Prostate Cancer Control Improved by Adding PET Imaging to Treatment Planning

Making advanced PET part of the treatment process for men who have recurrent prostate cancer can greatly improve their outcomes over solely using traditional imaging, according to new research.

Conventional imaging, such as CT or MRI, frequently does not offer enough detail for providers to have complete confidence in suggesting post-prostatectomy radiation, said a team of investigators from the Winship Cancer Institute at Emory University. But, using ¹⁸F-fluciclovine-PET/CT makes it easier for providers to see the uptick in amino acid movement that often factors into their decision.

The team published their findings this month in The Lancet.

“The decision to offer post-prostatectomy radiation is complex, because conventional imaging can leave unanswered questions on the best approach for treatment planning,” said co-principal investigator Ashesh B. Jani, M.D., professor of radiation oncology at Winship. “This research has found that integrating advanced PET imaging using ¹⁸F-fluciclovine into the treatment planning process allows us to do a better job of selecting patients for radiation therapy, guiding radiation decision and planning, and ultimately, keeping our patients’ cancer under control.”

The radiopharmaceutical, developed by Blue Earth, a subsidiary of Bracco, has been approved by the U.S. Food & Drug Administration for use in men who are suspected of prostate cancer recurrence based on their prostate-specific antigen (PSA) levels.

Based on their research, Jani’s team determined the men who received ¹⁸F-fluciclovine experienced a superior cancer control rate of 75.5 percent after three or four years. Their result outpaced what men who underwent conventional imaging experience – a 63-percent and 51.2-percent control rate at three and four years, respectively.

For this EMPIRE-1 study, from September 2012 to March 2019, the team enrolled 165 patients with prostate cancer who had PSA levels that were detectable post-prostatectomy, but who had no findings on conventional imaging. These men were, then, randomly assigned to one of two study arms – radiotherapy guided solely by conventional imaging or radiotherapy augmented by ¹⁸F-fluciclovine.

Both groups saw similar toxicity, and the most common adverse events were late urinary frequency or urgency (present in 37 out of 81 patients in the conventional imaging group and 31 out of 76 individuals in the PET group) and acute diarrhea (present in 11 conventional imaging patients and 17 PET patients).

These results validate what the researchers had believed about the effect of using this radiopharmaceutical.

“The question that we wanted to answer in this study was whether the treatment plan effect informed by ¹⁸F-fluciclovine-PET imaging had a positive effect in the lives of patients,” said David M. Schuster, M.D., FACR, professor of radiology and imaging sciences and director of the nuclear medicine and molecular imaging division at Emory. “The EMPIRE-1 trial allowed us to determine whether using ¹⁸F-fluciclovine-PET imaging influences patient outcomes for the better, and the significant results confirm that it does.”

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