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Androgen Deprivation Therapy for Prostate Cancer: Involving Primary Care

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: Tuesday, Dec 20, 2016



Transcript:

E. David Crawford, MD:
We just had a really nice discussion about laying the foundation for the multidisciplinary approach, the shared care. And I think a lot of, at least academic institutions, when they think about the multidisciplinary approach, it’s like we have a radiation oncologist, medical oncologist, and urologist. I think what we’re talking about is broader than that. We’re talking about really involving the primary care doctor who these patients have been with for years. And, as urologists, we happen to see prostate cancer early. So, we’re sort of making the diagnosis, thanks to patients being referred to us. And we talked about how there needs to be a clear signal for family practice doctors—a PSA cutoff below which there’s low risk, above which there’s risk and you go to the next level. And it’s like you’ve said to me many times, you do get a blood sugar, but you don’t start treating diabetes. You get an A1C or somebody has an abnormal EKG, they get referred for angiogram or something else. Let’s talk about androgen deprivation therapy because that’s the baseline. Now, we’re finding all these things that occur with androgen deprivation therapy, and probably the most significant one, and I need to talk to you about this, Matt, is cardiovascular. It seems to be that men who have preexisting cardiovascular disease are at very high risk of having a fatal event. Tell us about that. I have a guy who’s 75 years-old and he’s on ADT, and so he’s had an MI (myocardial infarction) in the past. What should we do? You need to know they’re on ADT. That’s communication, and then what happens?

Matthew T. Rosenberg, MD: Absolutely. I want to know those things. I would challenge you here because I’d like to know before he goes on ADT.

E. David Crawford, MD: Okay.

Matthew T. Rosenberg, MD: That’s the phone call. That’s the, “Hey, Matt, we have this guy, we want to do ADT, can you be involved in that process?” I would be really happy with that, and then I’ll bring him in and say, “This is what the doctor wants to do for you, and I’m going to look at your risk factors.” Now, an 80-year-old with a prior MI, I guarantee you I’m going to make a phone call to his cardiologist and he’s going to get evaluated. I can do that quickly. I can make a phone call, get that done quickly, and any primary care doctor can. We’re not going to delay his therapy. We’re just going to make sure he’s okay for it. Let’s say I have a patient who’s younger than that, who didn’t have a heart attack, I’m going to look at those risk factors. There’s a difference between a 60-year-old athletic male, where the only problem is prostate cancer, and the same patient who’s got a history of smoking, a history of high cholesterol, and a history of hypertension. So, we’re going to look at the risk factors and then make a decision on what to do next. It’s really easy for me to even call a cardiologist and just ask, “Should this guy get evaluated? These are the risk factors, and this is what we want to do.” And that doesn’t mean the patient has to go, so I might be able to streamline the process. But now we’ve looked at all the angles, we’ve informed the patient, and, just as you said, we’re working as a team.

E. David Crawford, MD: What triggers you to say, “Okay, I don’t feel comfortable handling this, I’m going to call a cardiologist.” I think most primary care guys are in pretty good shape to handle all of this, right?

Matthew T. Rosenberg, MD: I think we are, and we know when to call. We’re going to look at the patient, look at the risk factors, assess the situation, and do what’s best for that patient. Presumably, they would have had a screening EKG in the office. That will be part of the start of what we do, then we’re going to look at their medications, we’re going to look at their medical history and decide. But we do this for so many disease states. What are your risks of this, and what do we need to watch for?

E. David Crawford, MD: There are Web-based things, too, you can do, questionnaires about risk factors.

Matthew T. Rosenberg, MD: Well, [you can use] questionnaires, but I’m old school. There’s nothing like putting my hands on a patient.

E. David Crawford, MD: Okay. Dan, you give a lot of ADT. I’m thinking about 80-year-old guys I saw years ago that I would put on androgen deprivation therapy, and then a year later, they’d have a heart attack and die. I’d ask, “Well, that’s just what happens when you’re older.” And you see that enough and you’ve got to ask, “Did I induce that?” What are your thoughts about this?

Daniel P. Petrylak, MD: I think it’s very, very important, as you and Matt were saying before, that you need to talk to your patient about what their goals are. I had a perfect example of this yesterday in clinic: a gentleman who had minimal metastatic disease, an avid bicycle enthusiast; this was his major source of social interaction with people. Now that he’s been on ADT for 6 months, he’s short of breath, he’s put weight on, his muscle mass is down, and he can’t go and be with his friends and do what he likes to do. So, we had a long discussion yesterday about whether that extra life or time that he would have on androgen deprivation therapy would be worth the continuation and the risk with metastatic disease. I think you’re absolutely right. We really didn’t anticipate a lot of these particular problems: the weight gain, the loss of muscle mass, the fatigue—which is particularly important—and the cardiovascular issues. You can’t just simply ascribe these to old age in these patients, and, in fact, this is more of an issue as we become better at our treatments for metastatic disease. These patients live longer. We need to be more aware of what their general health is. So, for example, back in the 1990s, a patient with castrate-resistant prostate cancer lived a year. Now they’re living 3 years, at least from data from Provenge and Dendreon, at least that amount. They have to be cared for during that period of time, and these treatments that they receive have long-term implications.

