Tools for Accessing Personalized Advanced Prostate Cancer Treatment and Care

Tools for Accessing Personalized Advanced Prostate Cancer Treatment and Care from Patient Empowerment Network on Vimeo.

What steps can advanced prostate cancer patients take to help them access the most personalized treatment approach for their disease? This animated video reviews key treatment decision factors, how biomarker testing results affect care, and advice for self-advocacy. 

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What Questions Should Prostate Cancer Patients Ask About Testing and Test Results? 

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How Do Biomarker Test Results Impact Prostate Cancer Treatment Options

Essential Testing Following a Prostate Cancer Diagnosis

Essential Testing Following a Prostate Cancer Diagnosis 


Transcript:

Every advanced prostate cancer patient is unique AND so is their disease. Advances in research are making personalized medicine a reality, tailoring care and therapy choices based on the genetic makeup and individual characteristics of a patient’s disease.   

As prostate cancer research evolves and treatment options expand, it’s vital that patients work with their healthcare team to find the best treatment approach to treat their specific cancer.  

An essential step to accessing personalized medicine is biomarker testing, which identifies key markers such as genes, proteins, or other molecules in a sample of tissue, blood, or other bodily fluid. The results of these tests can provide a fuller picture of the prostate cancer’s type, stage, and aggressiveness and may help predict how the cancer will behave. 

The test results can also identify which treatment approach may be most effective, through the presence of certain molecular markers.  For example, if a tumor has either high microsatellite instability (MSI high) or mismatch repair defects (dMMR), a prostate cancer patient may benefit from immunotherapy. Or a PARP inhibitor therapy may be more effective if the presence of mutations in certain DNA damage repair genes is detected. 

In addition to biomarker test results, other factors that physicians consider when recommending a treatment approach include:  

  • A patient’s age, overall health, and any pre-existing conditions. 
  • The type, stage, and grade of prostate cancer. 
  • And, potential side effects or impact on their lifestyle. 
  • And, the patient’s preference. 

Along with these considerations, it’s vital that patients discuss the benefits and drawbacks of each option with their team. So, how can you be proactive in order to access personalized care? 

  • Ensure that your doctor has experience treating prostate cancer. Consider consulting a specialist or obtaining a second opinion, so you can feel confident in your diagnosis and treatment plan. 
  • Ask a friend or loved to join you during key discussions with your provider, to help you process the information and to make decisions. 
  • And, be sure to request all essential testing, including biomarker testing, and ask how the results may affect your prognosis and treatment options.  
  • Discuss ALL of the treatments available to you, including any potential side effects.  
  • And ask if there is a clinical trial that could be right for you.
  • Finally, and most importantly, YOU should be at the center of your prostate cancer care. Share your opinions and ask questions throughout the process, so you feel empowered and informed. 

To learn more about prostate cancer and to access tools for self-advocacy, visit powerfulpatients.org/PC. 

How Can Prostate Cancer Stigmas and Misconceptions Be Addressed?

How Can Prostate Cancer Stigmas and Misconceptions Be Addressed? from Patient Empowerment Network on Vimeo.

 How can prostate cancer stigmas and misconceptions be addressed? Expert Dr. Yaw Nyame with the University of Washington discusses common concerns and misconceptions, how doctor-patient communication can help, and support resources to aid patients and care partners.

See More from [ACT]IVATED Prostate Cancer

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Understanding Recommended PSA Screening Age and Frequency In Prostate Cancer

Understanding Recommended PSA Screening Age and Frequency In Prostate Cancer 

Emerging Promising Advanced Prostate Cancer Treatments

Emerging Promising Advanced Prostate Cancer Treatments

What Impact Does Advanced Prostate Cancer Have on Lifestyle

What Impact Does Advanced Prostate Cancer Have on Lifestyle?

Transcript:

Lisa Hatfield:

Dr. Nyame, have you encountered any misconceptions or stigmas related to prostate cancer within the underrepresented communities, and how do you address or mitigate these issues with your patients?

Dr. Yaw Nyame:

I think that there are a lot of misconceptions in all communities and stigmas around prostate cancer and its treatments, all the way from the early portion of diagnosis, stigma around maybe the rectal examination if you need one, take me around what may happen if you get a biopsy, misconceptions of biopsy, like will it spread the cancer all around your body, will it affect erectile function. And then through treatments. And so one of the primary jobs I feel like I have as a doctor who specializes in this area, is to take the time to hear patients express these concerns, do not diminish or belittle misconceptions, to really hear them, and then to try and educate and inform people about the realities without over-correcting either.

So someone comes to me and says, “Well, Doc, I hear that if I have surgery, I’m going to have erectile function.” I can’t, I shouldn’t, and I don’t say, Oh, you’re wrong, right? But I might say, “Well, that’s true. If you have poor erections before surgery, a likelihood that they’re going to get better is really low, and they’re likely to go away or diminish, but if you have good erections, that there’s a chance with certain techniques that they can come back and will come back.”And then I usually put something like 50 percent of men who have surgery and/or radiation will have some erectile dysfunction within the five years following their treatment. So it’s important to have a level ground where we share information candidly.

And I think it’s important for patients to come prepared to have these discussions, do your homework by talking to your people in your circles, by looking at trusted resources online from places like the American Cancer Society, Prostate Cancer Foundation, cancer centers produce their own information and be prepared to have these discussions.

