Redefining Advanced Prostate Cancer with Novel Imaging - Episode 2

Challenges Associated With ADT for Prostate Cancer


Raoul S. Concepcion, MD, FACS: Dan, at Duke, you’ve got a very aggressive medical oncology division, specifically for urology, as well as an outstanding surgical division in urology. What seems to be the interaction at Duke? Do the urologists tend to start the androgen deprivation therapy? Or are they pretty much coming over to you when the prostate-specific antigen (PSA) starts to rise, after definitive therapy?

Daniel George, MD: I think this is a really important evolution. When I came to Duke, urology had a very strong and long history in prostate cancer, in particular, and urologic oncology. Our goal was to integrate with that and to develop more of a multidisciplinary team approach that is similar to what Alec has in the community there. In the academic setting, we recognize that when patients come in and they choose a treatment at Duke, they’re not choosing a physician. They’re choosing a team. We talk about the modality that they start with, to survivorship, or, for the patients who do recur, what kind of salvage approaches we have for this population. And I want to get back to what Neal said, because I think this is really important.

When we order tests and we start thinking about the PSA coming back, I want to start the conversation by thinking, what’s our goal? If our goal in that population is to potentially get back to a complete response (CR), then I don’t look at it as the goal isn’t to avoid hormonal therapy. The goal is, how can we best get to a CR? Hormonal therapy may be part of that, on an interim basis—in a short-term situation. We may combine it with radiation therapy, with SBRT (stereotactic body radiotherapy), with cryoablation, or some other approach.

So, from our perspective, we look at that as a multidisciplinary team. But from a patient’s perspective, we’re looking at it as, what’s the goal? And then, what are all of the modalities that we have? If it requires surgery, we work with our surgeons. If it’s radiation, we work with our interventional radiologists—our radiologists. The medical oncologists probably do most of the hormonal therapy. We’re beginning to integrate some secondary hormonal therapies into those settings, with this limited metastatic disease population. So, I think that’s where there’s opportunity. We do a lot of clinical trials in that space. And there, too, we try to work together. It’s less and less about division of labor and more and more about a collective approach.

Raoul S. Concepcion, MD, FACS: Right, always making it patient-centered.

Daniel George, MD: That’s right.

Neal D. Shore, MD, FACS: Can I ask something about that, though? Right now, in the United States, in certain tier 1 programs, I’ve noticed a level of potential real-world disconnect between what’s happening in the teaching institutions, at the level of senior residents and Fellows, versus what’s going on in the community. More often, I tend to hear that a lot of our very best urology programs are not even administering ADT any longer. To your point, as the patient’s getting the best care and it’s multidisciplinary, that’s fantastic. Of course, who would argue with that? I certainly wouldn’t.

But when you get out into the real world, however, the urologists in big practices, who are seeing large volumes of patients outside of academic centers, have to be prepared to continue to give ADT. They need to know when to give the ADT, manage the side effects, and, as we’re going to be talking about, know about the next steps—the next lines of therapy. That’s a troubling disconnect that I’m seeing. The busy medical oncologist, in the community, is so overwhelmed with all of the other things outside of GU oncology. So, I think that in the United States, as well as globally, these are things that our educational centers are grappling with.

Daniel George, MD: I think that’s a great point. I don’t think that our training programs, and I would say this is true in medicine as well as in surgery, have really come to grips with that. Ultimately, these trainees need to know and be comfortable with real-world practice. We’re training people for academic careers. We’re not necessarily training them for real-world practice. And the problem is, now there’s a limited amount of hours these residents have. They’re needed on the inpatient side. Inpatient care isn’t necessarily what they’re going to be doing in the real world, for the majority of their time. Their outpatient experiences are probably more limited. We would love to have them in clinic, with us, to spend a day or spend a week, understanding and seeing it from the medical oncology perspective. I think it would be incredibly valuable to understand what they’re going to be setting up, in a multidisciplinary fashion, as a community urologist. But we need to recognize that we’re training people for all kinds of practices, not simply an academic career. I think that’s where the shortfall is.

Raoul S. Concepcion, MD, FACS: Neal, I think you made a great point, earlier. The urology world really needs to be more cognizant of the deleterious downstream effects of androgen deprivation therapy. It’s always been thought that, “Oh, this is an easy drug.” But as you pointed out, we are starting to see the neurocognitive dysfunction, and those types of things, as people get on ADT. And it’s a quality-of-life issue.

Transcript Edited for Clarity