Feature

‘Appetite has outpaced guidance’ on novel imaging for prostate cancer, researchers say

Vapiwala_Neha_80x106
Neha Vapiwala

The ability to identify more prostate cancers more often through the use of novel imaging techniques is altering — but not necessarily improving — treatment paradigms, according to Neha Vapiwala, MD, and colleagues.

“The appetite has outpaced the guidance for clinical application of these novel agents,” Vapiwala, associate professor of radiation oncology and assistant dean of student affairs at Perelman School of Medicine at University of Pennsylvania, and colleagues wrote in a review of strategies for evaluating novel imaging in prostate cancer published in Journal of Clinical Oncology. “[We] have great hope for and appreciation of innovative and vastly improved imaging technologies. However, we believe strongly that there is a time-sensitive need to address some of the existing challenges that have heretofore deterred relevant, feasible trial design intended to investigate the clinical implications of the avalanche of findings that these imaging tools provide.”

HemOnc Today spoke with Vapiwala about what prompted this review, what she and colleagues found, and what she hopes clinicians will take away from the findings.

Question: What prompted this review?

Answer: We were inspired by what we have observed in clinical practice and the research arena in terms of exciting new imaging technologies that enable greater detection of prostate cancer, yet a dearth of information as to how to actually interpret and incorporate these scans. We wanted to know if the extra information we glean carries any clinical relevance. There is an eagerness that accompanies advanced technology and improved imaging capability, but also the responsibility of making sound clinical decisions based upon the novel imaging findings — decisions that are benefiting the patients.

Q: How did you conduct the review?

A: We decided to predominantly discuss PET scans, although some of our key points could apply in principle to any new imaging modality. Historically, PET scans were rarely clinically indicated for prostate cancer, but because of the emergence of newer prostate cancer-specific PET radiotracers, there has been an explosion in utilization of these scans in certain parts of the world. We then systematically reviewed active clinical trials trying to address relevant questions within the realm of prostate cancer scenarios commonly encountered in the clinic, as well as gaps that remain. We also sought to illustrate how there can be favorable and potentially detrimental consequences of acting upon this imaging. For example, in some cases, we might not treat a patient with curative intent because we think his disease is further along than it truly is (false-positive test result).

Q: What did you find?

A: We found that there is no clear consensus among the governing bodies or associations on how to best incorporate existing PET scans, as well as those with novel radiotracers that are coming down the pike. Also, depending upon the area of the world in which a patient resides or flies to in order to obtain a scan, the safety and regulatory barriers and layers of bureaucracy may be overly strict or not strict enough. In jurisdictions where the bar is low for adopting PET scans, no one is incentivized to systematically collect the outcomes data, so we do not know if patients are ending up with more harm from overtreatment or undertreatment. Conversely, in countries like the U.S., our ability to come up with cohesive and successful clinical trial proposals requires some high-level coordination, guidance and flexibility from the various stakeholders — a daunting but important task. There remains a gap between the benefit that providers and patients hope and want these scans to provide and the evidence base supporting and describing said benefit. If we wait too long, it may be too late to contribute meaningfully to the evidence base.

Q: Were you surprised by what you found?

A: We hoped there would be more positive news to report. In the end, it is about limited resources and limited motivation to pursue this undertaking. A lot of patients in the U.S. are travelling to India, Australia and Europe to get the latest greatest PET scans. This may not be the best thing for them, but it feels right, and we cannot blame patients and providers who are searching for answers. However, we were pleasantly surprised by the number of folks who have reached out to us via social media and email, thanking us for putting the questions and information out there. It will ultimately take national and international efforts to get the answers.

Q: What should clinicians take away from this?

A: Clinicians should work toward helping patients to understand that whenever health care offers something new and advanced, it may play a role in diagnosis and treatment. But we would not want to make game-changing treatment decisions solely based upon the newest scans without first being able to collect and evaluate clinical outcome data. We will not be able to obtain such data without asking the right questions and being supported to open clinical trials. If there is an opportunity for a patient to participate in a clinical trial, he or she should strongly consider doing so, because the best way for us to learn and assess value is through research.

Q: Is there anything else that you would like to mention?

A: Patients are seeking answers, clinicians are highly motivated to provide those answers and do what is best for their patients, and researchers seek to ask the right questions. We should support researchers to get these studies done, because there is still an opportunity to do this in a responsible, data-driven way. We all need to work together on this one. – by Jennifer Southall

Reference:

Vapiwala N, et al. J Clin Oncol. 2019;doi:10.1200/JCO.18.01927.

For more information:

Neha Vapiwala, MD, can be reached at Perelman Center for Advanced Medicine West Pavilion, 2nd Floor, 3400 Civic Center Blvd., Philadelphia, PA 19104; email: vapiwala@uphs.upenn.edu.

