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Symptomatic: A Medical Mystery Podcast
A Reassessment of Prostate Cancer Treatment (Live from the 2024 ASCO Annual Meeting)
00:41:41
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- [00:34]
A
Welcome to Symptomatic. Today we are tackling prostate cancer. The most common cancer men face something one in eight men will navigate during the course of their lifetime, which also has a ripple effect on their friends and family. And we're recording this episode from the 2024 ASCO American Society of Clinical Oncology annual meeting. I am joined by a gentleman today ideally suited for this complicated conversation. Dr. Mohammed Atik is an assistant professor in the Department of Medicine at University of Chicago Medicine, where he specializes in hematology and oncology with a focus on genitourinary cancers. His research has appeared in leading publications and has earned him recognition as an American College of Physicians Young Achiever and a Prostate Cancer foundation young investigator. Welcome, Dr. Atik.
- [01:26]
B
Thank you. Thank you. Happy to be here.
- [01:28]
A
Now right out of the gate, what drew you to this specialty?
- [01:32]
B
Yeah, so it really kind of started out my father's medical oncologist. And so when I was younger, my siblings and I would kind of go into the clinic, maybe help out there. And we grew up in a small town in Arkansas, and we really got to see the development of the relations that he had with his patients. And so that development of relations was something that we always kind of grew to admire. But for myself, it was really, I began to learn more about molecular biology and genetics. And getting into that, I became fascinated with the science behind cancer. And so as I went through medical school, I knew that I wanted to do something with it. I just didn't know in what shape. And so I just kind of found myself gravitating more and more towards medical oncology as I finished residency and I was kind of looking at next steps. I was fortunate enough to have great mentors at University of Arkansas who advised me on considering joining a lab based in oncology or oncologic work that could then help me further delineate my pathway, whether that be in terms of a lab based physician, scientist, or clinical investigator. And I connected with Philip Kantoff at Memorial Sloan Kettering, joined his lab and began the work in prostate cancer at that bench side. And that kind of was basically the start of getting into this area.
- [02:52]
A
And medicine is a passion shared by your siblings as well.
- [02:56]
B
Yeah, yeah. So I have a elder brother who is a radiation oncology resident at Loma Linda. I have a younger brother who's actually presenting a poster right now. He is a medical oncology fellow at the National Cancer Institute, works in bladder cancer. And then I have a sister who's a first year resident at Cleveland Clinic, and interestingly enough, has Already kind of gravitated towards one of the GU oncology attendings there and is looking at doing research with her.
- [03:26]
A
Wow, that's amazing. If I ever get bad news, I'm going to come to your next family reunion. Now, in terms of breaking down prostate cancer, let's just start at a basic definition because a lot of people don't even understand what a prostate is.
- [03:43]
B
Right. So this is a gland. In men, its anatomical position tends to be, you could think, more kind of behind the bladder and sort of encompassing a tube that leads from the bladder that drains out urine. The prostate itself produces a protein. And so this kind of is something we'll probably talk about a little bit more, but prostate specific antigen, this then is a protein that comprises seminal fluid. And so it produces that protein that then becomes a component of that.
- [04:14]
A
Do we know why it is such a common cancer?
- [04:18]
B
So we don't really have a clear understanding of why we know, you know, different risk factors we obviously understand for the development of it. So one of the most common things is age. So about 70% of the cases diagnosed in men are in men over age 65. We know that family history plays a role in this. So those with a first degree relative who have prostate cancer have a two fold risk of developing disease, whereas those with two first degree relatives have a five fold risk of developing disease. We know that race also plays a role. So there's a much higher incidence of the disease in the United States. In African American men, there's not clear evidence that diet is causal, but we know that there are some associations where having a higher red meat consumption, the diet can be associated with an increased risk, but nothing that's clearly causal there.
- [05:13]
A
It's so interesting to me in how many ways prostate cancer for men almost mirrors statistically breast cancer for women.
- [05:23]
B
Yeah, you know, we look at both of these cancers and so even though they're obviously separate cancers, but then in terms of a commonality, you kind of describe it as a endocrine cancer. Right. So that's kind of a gland sort of cancer in that sense, obviously being very common in each individual sex, but also sharing that kind of general category.