My activation tip is the same as before, I think that building a community of survivors to share your concerns with and to get knowledge from is really important because there is no better source of information than the lived experience, and I think those individuals, especially the ones who volunteer to lead support groups and to share their stories, they’re wanting to impart their experience with other folks to empower them and support them, so it’s usually a really fantastic community to support understanding your diagnosis and what your journey is going to be like better and also a place to go to once you’ve experienced some of these things, right? It’s not just about the misconceptions up front and stigmas up front, but post-diagnosis and treatment, there are other concerns that may come up, and having the right network can sometimes help you navigate finding the solutions and the resources that are going to support you best.

[ACT]IVATED Prostate Cancer Post-Program Survey

Advanced Prostate Cancer Diagnosis and Survival | Black and Latinx Disparities

Advanced Prostate Cancer Diagnosis and Survival | Black and Latinx Disparities from Patient Empowerment Network on Vimeo.

For advanced prostate cancer diagnosis and survival, what are some disparities that Black and Latinx patients can help overcome? Expert Dr. Yaw Nyame with the University of Washington discusses ways that Black and Latinx communities can help shift the power dynamic for patients to help drive prostate cancer research efforts.

See More from [ACT]IVATED Prostate Cancer

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Prostate Cancer Clinical Trials _ Is Mistrust a Barrier

Prostate Cancer Clinical Trials | Is Mistrust a Barrier

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What Impact Does Advanced Prostate Cancer Have on Lifestyle?

Transcript:

Lisa Hatfield:

So a shout-out to Dr. Nyame for an outstanding article that you wrote. I’m going to read a quote from that. Worldwide Men of African Ancestry Demonstrate Worse Outcomes in Prostate Cancer, a phenomenon driven largely by social factors that inform biologic, environmental, and healthcare risks. So, Dr. Nyame, considering the disparities and taboos on prostate cancer, how can Black and Latinx men including their care partners play a role in eliminating these racial disparities surrounding prostate cancer diagnosis and survival rates?

Dr. Yaw Nyame:

I think because of the nature of what drives these disparities, there is no doubt that cancer is a biologic phenomenon, and so there is no reason to ignore biology, but a lot of inequity in the majority of inequity is rooted in structural and social inequities that really inform health, and when I look at our traditional mechanisms for providing healthcare, there is such a power differential, whether it’s in how we provide clinical care or how we do research, and so we as a research team here at the University of Washington, fundamentally believe that we have to reverse those roles that we have to hand the power back to community, so that they’re an equal partner at the table when we do the work that we do. And so we do a lot of work that is centered around engaging community and patients and partnering with community and patients, and I think that’s one way to ensure that we develop research and interventions that create equity.

My activation tip in this particular space is for Black and Latinx communities to think of ways to be partners in research and to really embrace the fact that it is their right to be at the table when we make decisions about how research is conducted, what the results of our research means and how we share those results so that they have impact in our communities, and so there are a variety of ways to be partners in research, sometimes it’s literally being part of the research team, like we do on showing up to meetings every week, and being engaged in the work in all forms, just asking to participate in the trial, being a member and a participant in the trial and making sure that your experience counts in the way we think about advancing the field of prostate cancer and making it better for everybody.

Sherea Cary:

My activation tip in this area for care partners would be encouraging communication, encouraging the patient to share with others, other men, what their experience has been. It seems to me that when you’re in community with other people and you have something in common then the person who is experiencing cancer or an illness, feel a connection, if they know that someone that they know has had it and survived it and seems to be doing well, that’s encouraging to them, and then we also want that person to pay it forward.

So what I remember about my dad is that after he had his cancer diagnosis, he would share with other men who were facing, who were having testing done and then who had been diagnosed, he talked to them about what happened with them, and they had their own sense of community.

[ACT]IVATED Prostate Cancer Post-Program Survey

What Impact Does Advanced Prostate Cancer Have on Lifestyle?

What Impact Does Advanced Prostate Cancer Have on Lifestyle? from Patient Empowerment Network on Vimeo.

What should advanced prostate cancer patients expect for treatment impact? Expert Dr. Yaw Nyame with the University of Washington explains common treatment side effects, advice for easing physical side effects, and ways for patients and care partners to find support.

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Prostate Cancer Clinical Trials | Is Mistrust a Barrier

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Advanced Prostate Cancer Diagnosis and Survival | Black and Latinx Disparities

Transcript:

Lisa Hatfield:

There is often a tendency to associate advanced prostate cancer with a risk to relationship intimacy. And can you speak to sexual dysfunction and other lifestyle concerns when it comes to prostate cancer and that diagnosis?

Dr. Yaw Nyame:

So, prostate cancer, it’s important to remember that the prostate itself is a sex organ for men, right? Its primary purpose is to produce seminal fluid, the fluid that comes out with ejaculation. And it’s closely linked to a whole lot of structures in your pelvis that support, you know, erectile function and sexual function. All of our treatments have the very real potential to impact sexuality and sexual function. And, I think part of what’s important to do is you go into these and to your conversation with your doctors is to understand how your sexual function, your urinary function, and sometimes your bowel function are going to be impacted by these treatments.

