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Monitoring Patients During Treatment for Advanced Prostate Cancer

Insights From: E. David Crawford, MD, University of Colorado in Denver; Matthew T. Rosenberg, MD, Allegiance Health Systems; Daniel Petrylak, MD, Yale School of Medicine
Published Online: Thursday, Dec 29, 2016



Transcript:

E. David Crawford, MD:
Let’s move on to more advanced castrate-resistant disease. It used to be called ‘androgen independent,’ ‘hormone refractory,’ and now it’s ‘castrate resistant.’ Dan, what are your thoughts about that terminology? Does it really matter? Does it make you feel comfortable, or patients feel comfortable?

Daniel P. Petrylak, MD: It’s interesting you bring this up because I had a discussion about this with a patient on Monday this week. And he mentioned that he feels that ‘castration resistant’ is a pejorative term. He doesn’t like the term ‘castrate.’ I actually brought up the editorial that you and I wrote for JCO about endocrine resistant or primary endocrine-resistant prostate cancer. Patients don’t like that term, and they hate hearing the word ‘castrate’ come back at them.

E. David Crawford, MD: And ‘resistant.’

Daniel P. Petrylak, MD: And ‘resistant’ at the same time. I guess ‘failure’ is not a word you want to use in front of a patient either, but ‘endocrine resistant’ or ‘endocrine-progressive disease’ will be a better way of describing it.

E. David Crawford, MD: That was all started just because you still respond to some of these new drugs, androgen biosynthesis inhibitors like Zytiga, or abiraterone, which I want to get into now. From when these drugs were studied, in the last 7 years, there have been 5 new drugs. There has been abiraterone, and that was studied in Cougar 301 and 302, pre- and post-chemotherapy. We had radium come along, and that was a breakthrough. And then, we had enzalutamide. We had Provenge and cabazitaxel. So, we have 5 new drugs. They’re all different. That’s exciting. They’re all different.

Daniel P. Petrylak, MD: All different mechanisms—really, 4 different mechanisms. When it comes down to it, you have hormonal agents, you have immune agents, and then you have DNA-damaging agents, such as radium. So, we have different treatments to choose. The trouble is, how do we sequence them? That’s really the big challenge for the urologists and oncologists.

E. David Crawford, MD: Let’s focus on androgen biosynthesis inhibitors, Zytiga, or abiraterone, right now. That was one of the first breakthrough drugs, and what it did was teach us that testosterone’s king. And lowering it more, you had unexpected benefits that a lot of us didn’t expect to see after chemotherapy. That got that approved. All these drugs are moving up earlier now, right? Where are we with the earliness, so to speak?

Daniel P. Petrylak, MD: Well, if we talk about early in the state of metastatic disease, docetaxel, right now, is the only one that has level 1 evidence. We know that there’s about an 18-month improvement in survival.

E. David Crawford, MD: CHAARTED study, right?

Daniel P. Petrylak, MD: From the CHAARTED study, right, showing for patients with high-volume disease, more than 4 lesions on bone scan or liver metastases. We’re looking to move up drugs like abiraterone and enzalutamide into the same space. One would think that a more prolonged deprivation or more profound deprivation of testosterone would lead to better survival, but that hypothesis still needs to be tested.

E. David Crawford, MD: These drugs are being studied in biochemical failure. We just did a large trial called the IMAGINE trial moving abiraterone up in the pre- castrate-resistant metastatic stage and having a prolonged survival rate. There’s no question that they move up. These drugs all have pretty unique side effects. They’re well tolerated. This is all about shared care. Sometimes urologists are a little apprehensive about using some of these drugs because they worry about, can I manage the side effects? And that’s where the shared care comes in. Let’s talk about abiraterone, or Zytiga. Pretty well-tolerated drug, but it says that we need to monitor potassium, and there’s a reason for that to occur. We need to look at liver enzymes. We need to look at blood pressure and things like that. Urologists say, “Well, we don’t do that in our office. We don’t draw blood.” Is there a way to work with you guys with these?

Matthew Rosenberg, MD: Pick up the phone. Just give me a call. We do this all the time. That’s the interesting thing. For example, we talk about potassium.

E. David Crawford, MD: It scares urologists. If the potassium is like 3.8, they go, “Oh my gosh,” and that’s not a worry.

Matthew Rosenberg, MD: It does scare you. And, remember, this is what I do all the time. We’ve had to deal with this recently with some other drugs that you all use that will change blood pressure—some of the medications we use for overactive bladder. Blood pressure doesn’t scare me. Just send them over. We have blood pressure cuffs. My guess is you don’t have them as readily available.

E. David Crawford, MD: We don’t know what to use.

Matthew Rosenberg, MD: Yes, I am okay with that. But, I don’t do what you do. So, you call me up and we take care of it. I check potassium regularly on my patients on diuretics. That’s easy. I check their blood pressure periodically. I check liver enzymes for patients who are on drugs, like the statin class of drugs. We don’t check it as frequently as we used to, but we’re still aware of it. And, then, we take care of it. So, if your SGOT (serum glutamic oxaloacetic transaminase) or your SGPT (serum glutamic-pyruvic transaminase) are high, I take care of it.