- [05:44]
A
What is the typical timeline in terms of symptom onset to prostate cancer diagnosis?
- [05:51]
B
So this is something that, you know, is actually kind of where the screening and prostate cancer also comes into play and why there's been a lot of debate and discussion there in the recent decade or so as well. So in terms of the timeline to diagnosis and symptom onset, the way that I kind of look at prostate cancer is we have a lot of diagnosis that happens in the asymptomatic stage, which is through screening. But in the symptomatic stage, that can be pretty variable. So symptoms could be anything from what are those associated with, say, just an enlarged prostate bph. And so that can just be issues with urinating. There can be, you know, some trouble with maybe weak streams, et cetera. But then symptoms kind of is sort of spectrum because it can be as mild as that versus a gentleman presenting to an emergency room with severe back pain or difficulty walking. At that point, the prostate cancer is typically very, very advanced. So it's a bit variable there in terms of that timeline to diagnosis.
- [06:54]
A
And then what key role does timing play in terms of fighting prostate cancer? And what are the hurdles many patients face in terms of recognizing early symptoms?
- [07:05]
B
Yeah, so in prostate cancer, early detection is very important. So you're able to kind of keep an eye on the disease going forward. You want to detect before the cancer has spread or is causing severe symptoms. Now, I say severe because there's different kinds of symptoms you can have. When I say severe, meaning back pain and ability to walk, or pain in the bone, specifically, that the prostate cancer is spread there, but also the less severe forms of symptoms, which would include urinary hesitancy or weaker streams. And so the ideal timing is obviously going to be before that you have severe pain in the bones. Absolutely. But, yes, in that earlier part, where maybe it's just some difficulty with urinating or even before that. But we have to differentiate that. Early detection does not equate early treatment.
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A
Okay.
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B
And the reason for this is that prostate cancer is risk stratified based on some of its components. And so what we look at here are the PSA level, which is a level that's detected from the blood. So this is a protein made by the prostate. If you have prostate cancer, then it tends to be made in higher amounts. So that's one thing that we look at in terms of risk stratifying. The other would be how the prostate cancer looks underneath the microscope. This comes out to what's called a Gleason score. And then we also look at what the prostate cancer, its extent of involvement is on exam or on imaging. So that's kind of called a clinical stage. So these things help risk stratify prostate cancer. Now, when we have prostate cancer that's detected early and it falls in the low risk categories, these are the ones that are really managed with active surveillance. And what I mean by that is that active surveillance doesn't mean you're not doing anything, but it means you're not going to surgery or radiation. What you're actually doing is having PSAs checked, digital rectal exams, repeat biopsies on a periodic basis. And the rationale behind this is that these low risk cancers, it's estimated about 50 to 68% of the patients who have these wouldn't need treatment within 10 years of diagnosis. And so some will say, okay, well if I don't need it within 10 years, but I'll need it later, why don't I just get it now? And that's because there are side effects and there are issues when you have surgery or radiation, just as within any medical treatment. And so delaying the time to which you would need that treatment and focusing on quality of life for a patient is something that I think is very important. Just because we can do something doesn't.
- [09:41]
A
Mean you have to.
- [09:42]
B
Exactly.
- [09:43]
A
So it's not even just a wait and see. It is strategize and observe.
- [09:48]
B
Oh, absolutely, absolutely. So yeah, it's not just, you know, oh, you have prostate cancer. I'll see you when I see you. Right. It's you have prostate cancer. But we have a plan for this and our plan is to monitor this in conjunction with you and we're going to do this together. But like, when do you do something right? Let's say it's not 10 years. I'm one of the guys. Within 10 years. Well, that's based on, say the PSA. So if it starts to increase rapidly, if on a repeat biopsy, so these are done periodically. If on that, say the Gleason score change of the prostate cancer upgrades, then that would be another trigger to then intervene. So, yes, it's not sit and wait, but it's actively watch and make sure nothing going on.