Transcript Edited for Clarity
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Transcript:

E. David Crawford, MD:
We just had a really nice discussion about laying the foundation for the multidisciplinary approach, the shared care. And I think a lot of, at least academic institutions, when they think about the multidisciplinary approach, it’s like we have a radiation oncologist, medical oncologist, and urologist. I think what we’re talking about is broader than that. We’re talking about really involving the primary care doctor who these patients have been with for years. And, as urologists, we happen to see prostate cancer early. So, we’re sort of making the diagnosis, thanks to patients being referred to us. And we talked about how there needs to be a clear signal for family practice doctors—a PSA cutoff below which there’s low risk, above which there’s risk and you go to the next level. And it’s like you’ve said to me many times, you do get a blood sugar, but you don’t start treating diabetes. You get an A1C or somebody has an abnormal EKG, they get referred for angiogram or something else. Let’s talk about androgen deprivation therapy because that’s the baseline. Now, we’re finding all these things that occur with androgen deprivation therapy, and probably the most significant one, and I need to talk to you about this, Matt, is cardiovascular. It seems to be that men who have preexisting cardiovascular disease are at very high risk of having a fatal event. Tell us about that. I have a guy who’s 75 years-old and he’s on ADT, and so he’s had an MI (myocardial infarction) in the past. What should we do? You need to know they’re on ADT. That’s communication, and then what happens?

Matthew T. Rosenberg, MD: Absolutely. I want to know those things. I would challenge you here because I’d like to know before he goes on ADT.

E. David Crawford, MD: Okay.

Matthew T. Rosenberg, MD: That’s the phone call. That’s the, “Hey, Matt, we have this guy, we want to do ADT, can you be involved in that process?” I would be really happy with that, and then I’ll bring him in and say, “This is what the doctor wants to do for you, and I’m going to look at your risk factors.” Now, an 80-year-old with a prior MI, I guarantee you I’m going to make a phone call to his cardiologist and he’s going to get evaluated. I can do that quickly. I can make a phone call, get that done quickly, and any primary care doctor can. We’re not going to delay his therapy. We’re just going to make sure he’s okay for it. Let’s say I have a patient who’s younger than that, who didn’t have a heart attack, I’m going to look at those risk factors. There’s a difference between a 60-year-old athletic male, where the only problem is prostate cancer, and the same patient who’s got a history of smoking, a history of high cholesterol, and a history of hypertension. So, we’re going to look at the risk factors and then make a decision on what to do next. It’s really easy for me to even call a cardiologist and just ask, “Should this guy get evaluated? These are the risk factors, and this is what we want to do.” And that doesn’t mean the patient has to go, so I might be able to streamline the process. But now we’ve looked at all the angles, we’ve informed the patient, and, just as you said, we’re working as a team.

E. David Crawford, MD: What triggers you to say, “Okay, I don’t feel comfortable handling this, I’m going to call a cardiologist.” I think most primary care guys are in pretty good shape to handle all of this, right?

Matthew T. Rosenberg, MD: I think we are, and we know when to call. We’re going to look at the patient, look at the risk factors, assess the situation, and do what’s best for that patient. Presumably, they would have had a screening EKG in the office. That will be part of the start of what we do, then we’re going to look at their medications, we’re going to look at their medical history and decide. But we do this for so many disease states. What are your risks of this, and what do we need to watch for?

E. David Crawford, MD: There are Web-based things, too, you can do, questionnaires about risk factors.

Matthew T. Rosenberg, MD: Well, [you can use] questionnaires, but I’m old school. There’s nothing like putting my hands on a patient.

E. David Crawford, MD: Okay. Dan, you give a lot of ADT. I’m thinking about 80-year-old guys I saw years ago that I would put on androgen deprivation therapy, and then a year later, they’d have a heart attack and die. I’d ask, “Well, that’s just what happens when you’re older.” And you see that enough and you’ve got to ask, “Did I induce that?” What are your thoughts about this?

Daniel P. Petrylak, MD: I think it’s very, very important, as you and Matt were saying before, that you need to talk to your patient about what their goals are. I had a perfect example of this yesterday in clinic: a gentleman who had minimal metastatic disease, an avid bicycle enthusiast; this was his major source of social interaction with people. Now that he’s been on ADT for 6 months, he’s short of breath, he’s put weight on, his muscle mass is down, and he can’t go and be with his friends and do what he likes to do. So, we had a long discussion yesterday about whether that extra life or time that he would have on androgen deprivation therapy would be worth the continuation and the risk with metastatic disease. I think you’re absolutely right. We really didn’t anticipate a lot of these particular problems: the weight gain, the loss of muscle mass, the fatigue—which is particularly important—and the cardiovascular issues. You can’t just simply ascribe these to old age in these patients, and, in fact, this is more of an issue as we become better at our treatments for metastatic disease. These patients live longer. We need to be more aware of what their general health is. So, for example, back in the 1990s, a patient with castrate-resistant prostate cancer lived a year. Now they’re living 3 years, at least from data from Provenge and Dendreon, at least that amount. They have to be cared for during that period of time, and these treatments that they receive have long-term implications.

Transcript Edited for Clarity
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