E. David Crawford, MD: That’s a very good point. The diuretics, you can get a low potassium. Urologists know that, but they don’t. Some are probably on the drugs. And it’s the same way with statins. You just mentioned that with liver enzymes, and so these are things that happen.

Matthew Rosenberg, MD: Right.

Daniel P. Petrylak, MD: For example, my biggest concern is with managing blood pressure because, often, these patients have cardiovascular disease, have other multiple medications that they’re on. I will always call up the primary care doctor, the cardiologist, to be sure that the medication I want to increase is the right one, or to ask what their opinion is as to what’s the proper increase.

Matthew Rosenberg, MD: There’s a very easy answer on that, that’s actually easy on the patient. So, if I’m making an adjustment, say, for blood pressure, I’ll tell the patient come in once a week for 6 weeks. You don’t see me, so they don’t have that office charge. If your blood pressure is abnormal, the nurses are going to get you back and we’ll talk about it. So, guess what, you can put them on the medicines, and say, “Matt, I want the blood pressure checked.” We’ll say, “Fine, just have them come in during the lunch hour, get their blood pressure checked, and if it’s high, I’ll see them. If not, we tell them they’re in good shape.”

E. David Crawford, MD: A lot of times, these things, at least in our Epic system and electronic medical record, can be sort of routine in the treatment plan. We get potassium every 2 weeks. What I’ve done a lot of times, I treat a lot of guys from way far away—Wyoming, South Dakota; they’re being managed—and I work with a primary care guy about checking the potassium and all those things, and it’s fine. You don’t have to be fearful. And, I actually feel more comfortable having them take care of the total picture as we’ve just been talking about.

Matthew Rosenberg, MD: And, my guess is, when you’re seeing somebody in Denver but who lives in Wyoming, you’re contacting that primary care doctor one way or another and you’re handing the baton off. You’re making sure that that baton is grabbed by them and they’re going to run with it, and that is so crucial to do that. Again, it doesn’t seem like it’s that hard to do, but, for some reason, we’ve gotten away from that. So, if any of the urologists or any of the oncologists can just contact the doctor, make sure they are aware, we’re happy to do it.

E. David Crawford, MD: It is very important to discuss. We’re putting this patient on abiraterone and these are the things that every primary care doctor doesn’t know, like what the drug is, but they find out and then you get the same thing. When we’re following some that you’re doing with chemotherapy, they follow up with their family-care guys. Knowing about seizures with some of these drugs and things like that, it’s all out there. It’s a matter of education in that. And, then, that makes for a really happy situation when you’re doing that with patients.

Transcript Edited for Clarity
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Transcript:

E. David Crawford, MD:
Let’s move on to more advanced castrate-resistant disease. It used to be called ‘androgen independent,’ ‘hormone refractory,’ and now it’s ‘castrate resistant.’ Dan, what are your thoughts about that terminology? Does it really matter? Does it make you feel comfortable, or patients feel comfortable?

Daniel P. Petrylak, MD: It’s interesting you bring this up because I had a discussion about this with a patient on Monday this week. And he mentioned that he feels that ‘castration resistant’ is a pejorative term. He doesn’t like the term ‘castrate.’ I actually brought up the editorial that you and I wrote for JCO about endocrine resistant or primary endocrine-resistant prostate cancer. Patients don’t like that term, and they hate hearing the word ‘castrate’ come back at them.

E. David Crawford, MD: And ‘resistant.’

Daniel P. Petrylak, MD: And ‘resistant’ at the same time. I guess ‘failure’ is not a word you want to use in front of a patient either, but ‘endocrine resistant’ or ‘endocrine-progressive disease’ will be a better way of describing it.

E. David Crawford, MD: That was all started just because you still respond to some of these new drugs, androgen biosynthesis inhibitors like Zytiga, or abiraterone, which I want to get into now. From when these drugs were studied, in the last 7 years, there have been 5 new drugs. There has been abiraterone, and that was studied in Cougar 301 and 302, pre- and post-chemotherapy. We had radium come along, and that was a breakthrough. And then, we had enzalutamide. We had Provenge and cabazitaxel. So, we have 5 new drugs. They’re all different. That’s exciting. They’re all different.

Daniel P. Petrylak, MD: All different mechanisms—really, 4 different mechanisms. When it comes down to it, you have hormonal agents, you have immune agents, and then you have DNA-damaging agents, such as radium. So, we have different treatments to choose. The trouble is, how do we sequence them? That’s really the big challenge for the urologists and oncologists.

E. David Crawford, MD: Let’s focus on androgen biosynthesis inhibitors, Zytiga, or abiraterone, right now. That was one of the first breakthrough drugs, and what it did was teach us that testosterone’s king. And lowering it more, you had unexpected benefits that a lot of us didn’t expect to see after chemotherapy. That got that approved. All these drugs are moving up earlier now, right? Where are we with the earliness, so to speak?