- [10:29]
A
Interesting. What do you think are the biggest misconceptions that people have about prostate cancer in general?
- [10:36]
B
One of the biggest things is that you hear the word cancer and you think, I need to treat this now. Right. And I think that's one of the things that we have to really make sure people understand is that you may not have to immediately proceed to treatment. I think the other thing is that there's a lot of misconceptions about what the treatments mean for a person. And I think it really requires discussion with a physician about what your treatment options are and where there's ability to do something different than say, just what one recommendation may be.
- [11:14]
A
That is interesting because you're right. When people hear cancer, they want to be as aggressive as possible. And perhaps the best strategy is much more nuanced and measured.
- [11:24]
B
Yeah, yeah. You hear cancer and you think, I have to fight this. And it's not that you're not fighting this. It's that you are fighting it appropriately in a way that really helps you enjoy life to the best of your ability.
- [11:37]
A
It can't be easy delivering that news to anybody. As a doctor, how do you emotionally prepare for that conversation?
- [11:45]
B
Right. So when we become physicians, we take our Hippocratic oath, and as physicians, we understand that it truly is a privilege to be caring for someone. When someone comes to you and you're two strangers and you walk in through that patient door, the clinic door, all of a sudden you're the most important person in that room. And the connection that you make with that person is very sacred. And so you understand that, yes, this is an honor to be able to take care of someone. A major responsibility as well. And so what that means is that you have to focus on your training and preparation for understanding of how to be able to be pragmatic with someone, but still balancing that with being too blunt. It's kind of a mix of things that you sort of have experienced during all your training that allows you to be able to walk in that room and be able to share with them the news that's going to be important. But letting them know that we have an idea, we have a plan of what we're going to do for this.
- [12:48]
A
And I should imagine anybody in that situation receiving that news is going to immediately go to a place of shock, fear, anxiety. How do you help the patient navigate the information overload, but also detach themselves emotionally enough to be able to wrap their head around treatment?
- [13:12]
B
That's a great question. Some advice that I generally have for patients is if you have someone who can come with you to an appointment that you involve in these decisions, it's great to bring them along, because as you rightly mentioned there, the moment that someone hears about what's going on with them, sometimes they just shut down. And you can be talking and you think they're receiving what you're saying, and at the end, they may have no clue. If you ask them to repeat back what you talked about or what their understanding is, it may just be blank stares. And so it's a matter of sort of going through the visit where you've set the stage and you're kind of doing it in increments. So it's not just an information dump all at once. Right. You kind of Work through things. You're frequently checking in with the patient to see, okay, do you have any questions about that? Are there things that you know you're wondering about there? I think it's also important for patients. So what I frequently advise is after our initial visit, that whenever a random question comes into your head about your disease, you're able to write it down. Because that way, when you come to see me the next time, we can talk about these things and you're not scrambling, oh, what was it that I want to ask? So I think it's a matter of just giving information in increments, checking with the patient to see how they're understanding that, and also understanding how you build on your visits with a patient. So a new patient visit, there's some very important things that need to come across and decisions to be made. And then there are other things that we add in that maybe won't affect the patient's immediate care plan, but would have a role as time goes on.
- [14:51]
A
We talked about the similarities and the parallels between breast cancer for women and prostate cancer for men. But in terms of the emotional impact and the fear that men have when they get that diagnosis, how do you help them process that in terms of being so attached to their masculinity and other fears?
- [15:15]
B
Right. It's through kind of having a very open and honest discussion with them about what it looks like with and without treatment, what things may look like for them, how making the decision to undergo treatment is something that, you know, is obviously a very difficult decision. We understand that. But at the same time, you know, is something that they have to balance. What kind of priorities are important for them?
- [15:44]
A
There are there common misconceptions that patients have about the likely outcome?
- [15:51]
B
So I think one of the common misconceptions is that when they are diagnosed with this, that instantly their lifespan has now just become within a matter of months. And I think that's something that's not necessarily unique to that. I would say, in general, patients, when they hear the word cancer, there's a lot of images and thoughts that are evoked from just maybe things they've seen and movies or TV shows, et cetera. You know, when patients come to see me sometimes, they say, so it's just a couple of months, like, you know, this is it. Right? And, you know, you have to kind of temper that and really let them know that not all cancers are the same things, behave differently, and kind of let them know where their cases are in terms of the spectrum of disease.