And to get some real clarity about what life will look like for you post-treatment and the setting of advanced cancer, there’s also the added potential of impact to sexual function from the hormone suppression. When we take away your testosterone, oftentimes we take away things like libido or your sexual desire, and we can impact erectile function as well.

You know, things that can help overcome some of the side effects of that hormone suppression are definitely diet and exercise, being active, keeping your muscle mass up, having good dietary habits seem to help. We have a lot of mixed reviews and the literature about the benefit, but I, yeah, I’m a strong believer that the healthier you can be as you undergo these treatments, the better you’re going to do overall. My activation tip when it comes to these new diagnoses is to really invest in advocacy organizations that exist in your community so that you can be connected to other men who are undergoing treatment to have candid conversations about life as a prostate cancer survivor. Organizations like ZERO – the End of Prostate Cancer. There are local groups the NASPCC, there are just chapters and groups of men all across the country that gather to talk about their journey.

And I think that that can be a really wonderful network to better understand what treatment realities may look like for you, but also to support the emotional and physical toll that treatment may take on you. And I think that, that being part of those networks actually will also arm you and empower you to have really good conversations with your doctors to understand what resources are available to support you in your survivorship.

What a lot of men and individuals of prostate cancer aren’t told is that there are some solutions for some of these problems may not be like it was before, but there are many treatments that can exist and do exist that can help preserve certain portions of this quality of life, these quality of life components. And if you don’t know about them, you can’t ask about them. And if you’re not willing to confront them, you may not ask about them and suffer unnecessarily.

My activation tip for care partners related to this question would be, have the tough conversation. Talk about having the tough conversation, schedule a time to try and do it. Don’t do the tough conversation when the football game is on, on Sunday evening. Don’t have it on Wednesday night when the baseball playoffs are going on, but have that conversation so that the care partner can help advocate for the patient about those things that the patient may feel uncomfortable talking about. But if we don’t talk about it, we can’t work on it. And if we don’t work on it, we can’t fix it. So it is important to have the tough conversation.

Lisa Hatfield:

Right, thank you both Dr. Nyame and Sherea, who is a care partner. Thank you for that. Those activation tips.

[ACT]IVATED Prostate Cancer Post-Program Survey

Emerging Promising Advanced Prostate Cancer Treatments

Emerging Promising Advanced Prostate Cancer Treatments from Patient Empowerment Network on Vimeo.

What emerging advanced prostate cancer treatments are showing promise? Expert Dr. Yaw Nyame with the University of Washington shares his perspective about the treatment landscape, updates on clinical trials showing promise, and how to help ensure optimal patient care.

See More from [ACT]IVATED Prostate Cancer

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Prostate Cancer Clinical Trials _ Is Mistrust a Barrier

Prostate Cancer Clinical Trials | Is Mistrust a Barrier

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Advanced Prostate Cancer Diagnosis and Survival _ Black and Latinx Disparities

Advanced Prostate Cancer Diagnosis and Survival | Black and Latinx Disparities

Transcript:

Lisa Hatfield:

Can you speak to the current treatment landscape and any new research coming out about advanced prostate cancer treatment that you are excited about? And how do you work with your patients to make treatment decisions, particularly those in underrepresented communities?

Dr. Yaw Nyame:

So, two very different questions. The first thing I’ll say is the landscape is changing, and there are a lot of exciting things. There are some trials that are showing that the combination of systemic therapies like the hormone blockade, whether it be hormone blockade at a large level, at the cell level with some of those novel agents like abiraterone (Zytiga) and enzalutamide (Xtandi) or even chemotherapy, how we combine those are all very exciting. But we also know that local control of the prostate, so either using radiation to the prostate, which was shown to be beneficial in a clinical trial from the UK called STAMPEDE, we have an ongoing clinical trial called SWOG 1802, which is looking at whether surgery locally to the prostate can add additional benefit to men with advanced prostate cancer.

So I think it’s exciting to understand how we can improve survival. It used to be around three-year survival for prostate cancer when you were diagnosed with advanced forms. We’ve moved that to beyond five years because of how many incredible new advances we have and these combinations of local therapy and systemic therapy. We also have new drugs coming into the landscape like lutetium Lu 177 vipivotide tetraxetan (Pluvicto), which is a PSMA tagged radioligand which has, you know, shown some really great results in the castration-resistant or hormone resistant space that’s being tested now earlier in the hormone sensitive space and high risk localized space.

So there are a lot of really fantastic and exciting new advances. I’m skipping over other types of medications that are really in the precision oncology space, like the PARP inhibitors which are shown to be beneficial in people who have, you know, certain genetic, you know mutations and DNA recombination.

So I think we continue to see evolution in this space where, you know, we used to sort of see this cancer as a one size fits all. And you know, we sort of try to sometimes hit a square peg into a round hole, and now we’re able to really say, okay, your cancer has these features and this combination of things is what’s going to work best. But the problem with that is the more nuanced and the more personalized our care gets, the more opportunity there is for people who are on the margins to be lost.

And so, you know, our historically, you know, marginalized and minoritized populations are sometimes going to be the ones at highest risk for not getting the latest and greatest. One of the things that I’m really interested in supporting and seeing supported in cancer centers and in clinical sites across the country is patient navigation.

