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Practical Advice on Follow-Up for Patients with M0 CRPC

Panelists: Judd Moul, MD, Duke Cancer Institute; Neeraj Agarwal, MD, Hunstman Cancer Institute; Tanya Dorff, MD, City of Hope National Medical Center; Alicia Morgans, MD, PhD, Northwestern University Feinberg School of Medicine
Published: Tuesday, Aug 13, 2019



Transcript: 

Judd Moul, MD:
From a practical standpoint, and considering that a lot of the folks listening are going to be urologists, when you start a patient on these drugs, how often do you see them back? Do you see them back every month, every 3 months, etc?

Neeraj Agarwal, MD: There’s no rule, in my view. It is very patient specific. It depends how frail the patient is, whether the patient is working full time and is fully independent, how many comorbidities a patient has, whether they are prone to falls, and if they are cognitively impaired. Those are factors that come into play in that decision making. If I’m seeing an otherwise healthy, full-time-working patient of mine who is golfing on a regular basis, I would say every 3 months is fine. If I have a patient who is on 3 other drugs for cardiovascular conditions, is frail, and is coming into my clinic with a walker or a cane, I would like to see the patient every month.

Judd Moul, MD: Key point. Alicia?

Alicia Morgans, MD, MPH: I agree, and I would say that when I start any medication, I usually have someone come back at 4 weeks if not a bit sooner, depending on these kinds of things and which drug I start. For these drugs, I typically prefer 4 weeks between visits. Based on the same factors, I’ll have them come back every 4 to 6 weeks or every 3 months. I do Lupron every 3 months or so, and I do ADT [androgen deprivation therapy] every 3 months. I will often do either 4 weeks, 6 weeks, or 3 months between visits.

Judd Moul, MD: Yes, it’s important for all the listeners to continue the LHRH [luteinizing hormone-releasing hormone] agents or GnRH [gonadotropin-releasing hormone] agents. These drugs are not FDA approved to be used alone, so a key teaching point is that we don’t want to discontinue the GnRH or LHRH agents when we have patients with nonmetastatic prostate cancer. Tanya, what’s your general follow-up for these guys?

Tanya Dorff, MD: Having been trained through internal medicine, I think any time you start a new medicine, it’s very important to see someone back in 4 to 6 weeks. Enzalutamide’s steady state occurs somewhere around 4 weeks, so that’s a rational time period to check in with the adverse-effect profile. If you’re reverting to the every-3-months schedule, which I do when everything is going smoothly, you have to remember that with the apalutamide, the median onset of rash is about 80 days. You want to warn your patient that this happens, because the time frame is little unusual. You normally take a medicine and get the rash right away. Be on the lookout for that, and counsel them to call you if that’s an issue.

Alicia Morgans, MD, MPH: How often do you check thyroid function when you have someone on apalutamide?

Judd Moul, MD: That’s a good question.

Tanya Dorff, MD: Quarterly or every 6 months is probably adequate.

Alicia Morgans, MD, MPH: That’s what I do too.

Judd Moul, MD: Again, to play devil’s advocate, as a urologist, I’ve treated about a dozen patients with either enzalutamide or apalutamide for M0 [nonmetastatic] prostate cancer since February of 2018. That’s roughly 1 patient a month. In a urology practice, so far I have not had any patients that Neeraj described—the patient who’s in the walker and has a lot of comorbidities. I’ve seen these patients back q3 [every 3] months. I think it’s an excellent point, but I also think we have to recognize the cultural training differences between urologists and medical oncologists. I applaud seeing these patients back at 4 to 6 weeks. You certainly can’t go wrong with that, but the patients I’ve treated have been pretty healthy guys, and I’ve done it at 3 months.


Transcript Edited for Clarity 

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Transcript: 

Judd Moul, MD:
From a practical standpoint, and considering that a lot of the folks listening are going to be urologists, when you start a patient on these drugs, how often do you see them back? Do you see them back every month, every 3 months, etc?

Neeraj Agarwal, MD: There’s no rule, in my view. It is very patient specific. It depends how frail the patient is, whether the patient is working full time and is fully independent, how many comorbidities a patient has, whether they are prone to falls, and if they are cognitively impaired. Those are factors that come into play in that decision making. If I’m seeing an otherwise healthy, full-time-working patient of mine who is golfing on a regular basis, I would say every 3 months is fine. If I have a patient who is on 3 other drugs for cardiovascular conditions, is frail, and is coming into my clinic with a walker or a cane, I would like to see the patient every month.

Judd Moul, MD: Key point. Alicia?

Alicia Morgans, MD, MPH: I agree, and I would say that when I start any medication, I usually have someone come back at 4 weeks if not a bit sooner, depending on these kinds of things and which drug I start. For these drugs, I typically prefer 4 weeks between visits. Based on the same factors, I’ll have them come back every 4 to 6 weeks or every 3 months. I do Lupron every 3 months or so, and I do ADT [androgen deprivation therapy] every 3 months. I will often do either 4 weeks, 6 weeks, or 3 months between visits.

Judd Moul, MD: Yes, it’s important for all the listeners to continue the LHRH [luteinizing hormone-releasing hormone] agents or GnRH [gonadotropin-releasing hormone] agents. These drugs are not FDA approved to be used alone, so a key teaching point is that we don’t want to discontinue the GnRH or LHRH agents when we have patients with nonmetastatic prostate cancer. Tanya, what’s your general follow-up for these guys?

Tanya Dorff, MD: Having been trained through internal medicine, I think any time you start a new medicine, it’s very important to see someone back in 4 to 6 weeks. Enzalutamide’s steady state occurs somewhere around 4 weeks, so that’s a rational time period to check in with the adverse-effect profile. If you’re reverting to the every-3-months schedule, which I do when everything is going smoothly, you have to remember that with the apalutamide, the median onset of rash is about 80 days. You want to warn your patient that this happens, because the time frame is little unusual. You normally take a medicine and get the rash right away. Be on the lookout for that, and counsel them to call you if that’s an issue.

Alicia Morgans, MD, MPH: How often do you check thyroid function when you have someone on apalutamide?

Judd Moul, MD: That’s a good question.

Tanya Dorff, MD: Quarterly or every 6 months is probably adequate.

Alicia Morgans, MD, MPH: That’s what I do too.

Judd Moul, MD: Again, to play devil’s advocate, as a urologist, I’ve treated about a dozen patients with either enzalutamide or apalutamide for M0 [nonmetastatic] prostate cancer since February of 2018. That’s roughly 1 patient a month. In a urology practice, so far I have not had any patients that Neeraj described—the patient who’s in the walker and has a lot of comorbidities. I’ve seen these patients back q3 [every 3] months. I think it’s an excellent point, but I also think we have to recognize the cultural training differences between urologists and medical oncologists. I applaud seeing these patients back at 4 to 6 weeks. You certainly can’t go wrong with that, but the patients I’ve treated have been pretty healthy guys, and I’ve done it at 3 months.


Transcript Edited for Clarity 
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