- [16:37]
A
And so that is probably how you have to individually tailor treatment to each specific patient. Can you just walk me through the stages of doing that?
- [16:46]
B
Yeah. So we're talking a little bit about risk stratification. And what I'm referring to here is the National Comprehensive Cancer Network risk stratification, so NCCN guidelines. So that's something we commonly use. And so that risk stratification goes from very low risk to very high risk. And it depends on PSA Gleason score and then kind of the clinical staging, meaning what? The prostate cancers anatomic involvement is based on digital rectal examine imaging. And so basically when a patient is first diagnosed with prostate cancer, so this, you know, is confirmed on a biopsy. So then that gives us a Gleason score to start. We have a PSA value that we'll get with that. Sometimes there's some imaging indicated there as well, or maybe it's just digital rectal exam, but that will kind of put the patient in one of these categories. Now, the risk categories are the risk of the patient's cancer progressing or spreading, essentially is kind of what those fall into. And so based on those risk categories, then we kind of look at life expectancy as well. Sometimes you can have men who are diagnosed with a prostate cancer, but they are much later in life. And so at that point, whether or not to even pursue active surveillance can be a question simply because there may be other things, natural causes that may shorten one's life versus the prostate cancer itself. So after you do have risk stratification, life expectancy is a big important part of that. Some patients may have severe other medical issues that are affecting their life expectancy. So those are kind of the initial sort of factors we weigh when trying to decide which sort of treatment route we're going to go with a patient after kind of determining that. So let's say, you know, we have a patient life expectancy, age, et cetera, Everything is within a range that makes sense to pursue treatment. Then the discussion on what treatment is more appropriate kind of comes down to what the patient's tolerance for particular side effects may be. Sometimes there are medical comorbidities that know they don't necessarily limit someone's life significantly to where treating the prostate cancer isn't a appropriate. But they still may mean that, say, radiation may be more appropriate than surgery or something along those lines.
- [19:06]
A
Assessing a variety of risk factors is just the starting point for creating a personalized treatment plan. Balancing each person's unique symptoms and treatment tolerance paves the road to recovery. After the break, we'll continue our conversation with Dr. Atik delving into the advancements made in prostate cancer therapies over the past few decades and how they are reshaping patient outcomes.
- [19:38]
C
There's a lot to take in when learning your advanced cancer has spread on your current treatment and is now called metastatic castration resistant prostate cancer or mcrpc. After all you've been through, you know that every option matters. Pluvicto Lutetium Lu177 Vipivitide Tetraxitan is a prescription treatment for adults with prostate specific membrane antigen positive mcrpc, previously treated with hormone therapy and chemotherapy. It's not chemotherapy. Pluvicto is the first and only radio ligand therapy for PSMA positive mcrpc. It works differently. It targets PSMA positive cells, including prostate cancer cells, and it could be the next step in your journey. Ask your doctor if pluvicto is right for you. Discover more@pluvicto.com Pluvicto involves contact with radioactivity, which may increase your risk for cancer and cause fetal harm. Drink plenty of fluids, urinate often, use contraception and talk to your doctor about ways to reduce the risk of exposing others to radiation. During and after treatment, Pluvicto can cause low levels of blood cell counts, kidney problems and infertility. Tell your doctor if you have weakness, pale skin, shortness of breath, bleeding or bruising, more easily an infection or changes in urination. Side effects include tiredness, dry mouth, nausea, appetite loss and constipation. These are not all the risks of fluvicto. Talk with your doctor.
- [21:12]
A
Now back to my conversation with Dr. Atik. Let's talk about advancements in treatment because obviously there's no good time to receive a diagnosis of cancer, but there's probably been no better time than right now. Tell me about the weapons you would have had in your arsenal 30 years ago as opposed to what you have now.