Providing services that help people get connected to all the different types of doctors, all the different types of institutions that might offer them the treatments and the workups that they need to make sure that they get access to the best care that’s available. And that’s not only supporting the patient oftentimes, but that’s supporting their caregivers, their families, and making sure that what is a really complex process. It’s not just going in for one doctor’s visit oftentimes, right?

Seeing a lot of different specialists, getting a lot of different tests. But that process is supported for people that have especially among people that have significant social needs and may not be able to navigate that on their own. My activation tip in this space is to absolutely do your homework and find resources to help you navigate this very confusing and very busy landscape when you have your diagnosis.

A lot of cancer centers have patient navigators, okay? And if they don’t, they should. So that is one resource that you should not be afraid to ask for and utilize is someone from the doctor’s office. That’s just going to take the time to make sure if you need to be connected to an insurance, you know agency like Medicare or Medicaid, that you’re connected, that if there are certain appointments you need to make, that they help you schedule and if you need transportation support, that they help connect you to that. And so finding those resources, whether it’s through your community and peer network or through the cancer center, is really important to make sure that you can get as comprehensive of care as you can.

Sherea Cary:

My activation tip for care partners when addressing things like treatment and new research is for the care partner to be as informed as possible about other health issues that the patient may have, and to be transparent with the oncologist about what other things are going on in the patient’s life to make sure that they fit some of the new research that’s coming out or be able to, or the patient and the care partner are able to overcome those barriers that may separate them in some of the treatment decisions. 

Lisa Hatfield:

Right, thank you both Dr. Nyame and Sherea, who is a care partner. Thank you for that. Those activation tips. 

[ACT]IVATED Prostate Cancer Post-Program Survey

Prostate Cancer Clinical Trials | Is Mistrust a Barrier?

Prostate Cancer Clinical Trials | Is Mistrust a Barrier? from Patient Empowerment Network on Vimeo.

Is medical mistrust a barrier to prostate cancer clinical trials participation? Expert Dr. Yaw Nyame with the University of Washington discusses the history of medical abuse with some people of color and how medical professionals must guard against excluding some patients from clinical trials.

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Emerging Promising Advanced Prostate Cancer Treatments

Emerging Promising Advanced Prostate Cancer Treatments

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What Impact Does Advanced Prostate Cancer Have on Lifestyle?

Advanced Prostate Cancer Diagnosis and Survival _ Black and Latinx Disparities

Advanced Prostate Cancer Diagnosis and Survival | Black and Latinx Disparities

Transcript:

Lisa Hatfield:

 My question about barriers is about the historical mistrust of trials. Do you find that fear and mistrust is a barrier? Have you experienced that at all in your practice?

Dr. Yaw Nyame:

There is no doubt that we have a history of medical and clinical abuse of vulnerable populations. We oftentimes point to examples like Tuskegee as an example of medical abuse. But medical abuse and medicine started in the slave chattels, and we have it, we have documented and published examples of Black slaves in the U.S. being the subjects of medical experimentation that’s carried out into, you know, the early forms of formal medical education where patients who showed up to county hospitals and public hospitals were subject to experimentation that no doubt has a deep rooted effect on populations of color who seek clinical care from academic institutions. However, we can’t let that history be an excuse for excluding Black and Brown populations from clinical trials. And what happens now is oftentimes I hear, well, these folks are, don’t trust us.

And so what can we do to build the trust? Well, in that process, we oftentimes fail to just ask people whether or not they want to participate in trials. There’s this presumption that while people aren’t interested, and I think what we need to do is ask everybody that comes through our doors to consider a clinical trial and to think about what barriers truly exist to prevent people from participating. because right now, if we really rely on this mistrust and distrust as a viewpoint of why people aren’t participating in trial, then we actually, we put the blame on our patients, right? And we don’t actually put the blame on ourselves as the main drivers of non-participation or what really it’s not a participation issue. It’s an exclusionist issue, right? We propagate a history of excluding you know, people of color from clinical trials.

[ACT]IVATED Prostate Cancer Post-Program Survey

Advanced Prostate Cancer Clinical Trials | Why Black and Latinx Participation Is Vital

Advanced Prostate Cancer Clinical Trials | Why Black and Latinx Participation Is Vital from Patient Empowerment Network on Vimeo.

Why is advanced prostate clinical trial participation important for Black and Latinx patients? Expert Dr. Yaw Nyame with the University of Washington explains how clinical trial participation helps patients and solutions toward removing barriers to participation.

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Understanding the Role of a Digital Rectal Exam in Prostate Cancer Care

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What Can Signal Hormone-Sensitive Advanced Prostate Cancer?

Transcript:

Lisa Hatfield:

Dr. Nyame, the importance of clinical trial participation can’t be underscored enough in cancer care. Can you speak to advanced prostate cancer clinical trials specifically for Black and Latinx men, and critically important, how are you and your colleagues removing barriers to accessing care and underrepresented communities, including the access to those clinical trials?

Dr. Yaw Nyame:

Yeah, I can’t state this enough. Clinical trials are a form of high-quality care, and I think a lot of people don’t understand that clinical trials don’t just test you in a vacuum with something that we think is really promising versus nothing at all. Clinical trials often are going to test a standard of care, so what we do currently versus something standard of click care and something that we think has benefit, and so at the very least, when you participate in the clinical trial, you are going to get what we think works best currently.

