Management of Advanced Prostate Cancer in Urology: Update on Androgen Receptor Inhibitors - Episode 3

Advanced Prostate Cancer: Mediating Treatment Through Multidisciplinary Management

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Experts in prostate cancer comment on the role of urologists in performing molecular testing and share how they facilitate treatment of advanced prostate cancer across multiple disciplines.

Neal Shore, MD, FACS: You brought up a lot of great points. We’re going to get into the meat of the conversation on AR [androgen receptor] pathway inhibitors. I want to stay with you for a brief second, Ash, because you’re the urologist seeing a lot of these newly diagnosed patients. We’re going to talk about genomic profiling, but let’s hold off on that. Let me get your thoughts on molecular testing, particularly on grade 1 and 2 patients. How are you approaching that? Of course, I’d love to hear Bobby and Vivek if they want to talk about this too, because it’s still a challenge, isn’t it? For patients who may be well suited for active surveillance, are we comfortable doing it? How do we have that patient share decision-making? Are there molecular markers? Is it MRI based on the percentage of core involvement, the number of cores, patient comorbidities? How are you thinking about this, Ash?

Ashley E. Ross, MD, PhD: I’m a high adopter of genomics in that setting. The NCCN [National Comprehensive Cancer Network] talks about how it might help restrictions from stage I all the way through stage IIC. I’m routinely using genomics. For men with very low-risk prostate cancer, I don’t need to know anything more. They should be on surveillance, but for all my low-risk, high-volume men, I’m getting genomics. I usually use the Decipher, but a lot of people use Prolaris and other things to help determine if this person is going to have a long duration on surveillance.

For a lot of these tests, their first use is going to be toward therapeutic deimplementation. Can we avoid radiation? Can we avoid surgery altogether? That’s also why I tend to use it in my IIC population, my favorite intermediate-risk guys. There are ongoing perspective trials looking at deintensification and intensification of hormonal therapy with radiation, depending on your genomic scores. For example, the Decipher is the genomic classifier. I’m ahead of the curve in the sense that I’m already using it. If I have an older gentleman with 1 unfavorable genomic feature—like they’re 437 but just in 1 core. They’re a little bit older, and I want to avoid ADT [androgen deprivation therapy]. They have low genomic scores, so I may implement that as well.

We’re going to talk shortly about genetics and the metastatic disease and how that can help us with targeted therapeutics, but in the clinically localized setting, it can be an important adjunct to help us deimplement and increase how much therapy we want to give. But it’s evolving. You and I have been using it for almost a decade. If we look at use nationwide, it’s still disseminating. People are still getting used to it as a new tool.

Neal Shore, MD, FACS: Bobby, I want to let you introduce the concepts for our listening audience regarding androgen receptor pathway inhibitors, androgen receptor access drugs, and novel hormonal agents. We have a lot of different acronyms. But before we do that…are you getting patients coming to you and saying, “My urologist recommended surveillance. Another urologist said no, I should have my prostate out. A radiation oncologist said no, I should have radiation. I’m in a great group too. I have 3+4, 2 cores positive.” Historically, the medical oncologist acts as a referee or an umpire in these situations. Vivek, I see you nodding, so maybe you too would comment briefly on that. Then we’ll get into AR pathway inhibitor drugs and advanced prostate cancer. Bobby, if you could start.

Bobby Liaw, MD: The short answer is yes, we do get in the middle of a lot of these discussions. Especially in a large city like New York, there are multiple specialists people can see. A lot of patients sometimes get 3 or 4 opinions before they land in my office and ask me what do I do. The tough thing in their situation is that without thinking about age, comorbidities, and stuff like that, they have a lot of options, all of which are very effective. It’s hard to give them a guarantee which 1 is going to work the best. In that vein, we’ve talked a lot about genomics because it adds an additional layer of data on top of this plain, old PSA [prostate-specific antigen] and histologic data that help us make more informed decisions. Because we have so many of these types of cases, we’ve also put together our multidiscipline prostate cancer clinic. It’s helped a lot of patients come in and get all their opinions at the same time, so they leave with at least 1 unified consensus on which way to move forward.

Neal Shore, MD, FACS: Great. Vivek, anything to add?

Vivek K. Narayan, MD, MS: Similar to what Bobby said, oftentimes these patients have come with multiple opinions already. As a nonurologic surgeon and as a nonradiation doctor, I don’t do it to speak pro or con but rather to serve as a sounding board and make sure they truly understand the disease, what disease risk stratification means, and the concept of clinically localized prostate cancer. Then they can use that understanding to weigh the pros and cons of surgery vs radiation.

Neal Shore, MD, FACS: As opposed to active surveillance.

Vivek K. Narayan, MD, MS: Exactly.

Neal Shore, MD, FACS: I 100% agree with that, and that’s where we’re making a lot of progress and becoming better in our communication skills. We can say to patients, “There’s no perfect answer, but you come to the decision.”

Transcript Edited for Clarity