- [21:39]
B
So 30 years ago we didn't have the radio ligands that we have today. There's a lot of immune therapies that although prostate cancer itself, you know, the disclaimer there is it hasn't been traditionally one where immune therapy has been as successful as compared to say other GU cancers like renal cancer, for example, but we didn't have that. Even chemotherapy had really just come about into usage in prostate cancer more in the late 90s. If we go back 30 years, we're talking right about the time that that came in there. Really what we had was hormone injections, androgen deprivation therapy, and basically steroids and Then there was also a agent called mitoxantrone, but that was really meant to be one that was shown to help with palliation for symptoms, so not really treating the disease. So, you know, you're talking about basically a handful of things that really one was using at the time.
- [22:34]
A
And why are technological advancements so important in terms of treating prostate cancer?
- [22:42]
B
Yeah, so in general, when you look at the population we have, people are living longer. So there are more people who are being diagnosed with prostate cancer. And so while a large number of those people have localized cancers, even out of the localized cancers, so this is about a little bit over a quarter million men are diagnosed every year. And out of that, around 30 to 40% who have treatment will have recurrence of disease. And then that eventually can progress to metastatic disease. And so this is metastatic disease currently is an incurable state of disease. But incurable doesn't mean that we can't control or manage it. And that's where having these treatment options is vitally important. And so what we've seen is that while we've been able to add newer treatments in the past decade or so to improve on the survival of men in these states, cancer has been able to develop mutations or mechanisms of resistance to get around those treatments. And that's where subsequent treatments are important to be able to have in our arsenal.
- [23:44]
A
Wow. So for patients, it's important to find a doctor who is evolving their arsenal as these new advancements come out.
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B
Right. There's a lot of advancements in options that are available, widely available, whether that's a physician in the community or at a tertiary academic center. But then there are options that include clinical trials, and those tend to be more isolated to kind of the larger groups or larger centers. And so those are important things that we have to have available for patients as options.
- [24:23]
A
It's very interesting in terms of cancer trying to outsmart the treatments.
- [24:28]
B
Yeah.
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A
What are radiopharmaceuticals?
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B
So basically you're thinking about a therapy that uses a radioactive particle for treatment. So that's kind of the short way of thinking about that. We've had that in prostate cancer for some time, but we've also had kind of a newer particle added within the last couple of years, getting FDA approval in the form of lutetium. So this is a beta emitter.
- [24:51]
A
We touched upon it a little bit. But why should healthcare providers discuss innovative treatments early with metastatic castration resistant prostate cancer patients?
- [25:04]
B
So in terms of discussing these early, so patients should be able to know what Their options are, I think, you know, when patients hear they have metastatic cancer, their mind just goes to how much time do I have? And you have to also let them know that just because you've heard this diagnosis doesn't mean there's nothing we can do. So letting a patient know about their options upfront, I think kind of frames things for them and gives them a sense that while this is not what we wanted to hear and this is not what we would have desired, we are here together, we're going to do this together, and we have a plan for you.
- [25:39]
A
Are there certain patients that are better candidates for innovative treatments?
- [25:45]
B
Yeah, absolutely. So having a number of treatments in metastatic castration resistant prostate cancer is great, or in metastatic prostate cancer in general. But what we're having to learn and discover in the current field is the sequencing of these treatments. So which one should go first? Right. We know, based on some data, you know, okay, well, yeah, we might start with X treatment and go to the next one. But then there's just kind of a mix of options which can all be appropriate. And so which one going next and which one is the best to continue and lengthens their survival is kind of a big plan discussion.
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A
Do you have a favorite success story that illustrates that?
