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Assessing for Treatment Failure in Advanced Prostate Cancer

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A brief review of the role that testosterone measurements play, amidst other monitoring strategies, in assessing for treatment failure in advanced prostate cancer.

Transript:

Paul R. Sieber, MD: But I’ll flip over. It’s a slightly different topic. Aaron, I’ll go back to you and you made a mention about difficulty with mixing. At least in my world, we routinely measure testosterone all the time and I had a tendency for my partners in the past to have somebody on an injectable and switched from one to another because the PSA [prostate-specific antigen] had changed, and it was done on chemiluminescence and that’s really not very accurate. And they’re making what I think were poor decisions. And I’ve had a really much easier time getting mass [spectrometry] testosterones done. And it’s amazing, the number of high readings I get under the chemiluminescence that in mass [spectrometry] are really OK. I must say, in my practice, I have virtually no one [who] I’m changing because of the drug itself not working. I’m having trouble with ‘the drug being inconsistently mixed seems to be the problem.’ When we’ve switched drugs to mesylated in particular, we just haven’t seen that breakthrough problem as frequently as we’re seeing with others. Your thoughts about measuring testosterone, do you do it routinely mass [spectrometry]? Do you use that and do you share the same ... thought that seems to be, it’s the mixing that gets the drugs in trouble more than anything else? I’ll open to you for that one.

Aaron Berger, MD: I think I 100% agree. I think in the vast majority of cases it is a mixing issue. Certainly, any of these drugs has a low rate of breakthrough, but it is very low. I think the mixing was the issue and I think … at least in our practice, the timing really corresponded to this huge influx of new staff … and in some cases it was the blind leading the blind. The few people who had been there maybe a few months were teaching the people who were newly hired. So we’ve ... revamped our whole teaching process and have a nurse educator … It’s almost like a residency program now. Patients, new staff who are coming in, new MAs [medical assistants], they basically have to see a certain number, do a certain number … under supervision, and then they’re cleared to do it themselves. It’s ... see one, do one, teach one, but it’s at least, I think, 5 or 10 of each of those. The technique and mixing certainly are important … [and] the mesylate ... eliminates that problem.

As far as testosterone, I’m used to ordering that. I check it pretty much every 3 months for my advanced prostate cancer patients. It still is a bit of a struggle for the rest of my colleagues, I think, who are just managing people on ADT monotherapy. A lot of times, I’ll see patients for referrals for non-metastatic CRPC [castration-resistant prostate cancer], and they come in and haven’t had a testosterone done in a couple of years. It’s really been a point of emphasis in education to just make sure they’re adding that testosterone along with their PSA when they’re coming in for their 3-month or 6-month visit, or at least twice a year to check a testosterone. It’s easy enough to do. It’s done with the same blood draw, so it’s not like they have to do extra testing. As far as the type of testing, the mass [spectrometry] vs chemiluminescence, honestly, I don’t know the answer to that. I just order it, and whatever lab it gets sent out to, per the patient’s insurance, that’s what they run. You know much more about the details on the testing than I do, which one they’re running. But certainly, a lot of these that haven’t been checked for a while and have a breakthrough, it’s not subtle. It’s not like they’re 51; they’re 110, 150, just haven’t had the testosterone checked for a while, but I do 100% agree. I think the mixing issue is the main issue rather than the product itself.

Paul R. Sieber, MD: I think that’s what I saw with my partners, that they were making decisions on a testosterone of 51, saying that was a difference, and especially without mass [spectrometry], you’re not seeing much of a difference there. But what we saw, as you alluded to, it wasn’t a matter of subtle changes. A chemiluminescence, if it’s 150, they got a problem. And then you basically say that that’s an issue, and I think basically the trial part of me is what’s got me motivated to do this, because all of our trials have always required guys to verify their testosterone along the way, and that’s years ago. It started me looking at this, and I started realizing you do see breakthroughs on a regular basis, and guys just don’t look for it. It’s exciting to me to see people adopting that model, say, we’re checking testosterone, because I think historically people haven’t done that, and even now people are backing up to say, you really should check testosterone at baseline and before you even start, because [if] you [have] a guy coming in the door whose testosterone is 105, you’ve got to approach that patient differently. He is not going to respond well, and I think you’ve got to start saying, hey, listen, this guy’s in trouble from day 1. Richard, how about on the West Coast? You guys pretty much doing testosterone? Are you slowly bringing the troops along to follow your lead? Is everybody doing it, or is no one doing it?

Richard David, MD, FACS: Our protocol is pretty much everybody has to have a testosterone at least every 90 days. How well do we enforce that? I don’t know. We’re getting way better at it, but that’s our protocol … every 90 days, patient comes in, gets a PSA in testosterone.

Paul R. Sieber, MD: I think what you’re hearing from everybody on the panel is we’re a little odd. I guess that’s because we all know each other. It must be we talk too much to each other, but it is interesting to start to hear people really are looking at that, and I think if we flip back the clock a decade or more, no one was talking about measuring testosterone. They just gave the stuff and watched their PSA, and it’s interesting to see how that’s changing, and I think it’s made us also more aware of each product as a little bit different, and again, [with] the problem with turnover and different administrative requirements, we suddenly realize there are differences.

Transcript is AI-generated and edited for clarity and readability.

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