Disclosure: Vapiwala reports no relevant financial disclosures.

Vapiwala_Neha_80x106
Neha Vapiwala

The ability to identify more prostate cancers more often through the use of novel imaging techniques is altering — but not necessarily improving — treatment paradigms, according to Neha Vapiwala, MD, and colleagues.

“The appetite has outpaced the guidance for clinical application of these novel agents,” Vapiwala, associate professor of radiation oncology and assistant dean of student affairs at Perelman School of Medicine at University of Pennsylvania, and colleagues wrote in a review of strategies for evaluating novel imaging in prostate cancer published in Journal of Clinical Oncology. “[We] have great hope for and appreciation of innovative and vastly improved imaging technologies. However, we believe strongly that there is a time-sensitive need to address some of the existing challenges that have heretofore deterred relevant, feasible trial design intended to investigate the clinical implications of the avalanche of findings that these imaging tools provide.”

HemOnc Today spoke with Vapiwala about what prompted this review, what she and colleagues found, and what she hopes clinicians will take away from the findings.

Question: What prompted this review?

Answer: We were inspired by what we have observed in clinical practice and the research arena in terms of exciting new imaging technologies that enable greater detection of prostate cancer, yet a dearth of information as to how to actually interpret and incorporate these scans. We wanted to know if the extra information we glean carries any clinical relevance. There is an eagerness that accompanies advanced technology and improved imaging capability, but also the responsibility of making sound clinical decisions based upon the novel imaging findings — decisions that are benefiting the patients.

Q: How did you conduct the review?

A: We decided to predominantly discuss PET scans, although some of our key points could apply in principle to any new imaging modality. Historically, PET scans were rarely clinically indicated for prostate cancer, but because of the emergence of newer prostate cancer-specific PET radiotracers, there has been an explosion in utilization of these scans in certain parts of the world. We then systematically reviewed active clinical trials trying to address relevant questions within the realm of prostate cancer scenarios commonly encountered in the clinic, as well as gaps that remain. We also sought to illustrate how there can be favorable and potentially detrimental consequences of acting upon this imaging. For example, in some cases, we might not treat a patient with curative intent because we think his disease is further along than it truly is (false-positive test result).

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Q: What did you find?

A: We found that there is no clear consensus among the governing bodies or associations on how to best incorporate existing PET scans, as well as those with novel radiotracers that are coming down the pike. Also, depending upon the area of the world in which a patient resides or flies to in order to obtain a scan, the safety and regulatory barriers and layers of bureaucracy may be overly strict or not strict enough. In jurisdictions where the bar is low for adopting PET scans, no one is incentivized to systematically collect the outcomes data, so we do not know if patients are ending up with more harm from overtreatment or undertreatment. Conversely, in countries like the U.S., our ability to come up with cohesive and successful clinical trial proposals requires some high-level coordination, guidance and flexibility from the various stakeholders — a daunting but important task. There remains a gap between the benefit that providers and patients hope and want these scans to provide and the evidence base supporting and describing said benefit. If we wait too long, it may be too late to contribute meaningfully to the evidence base.

Q: Were you surprised by what you found?

A: We hoped there would be more positive news to report. In the end, it is about limited resources and limited motivation to pursue this undertaking. A lot of patients in the U.S. are travelling to India, Australia and Europe to get the latest greatest PET scans. This may not be the best thing for them, but it feels right, and we cannot blame patients and providers who are searching for answers. However, we were pleasantly surprised by the number of folks who have reached out to us via social media and email, thanking us for putting the questions and information out there. It will ultimately take national and international efforts to get the answers.

Q: What should clinicians take away from this?

A: Clinicians should work toward helping patients to understand that whenever health care offers something new and advanced, it may play a role in diagnosis and treatment. But we would not want to make game-changing treatment decisions solely based upon the newest scans without first being able to collect and evaluate clinical outcome data. We will not be able to obtain such data without asking the right questions and being supported to open clinical trials. If there is an opportunity for a patient to participate in a clinical trial, he or she should strongly consider doing so, because the best way for us to learn and assess value is through research.

PAGE BREAK

Q: Is there anything else that you would like to mention?

A: Patients are seeking answers, clinicians are highly motivated to provide those answers and do what is best for their patients, and researchers seek to ask the right questions. We should support researchers to get these studies done, because there is still an opportunity to do this in a responsible, data-driven way. We all need to work together on this one. – by Jennifer Southall

Reference:

Vapiwala N, et al. J Clin Oncol. 2019;doi:10.1200/JCO.18.01927.

For more information:

Neha Vapiwala, MD, can be reached at Perelman Center for Advanced Medicine West Pavilion, 2nd Floor, 3400 Civic Center Blvd., Philadelphia, PA 19104; email: vapiwala@uphs.upenn.edu.

Disclosure: Vapiwala reports no relevant financial disclosures.