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B
So we had, you know, a great success story. And this was at my prior program when I was in training and I was working under the guidance of Dr. Robby Madden. So one of my mentors and friends, we had a patient, and this was on a clinical trial that we had there using an immunocytokine and that was in combination with androgen deprivation therapy. So the subcutaneous injections and then docetaxel, which is chemotherapy. And I really like this example because this was a much elderly gentleman. He had just gotten into his early 80s. And you know, when you get here and you have a movie, multitude of options, choosing one most appropriate for you is always a big question. And so there weren't particular mutations or things that would have said he should have one treatment versus another. So he was a great candidate for this study. And on the study, you know, he was able to have over a year and a half, two years on the same treatment in metastatic castration resistant prostate cancer, which the overall survival for this tends to be around two years. But he was still on one treatment in that area. And the reason that that story really stood out to me was, you know, he was a big hockey fan. The patient was able to go to games frequently, he was able to attend his daughter's wedding cross country. He had a very meaningful quality of life without having to undergo different or other treatments. Whereas sometimes certain treatments may be particularly tough for a patient tolerate, it may really limit what they're able to do on a day to day basis.
- [27:56]
A
What are you most excited about in terms of the advancements in terms of treating prostate cancer?
- [28:06]
B
There's a couple of different advancements coming into play, some with phase one and phase two study data. So meaning that, you know, they're being shown to have safety and or some efficacy in the disease state in the last just couple of years here. So we kind of talked about radiopharmaceuticals and I used the example of a lutetium based radiopharmaceutical, you know, and mentioned as that was a beta emitter there, but we also have alpha emitters coming into the play. And so a different kind of form of a radioactive particle. So phase one study ongoing with that. So actinium is one that kind of comes to mind currently another kind of radio pharmaceutical coming into play. The other things that are pretty exciting to me include antibody drug conjugates. And so what these are are basically molecules here, treatments that use a targeting monoclonal antibody. So it's kind of a portion of this treatment is designed to target say a protein that's expressed on prostate cancer cells. And then the other part of the treatment is, is what's considered to be a payload of a cytotoxic particle. And so these have approval and other cancers. And so bringing it to prostate cancer is something that's pretty exciting. And then another thing that actually comes to mind as well, so those are the antibody drug conjugates. But then we also have a form of immune therapy called bispecific T cell engagers. And so basically again has one part of it that targets certain protein and another part of it that brings in a T cell. So basically brings a part of your immune system to a cancer cell and kind of has it recognize it to get a therapeutic effect. So basically overall kind of summarizing it is all comes back to targeted therapies, right? So whether that's in the form of an antibody drug conjugate, a bispecific T cell engager, or in a radio pharmaceutical that's, you know, targeting psma.
- [30:06]
A
As somebody who is so on the cusp of advancements as they're happening, do you find a hesitancy with more traditional or old school providers and patients even to embrace these advancements?
- [30:26]
B
So I think that, you know, My interactions with fellow physicians and, you know, colleagues around the country has been pretty open to clinical trials because part of your training is exposing you to understanding clinical research and trials and the importance of these in developing the treatments that we currently have. So especially being at University of Chicago, we do get a large number of referrals from physicians in the community who have been practicing for a number of years because, you know, they kind of recognize when the standard options may not be appropriate for patients. There can be obviously some skepticism, and this isn't, I don't think, unique necessarily to physicians in the field for longer durations versus, you know, some who are just out of kind of training. But, you know, there can be some skepticism about a trial, but that tends to be more on scientific merit. So there can be debates about these things. Right. That's why we're doing trials. We don't know that X treatment is really going to change the world. That's why we're obviously trying to learn about it. I think for patients there can be some hesitancy as well. So, you know, when you use the word clinical trial, sometimes, you know, just a kind of flat out response is, you know, doc, I don't want to be a guinea pig.
- [31:37]
A
I was going to say guinea pig is the first.
- [31:39]
B
Right. And obviously, you know, in past years, with recent climate and questions about some treatments that were around during the pandemic and all, you know, from patient side and a lot of misinformation that had kind of been felt around, there's a higher sense of sort of maybe a garden nature at times from patients that you may meet. But it's really on physicians to explain kind of what we're doing and why we're doing it. And you know, I think through that, when you're able to kind of let the patient know first, you are there to establish a relation with the patient. When you are there and they know that you're there to care for them and you, you're on the same team with them. I think that makes it easier to bring up these subjects of some unknown therapy and when it may or may not be appropriate for them.