And then there’s the additional benefit that you might get something that we think works a little bit better or a lot better than what we do currently, and you do it in a space where people are monitoring you really closely, right? Because the clinical trial needs to collect data and understand how things work and how well they work. So it is a form of really high quality care, and I urge Black, Latino, and other minoritized patient populations to find ways to get access to this really high quality care. Now, what we have to do as medical institutions, as cancer center, is figure out ways to remove the barriers that limit people’s ability to participate in clinical trials.

Those barriers are usually social barriers, right? It is the, do I have the ability to take off time from work to participate in this trial? How’s this going to affect my household if I’ve got to come in my case to Seattle and take a whole day off from work to participate? Can I afford transportation to be coming to the cancer center every week? You know, do I have child care to participate in this trial? And so we as cancer centers are starting to think more holistically about how we can remove social barriers to clinical trial participation. And I do think until we get that right a lot of the inability for marginalized and minoritized populations to participate in clinical trials falls at our feet. So what are we doing to address barriers? Well, I think we’re trying to think about ways of putting clinical trials directly in communities.

So some of those social barriers are removed so that it’s not always on the patient to come to us. We’re thinking of ways to support those patients that have to absolutely come to us for a variety of reasons for a clinical trial so that there isn’t that financial and social burden. But it’s very much a work in progress. And I think we’re really in the early phases of understanding how we can support people. My activation tip when it comes to clinical trials and prostate cancer is to ask for them and to demand opportunities to participate in them because they are such high, they’re such incredible forms of high quality care.

And I think by participating in a clinical trial, you’re giving yourself and future versions of yourself and your community opportunities to have better outcomes when it comes to these cancers. And I think the second portion of that is to demand and ask from your cancer centers that they find ways to support you in participating in those clinical trials. Because as a cancer center and as an academic clinical institution, our mission is to serve. And we do have resources that we can sometimes make available to make sure that you can afford to and not be put out by participating in a clinical trial.

[ACT]IVATED Prostate Cancer Post-Program Survey

Evolving Research | Advanced Prostate Cancer Treatment

Evolving Research | Advanced Prostate Cancer Treatment from Patient Empowerment Network on Vimeo.

Prostate cancer research continues to evolve, but what’s important for patients to know? Expert Dr. Xin Gao shares updates about recent clinical trial developments, where research stands, and the outlook for future prostate cancer treatments.

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

See More From INSIST! Prostate Cancer

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How Is Advanced Prostate Cancer Treatment Personalized

How Is Advanced Prostate Cancer Treatment Personalized?


Transcript:

Katherine:

This actually leads me to my next question which is about research news. 

Prostate cancer research is evolving quickly, like so many other cancers. And it’s important for patients to stay up to date on developing news. So, are there research advances that patients should be aware of? 

Dr. Gao:

Yeah, I mean some of the treatments that I just mentioned, PARP inhibitors, pembrolizumab (Keytruda) for MSI higher and mismatch repair deficient tumors and lutetium. Those have come out of recent major clinical trials and have become the standard of care in a lot of different…in various different settings for patients. And there are always new research trials, clinical trials, that are going to either move some of these established treatments to earlier lines of setting, earlier lines of treatment, or using them in maybe combination with other drugs where we might learn that they’re more useful if we combine it with another drug or maybe combine it with hormone treatments earlier rather than later. 

So, there are always clinical trials for advanced prostate cancer. There are even newer trials, novel therapies, completely new treatments that have been studied in the laboratory in say petri dish models of cancer or animal, mouse models of prostate cancer, but have shown enough early exciting data to try to move them into human beings and hopefully help advanced prostate cancer patients.  

Katherine:

As we wrap up, Dr. Gao, I’d like to get your thoughts. How do you feel about where we stand with advanced prostate cancer care? 

Dr. Gao:

Yeah. I think there have been a lot of advances in advanced prostate cancer care in recent years. Newer and better treatment strategies seem to come along every couple of years, and I think what we’ve seen for advanced prostate cancer patients over the past, really, since probably 2015 or so, is a significant improvement in outcomes, long-term outcomes like survival and slowing down of the cancer. 

And it’s…I think it’s important to acknowledge that and to acknowledge that the clinical trials in recent years have really led to a lot of improvements and really the hope that in the coming years, there’s going to be additional research, additional clinical trials, newer treatments hopefully, that will continue to improve outcomes for advanced prostate cancer patients. I also think that it’s really critical to evaluate the specific patients’ cancer characteristics, things like the genetic testing that I mentioned earlier, as well as their sort of life situations and other medical comorbidities to come to a shared decision about what makes the most sense in terms of their cancer management.  

Genetic testing might open up the option for certain FDA-approved therapies or consideration of certain targeted therapies that still might be in clinical trials. And clinical trials, again, are also an option for additional treatment strategies that otherwise would not be available. 

Establishing Treatment Goals: What Are Options for Advanced Prostate Cancer Therapy?

Establishing Treatment Goals: What Are Options for Advanced Prostate Cancer Therapy? from Patient Empowerment Network on Vimeo.

Prostate cancer treatment goals can vary by patient – thus why it’s essential to have different treatment options. Expert Dr. Xin Gao explains the importance of establishing treatment goals and shares an overview of available options. 

