Dr. Jose De La Cerda and Dr. Christopher M. Pieczonka shed light on their approach to prescribing medicines for patients with metastatic castration-resistant prostate cancer (mCRPC). They highlight the importance of patient access to care, discuss the availability of various therapies, including novel hormonal agents and infusions, and anticipate a positive shift in treatment accessibility in the coming years due to government initiatives.
Christopher M. Pieczonka, MD: I did want to ask you a question, though, about how you assess different populations in terms of your choice for medicine. So I think it's easy for surgery. Surgery is like robotics, and there's not a lot of other things, but what kind of things come to your mind in terms of your choice for medicines in the mCRPC setting? Maybe I'll hone that down for the oral therapies. What are the things that run through your mind when you're trying to prescribe something to somebody?
Jose De La Cerda, MD, MPH: Well, I think it all depends on what they get early on in the mCRPC state, but in general, we provide a lot of these therapies, and we have them actually in-house within our own pharmacy. So we're able to prescribe abiraterone, the micronized and the non-micronized form of abiraterone. We also have new NHDs such as Enzalutamide. We're developing Pluvicto here within our practice as well. And we're actually able to do infusions within our facility. We have access to an oncologist who will give taxane-based therapy and things of that nature. So fortunately, everything that's in the NCCN we're able to do here in-house and be able to kind of facilitate that practice. And to your point, the PET scanning and having all these access to care is the most important thing, making sure that patients have access to care and adequate care. Because of the high minority population, that goes hand in hand with a lot of health inequities. And these are often associated with a lack of screening, advanced diseases, including prostate cancer, and difficulty in obtaining affordable treatment options.
Jose De La Cerda, MD, MPH: We're a large group practice, so we have the capacity to get navigators to assist with this, to have prior authorization departments, to have our billing help us find foundation funds to have patients able to access their care, but the majority of practices across the United States don't have this capacity, and I think that's something that can be pretty limiting to some of these patients. Do you all have access to and actively use programs like Thrive Well Live Well or a lot of these foundation programs?
Christopher M. Pieczonka, MD: Yeah, when they're open. I think that, you know, obviously, financial toxicity is a big thing for our patients and you know, sometimes we have patients who want to put on a particular therapy and, you know, they may not be able to simply afford it. I think that that's going to be helped next year. In 2024, the Inflation Reduction Act part of the provisions kick in, and essentially what the government is doing is they're taking money from the rich and maybe giving to the poor, so they're taking some of the 10 worst, their highest cost to the Medicare system. They're forcing drug price negotiations on them, and essentially then making that money into making Part D drugs more affordable. So for the viewing audience, one of the things that's going to happen next year is there's going to be a cap that's going to be put in place. And that cap will be for all Part D drugs. So I think it's going to be easier for us to get branded products for our patients because if they're on one of the newer oral blood thinners or one of the anti-diabetic agents that may be a branded medicine, all of that will count towards that. And if we end up layering a novel hormonal therapy on top of that, it may be that effectively the patient might get it for free once they've met their deductible. So I think that's something that's going to be a good thing for all of our patients.
Christopher M. Pieczonka, MD: I do have a different question for you, though. Tell me about the type of patient that has metastatic CRPC for you, specifically how many patients do you have that have not been previously treated with a novel hormonal agent that have mCRPC?
Jose De La Cerda, MD, MPH: That's rare nowadays, at least in our practice. I think about 90% of the patients that we're treating in the mCRPC state have already been treated with some sort of NHD, whether it's something like apalutamide, abiraterone, enzalutamide, or even a taxane-based therapy. So the ADT alone, mCRPC, I think, is really dwindling down in terms of population. PSMA PET scans have really changed the game in prostate cancer. I mean, compared to conventional imaging with CT and bone scan, we're finding more advanced disease with earlier PSA rises in clinical progression. And I think what we're finding now is that when we don't intensify early on with all this data that we have, patients live longer. And so a lot of these patients are getting therapies early on in their prostate cancer diagnosis. And now with new trials coming out like MBARC, we're going to see that happening even in the biochemical recurrent states.
Christopher M. Pieczonka, MD: So I think we're going to see this sort of shift coming where we're going to be intensifying treatment early on because we do have this improvement in progression-free survival, overall survival of metastatic prostate cancer. And the mCRPC with ADT alone will kind of continue getting smaller and smaller.
*Video transcript AI-generated and reviewed by Urology Times® editorial staff.