Announcer:
Welcome to On the Frontlines of Prostate Cancer on ReachMD. On this episode, we’ll hear from Dr. Tanya Dorff. Not only is she a Professor at the Department of Medical Oncology and Therapeutics Research, but she also serves as the Division Chief of the Genitourinary Disease Program at City of Hope in Duarte, California. She’ll be discussing how we can create personalized treatment plans that incorporate combination therapies for prostate cancer patients. Here’s Dr. Dorff now.
Dr. Dorff:
At this point, we are still really reliant on androgen deprivation therapy in almost all spheres of prostate cancer treatment, but especially in advanced prostate cancer. So we are learning that intensifying our androgen deprivation to add one of the AR pathway inhibitors in many scenarios results in superior outcomes. So whether it’s abiraterone, enzalutamide, apalutamide, or darolutamide, we are really getting to a point where many patients are exposed to intensive suppression of the androgen receptor axis. But the upside of that is we are curing more patients and able to use more defined courses outside of the metastatic setting where we still use a lifelong approach.
It’s really important to start by looking at the patient and their overall health status, comorbidities, life expectancy, and goals. Because as much as guidelines can provide a one-size-fits-all approach and tell us the level one evidence about which combinations have been tested and proven to be successful, we can’t forget that the person in front of us has other medical issues that need to be taken into account. So I always start by taking a look at the patient’s list of medications, performance status, and social support as I’m looking at which combination strategy I’d like to leverage. I think oncologists are great at doing this when it comes to chemotherapy, and many of us might feel that the androgen receptor pathway inhibitors are milder and so maybe we aren’t as worried about exposing patients to these types of drugs. But it actually becomes really important when we’re looking at a more frail, elderly population to make sure that some of the cardiovascular risks that we’re learning about in some of our antigen receptor pathway inhibitors don’t overshadow the benefit of these agents. And, to the best of our abilities, we try to select the drug that might maintain the patient’s functionality, quality of life, and safety in terms of drug interaction, while at the same time achieving those really outstanding prostate cancer control outcomes.
For patients with metastatic prostate cancer, a lot of the emphasis has been on triplets versus doublets. And at this point, we’re still using clinical characteristics such as synchronous or de novo high-volume status for patients where chemotherapy is a really strong consideration, versus a low-volume or a metachronous scenario where doublet therapy with the androgen receptor pathway inhibitor might be very appropriate, without forgetting that radiation to the prostate primary in a de novo low-volume setting has been shown to be beneficial.
I think having resources like support groups, social workers, and psychology are important. We need to make sure we’re thinking broadly about how we can support our patients through some of these more nuanced and challenging side effects that are not life threatening, but potentially impact a patient’s ability to comply or to have a good quality of life while they’re on treatment.
We don’t have a great fix, and we know there’s a lot of fatigue that comes from androgen deprivation therapy. We do try to help patients work on the things they can control, like sleep, exercise, and diet. Those things can contribute. We can also dose modify. So for some of our androgen receptor pathway inhibitors, when we’re hitting fatigue, sometimes a dose reduction can be beneficial, and sometimes we even back away from combination therapy if it’s getting to a point where the patient’s function is significantly impacted.
Antidepressants are helpful for hot flashes with androgen deprivation, and I will often push these a little harder when I’m hearing either from the patient, the partner, or the family members that there is some emotional change that’s happening. It’s a difficult subject to tackle and one that takes time and sensitivity, which is a challenge for us in our oncology clinic, but whether it’s offering an antidepressant or a referral to social work or psychology, I think this is a really important aspect of providing total-person care for our prostate cancer patients.
Announcer:
That was Dr. Tanya Dorff discussing personalized care for prostate cancer patients. To access this and other episodes in our series, visit On the Frontlines of Prostate Cancer on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
