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ADT and Its Consequences in the Treatment of Prostate Cancer

Panelists: Dan George, MD, Duke Cancer Center; Joe M. O'Sullivan, MD, FRCPI, FFRRSCI, FRCR, Queens University Belfast ; Charles Ryan, MD, Masonic Cancer Center; Christopher Sweeney, MBBS, Dana-Farber Cancer Institute; Bertrand Tombal, MD, PhD, Cliniques Universitaires Saint-Luc
Published: Friday, Oct 25, 2019



Transcript: 

Dan George, MD: 2019 has been an exciting year in the field of genitourinary oncology, including for prostate cancer, where we’ve made significant progress with several new FDA approvals. 

Today I am joined by a panel of colleagues, all experts in treating prostate cancer, and we’re going to highlight clinical data from the ESMO [European Society for Medical Oncology Congress] 2019 annual meeting.

Hi, I am Dr Dan George, a professor of medicine and surgery at the Duke Cancer Institute in Durham, North Carolina. Today on this distinguished panel I am joined by Dr Joe O’Sullivan, a clinical professor in the School of Medicine, Dentistry and Biomedical Sciences at Queen’s University Belfast in Northern Ireland; Dr Charles Ryan, a professor of medicine and a medical oncologist at Masonic Cancer Center, University of Minnesota, in Minneapolis, Minnesota; Christopher Sweeney, a professor of medicine and a medical oncologist at Dana-Farber Cancer Institute and Harvard Medical School in Boston, Massachusetts; and finally Dr Bertrand Tombal, the chairman of the division of urology at the Cliniques Universitaires Saint-Luc in Brussels, Belgium.

Thank you so much for joining us. Let’s begin. Let’s start first with an update on hormonal therapy. Chuck, maybe we can start with you on how we manage patients with localized prostate cancer beginning on hormonal therapy—say, in the context of radiation therapy. Are there any things we need to be mindful of in terms of the consequences of hormonal therapy in that setting?

Charles Ryan, MD: Sure. It’s really important to note that many men with high-risk disease are being treated with a combination of radiation and hormonal therapy and that the duration of hormonal therapy for some of them can be as long as 2 years. In fact, some patients will ultimately end up on lifelong hormonal therapy. We now know that androgen deprivation therapy [ADT] is a major metabolic event for a patient with prostate cancer. We’ve known for a long time that there are consequences with regard to bone health, cardiovascular health, and the potential for diabetes. There’s an increasing awareness and concern about the long-term cognitive implications of androgen deprivation therapy.

First of all, for clinicians who treat these patients, we need to counsel our patients about this, and it’s quite surprising that many patients don’t get a full understanding from their physician or their medical team about the consequences of androgen deprivation therapy.

But to make a list and think about the things that we would do before starting ADT and within the early months of this therapy, I generally will try first to get a sense of what the patients’ baseline testosterone is—a frequently overlooked issue. Second, I will do an assessment of bone health. Third, I will check the hemoglobin A1C [glycated hemoglobin] to make sure the patient does not already have diabetes. Fourth, I will talk to them about a healthy lifestyle—exercise, etc. I counsel all my patients around resistance exercise because that has been proven in randomized controlled trials to reduce the risk of fatigue that’s associated with ADT. So that’s a conversation that I have.

From there, you integrate the more long-term monitoring effects over time. When patients come in every 3 months, their PSAs [prostate-specific antigens] are going to be down, and their cancer is going to be under control in general in this setting. But that’s when you begin to have the conversations about “How are you doing exercise, how’s the diet, let’s repeat the bone mineral density after a year,” and those types of things. I consider it a long conversation that’s drawn out over the whole course of ADT.

Dan George, MD: That’s really interesting. It has a lot of implications, a lot of the same kinds of issues that primary care doctors are covering. But now it’s a little heightened because of this change with hormonal therapy. It’s going to have a different dynamic to it, and they may not be tuned in to that, so it’s important to recognize that and talk to patients about it.

Transcript Edited for Clarity

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Transcript: 

Dan George, MD: 2019 has been an exciting year in the field of genitourinary oncology, including for prostate cancer, where we’ve made significant progress with several new FDA approvals. 

Today I am joined by a panel of colleagues, all experts in treating prostate cancer, and we’re going to highlight clinical data from the ESMO [European Society for Medical Oncology Congress] 2019 annual meeting.

Hi, I am Dr Dan George, a professor of medicine and surgery at the Duke Cancer Institute in Durham, North Carolina. Today on this distinguished panel I am joined by Dr Joe O’Sullivan, a clinical professor in the School of Medicine, Dentistry and Biomedical Sciences at Queen’s University Belfast in Northern Ireland; Dr Charles Ryan, a professor of medicine and a medical oncologist at Masonic Cancer Center, University of Minnesota, in Minneapolis, Minnesota; Christopher Sweeney, a professor of medicine and a medical oncologist at Dana-Farber Cancer Institute and Harvard Medical School in Boston, Massachusetts; and finally Dr Bertrand Tombal, the chairman of the division of urology at the Cliniques Universitaires Saint-Luc in Brussels, Belgium.

Thank you so much for joining us. Let’s begin. Let’s start first with an update on hormonal therapy. Chuck, maybe we can start with you on how we manage patients with localized prostate cancer beginning on hormonal therapy—say, in the context of radiation therapy. Are there any things we need to be mindful of in terms of the consequences of hormonal therapy in that setting?

Charles Ryan, MD: Sure. It’s really important to note that many men with high-risk disease are being treated with a combination of radiation and hormonal therapy and that the duration of hormonal therapy for some of them can be as long as 2 years. In fact, some patients will ultimately end up on lifelong hormonal therapy. We now know that androgen deprivation therapy [ADT] is a major metabolic event for a patient with prostate cancer. We’ve known for a long time that there are consequences with regard to bone health, cardiovascular health, and the potential for diabetes. There’s an increasing awareness and concern about the long-term cognitive implications of androgen deprivation therapy.

First of all, for clinicians who treat these patients, we need to counsel our patients about this, and it’s quite surprising that many patients don’t get a full understanding from their physician or their medical team about the consequences of androgen deprivation therapy.

But to make a list and think about the things that we would do before starting ADT and within the early months of this therapy, I generally will try first to get a sense of what the patients’ baseline testosterone is—a frequently overlooked issue. Second, I will do an assessment of bone health. Third, I will check the hemoglobin A1C [glycated hemoglobin] to make sure the patient does not already have diabetes. Fourth, I will talk to them about a healthy lifestyle—exercise, etc. I counsel all my patients around resistance exercise because that has been proven in randomized controlled trials to reduce the risk of fatigue that’s associated with ADT. So that’s a conversation that I have.

From there, you integrate the more long-term monitoring effects over time. When patients come in every 3 months, their PSAs [prostate-specific antigens] are going to be down, and their cancer is going to be under control in general in this setting. But that’s when you begin to have the conversations about “How are you doing exercise, how’s the diet, let’s repeat the bone mineral density after a year,” and those types of things. I consider it a long conversation that’s drawn out over the whole course of ADT.

Dan George, MD: That’s really interesting. It has a lot of implications, a lot of the same kinds of issues that primary care doctors are covering. But now it’s a little heightened because of this change with hormonal therapy. It’s going to have a different dynamic to it, and they may not be tuned in to that, so it’s important to recognize that and talk to patients about it.

Transcript Edited for Clarity
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