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

See More From INSIST! Prostate Cancer

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How Is Advanced Prostate Cancer Treatment Personalized

How Is Advanced Prostate Cancer Treatment Personalized?


Transcript:

Katherine:

Dr. Gao, now that we know what goes into understanding a patient’s disease, I’d like to talk about treatment, starting with treatment goals. How do goals vary by patient, if they vary at all? 

Dr. Gao:

Sure, yeah. I do think they vary, and I think it is important to be clear about what the realistic goals of treatment might be so that the patient can make an informed decision on how the prostate cancer should be treated or managed. 

Some prostate cancers are highly curable, although there isn’t anything that’s 100 percent, right? And others are curable, but we acknowledge that there may still be a significant risk of relapse despite treatment. And maybe that rough percentage, the probability of cure and sort of the potential downsides or side effects of treatment, that’s something that the patient has to weigh in terms of whether they want to proceed with that treatment or not.   

And then, there are cancers, especially with advanced prostate cancers, that are unfortunately not curable, but yet treatments have the ability to significantly prolong somebody’s life, to slow the cancer progression down or even to shrink it, and to improve cancer-associated symptoms and other sources of distress that we talked about earlier.  

And so, with each patient, I think it is important to talk about these treatment goals because it may not be readily clear, is this a curable cancer or not? And it might not be clear how much benefit they might expect with treatment or are we talking about a marginal benefit? And then that way, you know, they can think about it, talk about it with their family, and kind of factor into their overall benefit risk calculation about whether to do something or not. 

Katherine:

Would you provide an overview of current treatment options for advanced disease? 

Dr. Gao:

Sure. So, it’s a big, very open-ended question, I think.  

So, I think you can divide it up into sort of the major treatment modalities, so things like radiation or radiation types of therapies, chemotherapy, hormonal therapies which are the mainstay of prostate cancer treatments, targeted therapies, and immunotherapies.  

Starting with hormonal therapies which are the backbone of prostate cancer treatments, for advanced prostate cancer, androgen deprivation therapy or ADT is often given indefinitely as the typical standard of care treatment and there are various forms of ADT, most commonly in the form of long-lasting injectable medications – leuprolide (Eligard/Lupron Depot), goserelin (Zoladex), sometimes degarelix (Firmagaon)  is used. And then more recently, there was an FDA approval a couple years ago of an oral pill called relugolix (Orgovyx), which is also a form of ADT or androgen deprivation therapy.  

These medications block the body’s ability to make testosterone which is important for prostate cancer survival and spread. In addition, abiraterone is an oral medication that is also considered a hormonal therapy. It blocks the production on androgens or male sex hormones outside of the testes. That includes the adrenal glands and some other tissues such as prostate cancer itself. And abiraterone (Zytiga) is commonly used in advanced prostate cancer management, in addition to androgen deprivation therapy whereas ADT blocks the testes from making testosterone and androgens, abiraterone blocks the production of androgens outside of the testes.  

And then finally, oral anti-androgen medications that block the prostate cancers from being able to detect androgens or male hormones and to block the androgen receptors on prostate cancers from sending cellular signals for growth and survival are also very commonly used.  

There are older anti-androgen medications like bicalutamide (Casodex), flutamide (Eulexin), lutamide, and there are newer ones, stronger versions, called enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa). For most patients who present with advanced prostate cancer, I think this is much easier, ADT along with either abiraterone or one of the newer, stronger anti-androgens, is the standard of care for most advanced prostate cancer patients with metastatic disease.  

And then, sometimes for patients with higher volume or more aggressive cancers even in the group with metastatic disease, we even add on another treatment, usually chemotherapy, something called docetaxel for what we call triple therapy. And then, maybe that’s a segue to chemotherapy, so docetaxel chemotherapy is a common chemotherapy used for prostate cancer, certainly advanced prostate cancers. Cabazitaxel (Jevtana) is also a common chemotherapy in this situation. These two are related drugs in a family of drugs called taxane chemotherapies and basically they kind of block the trafficking of important components within cancer cells and cause the cancer cell death.  

Docetaxel (Taxotere) is the more commonly used one. It’s typically used earlier, before cabazitaxel. And like I said earlier, for certain patients with what we call high volume metastatic prostate cancer, it’s often used in combination with hormonal therapies early on, what we call upfront therapy for six cycles. If a patient doesn’t receive docetaxel up front, docetaxel is commonly used after progression, after the cancer has progressed on ADT and one of the oral hormone medications.  

Cabazitaxel is more commonly used after a patient has previously received or progressed on docetaxel. Both drugs have been evaluated in randomized Phase III clinical trials and have shown to provide efficacy for patients with advanced prostate cancers.  

In addition to these taxane chemotherapies, platinum chemotherapy, such as carboplatin or cisplatin, are sometimes used for advanced prostate cancers as well, especially for certain neuroendocrine or small cell prostate cancers. These are rarer cancers, but they tend to respond better to platinum-based chemotherapies.   

Or for certain what we call aggressive variant prostate cancers, these platinum-based chemotherapies are also used in combination with either one of the taxanes or with another chemotherapy drug called etoposide. In terms of other treatment modalities, I think recently what we call radiotherapeutics or radioligand therapies have gotten a lot of press with the approval of a new medication called lutetium PSMA or 177 lutetium PSMA 617 (Pluvicto). 

