Transcript
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Dr. Tagawa:
This is CE on ReachMD, and I'm Dr. Scott Tagawa. Here with me today is Dr. Mary-Ellen Taplin. Let's jump in. How do you identify which patients with metastatic HSPC are most appropriate for treatment intensification with ADT and ARPI?
Dr. Taplin:
Thank you, Scott. It's a very important question. Today in our genitourinary clinical practices, we see a lot of patients with metastatic hormone-sensitive prostate cancer, and drawing up an initial treatment plan for them takes a lot of thought and consideration.
The things that I think about first are whether the patients presented with synchronous or metachronous prostate cancer. That is, have they had prostate cancer for many years, had local therapy, and now they have metastatic disease? Or a more poor prognostic group is, did they get diagnosed initially with metastatic hormone-sensitive prostate cancer?
So I take that into consideration, and then the next thing I look at is: do they have high-volume or low-volume disease? And I use criteria sort of loosely, more or less, from the CHAARTED trial. In my mind, I think of, is it 4 or more metastases or less than 4 metastases, sort of in general.
And then the next thing I look at is, where are those metastases? Do they have visceral metastasis? For instance, do they have liver metastasis, which are a poor prognostic feature. Other types of visceral metastasis, like lung metastasis, I think of as more favorable than liver metastasis. But in the end, I'm considering all the sites of disease for the patient.
So those are the types of things that I look at initially. And then of course, I look at the overall health of the patient and what their underlying medical issues are while I'm thinking of the treatment plan that I'm drawing up for them.
And then, after I take all those things into consideration—the volume of disease, the sites of disease, the general health of the patient—I will make a treatment plan with consideration for doublet therapy, ADT plus ARPI, or triplet therapy: ADT, ARPI, plus chemotherapy, usually docetaxel.
And then I will also give consideration, especially in the low-volume patients, for adding some radiation treatment to the prostate, especially for the low-volume situation, but also sometimes I also consider it to reduce risk of future GU problems in high-volume patients.
And then lastly, I will consider SBRT to oligometastatic sites. Although our data for that is evolving, I will consider that especially in the very low-volume patients.
Dr. Tagawa:
Yeah, I think there's a lot of different aspects to cover any individual patients. One of the comments about volume is—you know based on CT and bone scan, and you know we don't always have that—should we do that if we start off with a PET scan that shows a lot of metastases?
But, I agree, we're going to look at the tumor—what we can in terms of the distribution, the presentation, etc.—certainly the patients’ comorbidities, etc., and of course the patients and their families wishes, and then hopefully do what we can to maximize both duration of cancer control as well as overall survival and maintenance of quality of life.
Dr. Taplin:
I would like to add also, Scott, that the patient's goals and their underlying health are very important to these considerations for treatment plans for metastatic hormone-sensitive prostate cancer patients. A patient's age and their overall life expectancy and goals of course need to be considered. But then a careful detailed medical history regarding their underlying health, with special attention in these treatment decisions for underlying cardiovascular health, I believe, is very important. And for the patients with hypertension that's not adequately controlled, all of the ARPIs can influence hypertension, and we need vigilance for treating these patients and ensuring that we don't add to their health burdens more by adding up the complications.
So understanding the overall health of the patient, taking a detailed medical history, taking these factors into consideration when choosing doublet versus triplet therapy, and in specifics, choosing which ARPI is best for a patient.
Dr. Tagawa:
Meaningful conversations like this lead to better care decisions. Until next time.
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Global Learning Collaborative (GLC) has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit(s) for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credit(s). Approval is valid until Jun