Daniel P. Petrylak, MD: Well, if we talk about early in the state of metastatic disease, docetaxel, right now, is the only one that has level 1 evidence. We know that there’s about an 18-month improvement in survival.

E. David Crawford, MD: CHAARTED study, right?

Daniel P. Petrylak, MD: From the CHAARTED study, right, showing for patients with high-volume disease, more than 4 lesions on bone scan or liver metastases. We’re looking to move up drugs like abiraterone and enzalutamide into the same space. One would think that a more prolonged deprivation or more profound deprivation of testosterone would lead to better survival, but that hypothesis still needs to be tested.

E. David Crawford, MD: These drugs are being studied in biochemical failure. We just did a large trial called the IMAGINE trial moving abiraterone up in the pre- castrate-resistant metastatic stage and having a prolonged survival rate. There’s no question that they move up. These drugs all have pretty unique side effects. They’re well tolerated. This is all about shared care. Sometimes urologists are a little apprehensive about using some of these drugs because they worry about, can I manage the side effects? And that’s where the shared care comes in. Let’s talk about abiraterone, or Zytiga. Pretty well-tolerated drug, but it says that we need to monitor potassium, and there’s a reason for that to occur. We need to look at liver enzymes. We need to look at blood pressure and things like that. Urologists say, “Well, we don’t do that in our office. We don’t draw blood.” Is there a way to work with you guys with these?

Matthew Rosenberg, MD: Pick up the phone. Just give me a call. We do this all the time. That’s the interesting thing. For example, we talk about potassium.

E. David Crawford, MD: It scares urologists. If the potassium is like 3.8, they go, “Oh my gosh,” and that’s not a worry.

Matthew Rosenberg, MD: It does scare you. And, remember, this is what I do all the time. We’ve had to deal with this recently with some other drugs that you all use that will change blood pressure—some of the medications we use for overactive bladder. Blood pressure doesn’t scare me. Just send them over. We have blood pressure cuffs. My guess is you don’t have them as readily available.

E. David Crawford, MD: We don’t know what to use.

Matthew Rosenberg, MD: Yes, I am okay with that. But, I don’t do what you do. So, you call me up and we take care of it. I check potassium regularly on my patients on diuretics. That’s easy. I check their blood pressure periodically. I check liver enzymes for patients who are on drugs, like the statin class of drugs. We don’t check it as frequently as we used to, but we’re still aware of it. And, then, we take care of it. So, if your SGOT (serum glutamic oxaloacetic transaminase) or your SGPT (serum glutamic-pyruvic transaminase) are high, I take care of it.

E. David Crawford, MD: That’s a very good point. The diuretics, you can get a low potassium. Urologists know that, but they don’t. Some are probably on the drugs. And it’s the same way with statins. You just mentioned that with liver enzymes, and so these are things that happen.

Matthew Rosenberg, MD: Right.

Daniel P. Petrylak, MD: For example, my biggest concern is with managing blood pressure because, often, these patients have cardiovascular disease, have other multiple medications that they’re on. I will always call up the primary care doctor, the cardiologist, to be sure that the medication I want to increase is the right one, or to ask what their opinion is as to what’s the proper increase.

Matthew Rosenberg, MD: There’s a very easy answer on that, that’s actually easy on the patient. So, if I’m making an adjustment, say, for blood pressure, I’ll tell the patient come in once a week for 6 weeks. You don’t see me, so they don’t have that office charge. If your blood pressure is abnormal, the nurses are going to get you back and we’ll talk about it. So, guess what, you can put them on the medicines, and say, “Matt, I want the blood pressure checked.” We’ll say, “Fine, just have them come in during the lunch hour, get their blood pressure checked, and if it’s high, I’ll see them. If not, we tell them they’re in good shape.”

E. David Crawford, MD: A lot of times, these things, at least in our Epic system and electronic medical record, can be sort of routine in the treatment plan. We get potassium every 2 weeks. What I’ve done a lot of times, I treat a lot of guys from way far away—Wyoming, South Dakota; they’re being managed—and I work with a primary care guy about checking the potassium and all those things, and it’s fine. You don’t have to be fearful. And, I actually feel more comfortable having them take care of the total picture as we’ve just been talking about.

Matthew Rosenberg, MD: And, my guess is, when you’re seeing somebody in Denver but who lives in Wyoming, you’re contacting that primary care doctor one way or another and you’re handing the baton off. You’re making sure that that baton is grabbed by them and they’re going to run with it, and that is so crucial to do that. Again, it doesn’t seem like it’s that hard to do, but, for some reason, we’ve gotten away from that. So, if any of the urologists or any of the oncologists can just contact the doctor, make sure they are aware, we’re happy to do it.

E. David Crawford, MD: It is very important to discuss. We’re putting this patient on abiraterone and these are the things that every primary care doctor doesn’t know, like what the drug is, but they find out and then you get the same thing. When we’re following some that you’re doing with chemotherapy, they follow up with their family-care guys. Knowing about seizures with some of these drugs and things like that, it’s all out there. It’s a matter of education in that. And, then, that makes for a really happy situation when you’re doing that with patients.

Transcript Edited for Clarity
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