The brand name for that in the U.S. is Pluvicto and what this is is a drug that’s a small molecule that binds to PSMA, which is a protein highly expressed in close to 90% of prostate cancer, advanced prostate cancers. And the small molecule will home to the cancer and it’s linked to radioactive lutetium and the lutetium will decay in that area and lead to cancer cell death.  

So, Pluvicto or lutetium was FDA approved in spring of 2022 based on randomized Phase III trials that show significant efficacy for patients with metastatic castration-resistant prostate cancer who have previously received a second-generation androgen receptor pathway inhibitor, such as abiraterone and enzalutamide, as well as a taxane chemotherapy, like docetaxel or cabazitaxel.  

The medication is given intravenously, once every six weeks, for up to six doses, and there are ongoing clinical trials, actually, that are trying to evaluate this medication in earlier settings where patients haven’t gotten prior chemotherapy before. There was a press release from about half a year ago stating that they’re seeing some early encouraging signs of efficacy with this drug, even in patients who had never received chemotherapy before, so it may be a medication that is going to be used more and more so in more patients even earlier in their course of disease. they’ve shown pretty solid activity for those kinds of cancers. 

How Is Advanced Prostate Cancer Treatment Personalized?

How Is Advanced Prostate Cancer Treatment Personalized? from Patient Empowerment Network on Vimeo.

Tests results, including results of biomarker testing, may help to personalize advanced prostate cancer treatment. Expert Dr. Xin Gao shares an overview of the testing that patients should undergo and how the results are used in determining a treatment plan for optimal care.

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

See More From INSIST! Prostate Cancer

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Transcript:

Katherine:

I’d like to talk about what goes into deciding on a treatment path. What testing is used to understand a patient’s individual disease?  

Dr. Gao:

There is a lot of testing that we do for – to try and characterize a patient’s individual disease and try to select an optimal management strategy for their specific cancer and their specific situation.  

We look at the biopsy, the pathology. The most common type of prostate cancer is called adenocarcinoma, but rarely we see certain other types under the microscope, things like neuroendocrine or small cell prostate cancers that tend to be treated in a different way. We look at things like the Gleason score.  

That tells us a bit more about sort of the aggressiveness of this cancer, as well as the PSA, you know, it’s a very good correlate for how the cancer is doing in general once somebody has been diagnosed with prostate cancer. For imaging tests, we commonly rely on imaging. We look at prostate MRIs to get an idea of the local extent of the prostate tumor. We get things like bone scans and CAT scans to look at the entire rest of the body to see if or where the cancer may have spread to.  

And there are newer imaging tests like the PSMA PET scan, which we commonly use now, which is a much more sensitive test for detecting prostate cancer in 2023 compared to traditional scans like CAT scans and bone scans. I also commonly make use of genetic testing and molecular information.  

So, for any patient with an advanced prostate cancer, I do recommend both what we call a germline test, which is testing for inherited cancer genes that a patient could have gotten from the parents and pass onto their kids, as well as somatic testing, which is testing the cancer itself to see what genetic mutations or alterations might’ve developed within their cancer. And that can actually factor into certain treatments that the patient may or may not be more likely to benefit from if they have these genetic mutations. 

Katherine:

Dr. Gao, a patient sent in this question prior to the program. What other genetic testing, beside BRCA markers, are important for deciding future targeted therapies and how are each of them used? 

Dr. Gao:

Yeah, that’s a great question. Targeted therapies have been used in a lot of different cancers and it’s only really within the past few years that we’re using them as a standard of care routinely in prostate cancers. So, BRCA2 and BRCA1 mutations are some of the more common mutations or genetic alterations that are targetable in prostate cancer. Recently, there have been multiple FDA approvals of different drugs that are called PARP inhibitor, which are able to target the cancer if they have BRCA1 or BRCA2 mutations.  

Beyond BRCA2 and BRCA1, there’s a panel of what’s called homologous recombination repair genes and that’s defined differently in varying extents, depending on the specific drug. That has been FDA approved, but in general, it’s about 12 to 14 genes total and they actually include the BRCA2 and BRCA1 genes.  

So, some of the ones that have been…it seems like the data shows maybe more activity or better efficacy with these PARP inhibitors include a gene called PALB2, P-A-L-B 2. It’s not a very common mutation that we see, but it is something that we should look for because even if it’s not common overall for the patient who has it, it could be a very helpful and useful gene to know that that they have and it certainly would warrant treatment with a PARP inhibitor. 

The other sort of dozen  or so…10-12 genes in this homologous recombination repair pathway, the data, I would say, is still early and it is still somewhat limited in terms of how much people with those gene mutations truly benefit from these PARP inhibitors, but I do think it’s important to look for them, to know that if they do have one of these genetic mutations that it does make a PARP inhibitor an option for them. And then, beyond these HRR genes, I always look for something called a microsatellite instability or mismatched repair deficiency. These are sort of genetic features or really a panel of about four genes involved in a cellular process called – a DNA repair process called mismatch repair.  

For those patients that have either mismatched repair deficiency or microsatellite instability high cancers, I do recommend that they consider an immunotherapy medication called pembrolizumab which is FDA-approved regardless of cancer type for any MSI high or mismatched repair cancer and they’ve shown pretty solid activity for those kinds of cancers. 