- [32:25]
A
You just answered it. But I was going to touch upon the challenges that healthcare providers face in terms of new treatment plans.
- [32:34]
B
Absolutely. I mean, again, it comes back to, while looking up and trying to understand as much about your disease as possible is great, there can be a lot of less reliable sources out there that make it difficult for people to understand their care to the level that's needed to make a well informed decision. So that is kind of, I think, one of the bigger challenges in terms.
- [32:56]
A
Of well informed decision. How do you navigate the topic of risk in terms of treatment with your patients?
- [33:04]
B
In terms of that, we have adverse effects of treatments which are important for patients to understand. So what those possibly are. Now, as you can imagine, that list of adverse effects can be pretty long. Anything from things that, yes, okay, we're more likely to see this to this was reported. And I don't know that in treating, you know, 300, 400 patients I've ever seen this happen. And so I think, you know, you obviously relay the risk, you provide information in written form as you can, and then obviously letting them know of any sort of important additional potential adverse risks. So there are some very uncommon things, but can be particularly severe that you make sure patients are aware of.
- [33:45]
A
So you're constantly monitoring and adjusting?
- [33:49]
B
Oh, absolutely, absolutely. So if you initiate a patient on treatment, then ultimately you are the one who's making sure that if there's any issues or problems that come up, that those are being managed and as best as you can, being cut off before they become major issues.
- [34:05]
A
How much is avoiding recycling existing therapies a factor when you are creating a treatment plan?
- [34:13]
B
Yeah, so that's something we definitely look at in terms of, especially in metastatic prostate cancer. So you're essentially trying to get as much mileage as you can out of every treatment option. Right. And you want to be able to go through and use it until the point at which maybe the cancer develops a sort of resistance mechanism to that. There are scenarios in which reusing therapies that have been used before are reasonable. But the way that I kind of look at it is more if a patient has progressed on. So, and what I'm thinking about here is one of the chemotherapy options in mind, but also one of the oral second generation androgen receptor pathway inhibitors. So these are two, two common drugs used in metastatic prostate cancer. And so there is some sense of, well, if someone progresses on, say, one of the ARPIs for short or one for the chemotherapy, then maybe you could come back to that same chemotherapy or the arpi. Now that concept is there, but in the field we understand that, especially in particular when it comes to ARPIs, if one has progressed on them, coming back to a different form of it is unlikely to produce a meaningful benefit. And so that's where having all these other treatment options, including the radio, pharmaceuticals and clinical trials, come into play.
- [35:28]
A
We've talked a lot about treatment options and also the importance of having a support Person for someone who receives a diagnosis in terms of processing the information and helping navigate treatment. But on your end, I know with breast cancer there's a very much a team approach. Is there a medical team approach to prostate cancer and ideally, who would be on your team?
- [35:54]
B
Yeah, absolutely. So there are some patient interfacing team members and there are some who work more directly with the physicians involved in this case and the other clinical staff involved in this case. So in terms of patient facing members, so there it can be a urologist, a radiation oncologist, a medical oncologist. Obviously our nurses, who are a major backbone and really do a lot of interactions and care with our patients, They're a big part of the patient facing team approach. We also have members of the team who don't necessarily have patient facing roles, but have critical roles in the treatment of this patient. So that includes pathologists and then radiologists as well. There's also nuclear medicine physicians that can be involved depending on the treatment. So it can be a pretty broad group of people working together to take care of you.
- [36:44]
A
Is there also an emotional psychological component that you find certain patients need?
- [36:52]
B
Yes, absolutely. I mean, we do have psychological support and all through our center and there's other resources available for patients for that. Because it is critically important for patients. It's sometimes hard to wrap your head around the diagnosis. You know, it's hard to just get that first step in. But also, even with the treatment options or understanding what that looks like, having the support of people who have gone through the same situation, or from psychologists or in some cases psychiatrists, if there are issues with emotional adjustment to this, can be very helpful.
- [37:27]
A
Yeah. Because I should think that, you know, for men it's as equally loaded and complicated an emotional journey to process.
