors in the setting of biochemical recurrent premetastatic prostate cancer.

Beth Israel Deaconess Medical Center, in conjunction with Dana-Farber Cancer Institute, is currently accruing to a trial with PROSTVAC, which is a prostate vaccine out of the National Cancer Institute. Several of Einstein’s patients are on that trial. So far, several patients have experienced prostate specific antigen (PSA) stabilization and occasional declines. Furthermore, checkpoint inhibitors are also being tested in this setting and are thought to be more efficacious in a less advanced setting, concludes Einstein.

David J. Einstein, MD, instructor of medicine at Harvard Medical School, and attending physician of medicine at Beth Israel Deaconess Medical Center, discusses research with immune therapy in prostate cancer.

Dr. Einstein on Immune Therapy in Prostate Cancer

David J. Einstein, MD, instructor of medicine at Harvard Medical School, and attending physician of medicine at Beth Israel Deaconess Medical Center, discusses biochemical recurrence in patients with prostate cancer.

Biochemical recurrence is a big area of prostate cancer, says Einstein. Biochemical recurrence is defined as detectable levels of prostate-specific antigen (PSA) following primary therapy. There are slight variances in how this is quantified depending on the type of therapeutic intervention patients receive, explains Einstein. Biochemical recurrence is also often defined by the lack of metastases on imaging via CAT scan or bone scan.

This can adversely affect patient quality of life, he adds. A rising PSA often indicates the presence of micrometastatic disease, which will more often than not lead to metastatic disease. The time before patients reach that metastatic state can vary. For example, a patient can go years before developing metastatic disease, prior to which they may die of unrelated causes, or they may develop metastatic disease fairly quickly, he concludes.

David J. Einstein, MD

Articles

Dr. Einstein on Treatment Approaches in Early Oligometastatic Prostate Cancer

Dr. Einstein on Novel Imaging Tools in Prostate Cancer

Dr. Einstein on Immune Therapy in Prostate Cancer

Dr. Einstein on Biochemical Recurrence in Prostate Cancer