- [37:36]
B
Yeah, absolutely. Just cancer in general carries that. Right. And then also because, you know, there is a lot of thought about the treatment we're using does lower the man's testosterone, can affect things on a very emotional and personal level for them. And so these are things that do require, you know, more support than just from the medical side of things.
- [38:01]
A
How has your specialty changed you personally in terms of your relationships with patients? And just looking back, how has it shaped you as a doctor?
- [38:14]
B
So I think going into being a physician and kind of gravitating more into medical oncology, I think personally you've really had to exercise a much greater degree of empathy than I probably possessed before. To be very frank, I treat prostate cancer all the time. I may be able to, you know, sit there and I'M not worried at all about something, but that's because of what I see and what I do every day. And so I think personally, you know, it's kind of made it to where you really have to sit there and really put yourself in the other person's shoes a lot more. So, and really kind of think, okay, if this is someone coming in who has little to no understanding or doesn't have this training, doesn't see this all the time, then how are they going to feel about this? What could be going through their head? And I think that's probably one of the biggest things that I always try to keep in mind with my patients.
- [39:06]
A
I love that. I love that your empathy has evolved and progressed, as have the treatments. What would you like listeners to take away?
- [39:18]
B
So, a couple of key things. One is that when you have prostate cancer, not treating it in some cases is a reasonable option, and that comes down to how it may affect your life and how the disease evolves. There's, you know, hundreds of men who, you know, would undergo procedures and things when they could very well have just been monitored and watched for several years. So I think that's one key thing. The other is that there are, are a lot of new technologies coming into play in prostate cancer, and we're learning the best ways to utilize those. But I think it's important to understand that while these are there, some of these are not appropriate for every scenario. And so it's good for patients to read and do their own research and learn about what's out there, but also to understand that having every test done or every procedure, every treatment is not necessarily the ideal way to go about treating something, to managing a disease. You know, you can lead to a lot of over diagnosis, over treatment and issues there. I think the other thing is that just because you have prostate cancer doesn't mean you don't have options. And so I think that's, you know, kind of a key thing I think all people keep in mind. I obviously encourage patients do their own research, but in doing so, you know, talk to your physician, see what they might recommend as an appropriate resource, and you'll go from there.
- [40:41]
A
And then on the flip side of that coin, what do you want healthcare providers to take away?
- [40:47]
B
So I think that it actually kind of comes down to almost similar advice. So in terms of when we're advising patients, we need to make sure that we're doing a good job of informing them about the risk of the disease that they have, about the risk of the treatments associated with it. But we also have to be keeping up with the latest advancements in our area so that we understand when it's appropriate to use something or not. There can be over diagnosis or over treatment with all the new technologies and things that are available. And so it's on us to kind of be understanding when it's appropriate to use something or not.
- [41:26]
A
Is there anything else you'd like to add?
- [41:28]
B
No, I'm just really thankful for the opportunity to be on today and to talk with you all. And obviously for any patients out there who are being faced with this diagnosis, there's teams of people across the country working on this, trying to come up with advancements and there to support you.
- [41:44]
A
Excellent answer. Thank you Dr. For speaking with us.
- [41:47]
B
No, thank you very much for having me. I really appreciate it.
- [41:54]
A
Thanks for listening Listening to this special episode of Symptomatic Be on the lookout for all new episodes of Symptomatic in the coming months. And if you haven't already, be sure to go back and check out our two part episode on Dr. David Fagenbaum. Seemingly in the prime of his life, David went from determined medical student to dying in the ICU in a matter of days.
- [42:17]
B
I'll never forget my doctor walking into the room and saying, david, your liver, your kidneys, your bone marrow, your heart and your lungs are shutting down. I was just treating patients down the hall.
- [42:32]
A
Follow David's race against the clock for a diagnosis as his efforts towards finding life saving treatment for himself quickly become the first piece of an even larger puzzle. As always, we would love to hear from you. Send us your thoughts on this episode or share a medical mystery of your own@ symptomaticheartmedia.com and please don't forget to rate and review Symptomatic Wherever you get your podcasts, we'll see you next time. Until then, be well.
- [43:12]
C
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