Common Symptoms of Advanced Prostate Cancer

Common Symptoms of Advanced Prostate Cancer from Patient Empowerment Network on Vimeo.

What are common symptoms of advanced prostate cancer? Expert Dr. Xin Gao discusses the various symptoms that patients may experience and treatments that may be used to manage these common issues.  

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

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Transcript:

Katherine:

What are common symptoms of advanced disease, and how are the symptoms managed? 

Dr. Gao:

So, with advanced disease, the symptoms can present in a variety of different ways. 

They’re often related to where the cancer has spread to. If there’s a tumor in the prostate gland itself or next to it, some patients might experience urinary symptoms, urinary frequency, feeling of incomplete emptying or a weak urinary flow. Or even pain or discomfort of leading with urination. That’s sort of the primary prostate tumor itself. Bone metastases can cause bone pain and commonly this involves bones in the spine or back or in the pelvis.  

There’s also a heightened risk of fractures with bone metastases and obviously that can sometimes cause pain. However, I think I should mention, many bone metastases actually don’t cause pain. It’s not uncommon that we see a bone scan or a CAT scan that the cancer is in multiple bones, but the patient actually, you know, I think fortunately, doesn’t feel any pain from that. 

Lymph node spread, I would say, rarely causes symptoms early on, but if there’s significant enlargement of these lymph nodes or in risking anatomic areas, sometimes the lymph nodes can cause discomfort or pain. Sometimes they can compress upon major veins or blood vessels or on the ureters that drain the kidneys and cause either blood clots or lower extremity swelling if it’s the major veins or cause kidney dysfunction because the ureters aren’t draining the kidneys appropriately. And then, I think in general, as with any advanced cancer, advanced prostate cancer can commonly cause fatigue and cause patients to just kind of generally feel unwell in sort of a hard to pinpoint type of way.  

I think it’s sort of the general toll that the cancer – the burden of the cancer is causing on the body and maybe taking, you know, essential nutrients or other things away from normal body organs or body cells. 

Katherine:

How are some of these symptoms managed? 

Dr. Gao:

So, pain, if people have pain, it’s typically managed with analgesics and pain medications, whether it’s Tylenol or ibuprofen. Other NSAID types of medications. Opiates and narcotic pain medications are commonly used for advanced prostate cancers as well to control and manage and treat the pain. And patients with cancers involving the bones that have become resistant to standard hormone therapy, we also commonly give medications called bisphosphonates. 

Zoledronic acid is a common one. Or a related medication called denosumab to try to reduce the risk of fractures, to strengthen the bones a bit. And these medications can also help with bone pain to some extent. And sometimes we treat other symptoms of cancer with medications that might help improve energy levels and improve the fatigue, for example.  

So, methylphenidate or methylphenidate  (Ritalin) is a common medication that is used to try to help with energy levels or reduced energy in advanced cancer patients. Sometimes steroid medications can do that as well, could be helpful. Appetite, reduced appetite with advanced cancer is not uncommon, although I think for prostate cancer, we see it to a lesser extent compared to other advanced cancers. 

There are other medications, steroids being one of them, and medications like mirtazapine or Remeron can be used to help try to simulate the appetite a little bit more. In terms of other symptoms, urinary symptoms, let’s say from the primary prostate tumor, that’s often co-managed with my colleagues in urology. There are medications that can be used to try to help with the urinary flow or stream in some situations or perhaps procedural interventions that might be able to help open up the urinary outlet a little bit more. Those things can be considered as well. 

How Does Prostate Cancer Progress? Understanding the Stages of Prostate Cancer

How Does Prostate Cancer Progress? Understanding the Stages of Prostate Cancer from Patient Empowerment Network on Vimeo.

What do prostate cancer patients need to know about progression and recurrence? Expert Dr. Xin Gao discusses the difference between progression and recurrence and explains what occurs in the body in different stages of prostate cancer.

Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about this expert Dr. Gao.

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Transcript:

Katherine:

Dr. Gao, this program is focusing on advanced prostate cancer. Would you walk us through how the disease progresses in each stage?  

Dr. Gao:

Sure. I think advanced prostate cancer can mean a lot of different things, but in general, it means a prostate cancer that has either spread out from the prostate gland itself to other areas of the body or has recurred despite either surgery or radiation-based therapy to the primary prostate tumor. 

In each of these situations, typically the focus would on medication types of treatments and we think about advanced prostate cancer as either hormone-sensitive or hormone-resistant, or the other term in the field for it would be castration-resistant, meaning that the prostate cancer is either sensitive to hormonal therapies or perhaps it’s no longer sensitive to the most common type of hormone therapy called androgen deprivation therapy. So, those are sort of the ways that the cancer can progress, and typically all these cancers start as hormone-sensitive prostate cancers and over time, they may evolve and become resistant and become what we call castration-resistant prostate cancer. 

Katherine:

Okay. So, they’re not numbered as in a lot of other cancers, like stage I, stage II?  

Dr. Gao:

Meaning by stage, oh. So, there are stages. All advanced prostate cancers are by definition stage IV. All advanced cancers, in general, are stage IV but advanced prostate cancer would be stage IV. Most prostate cancers actually present as localized prostate cancer, stage I, stage II, even stage III prostate cancers and the majority of localized prostate cancers are actually, fortunately, quite curable with either surgery or radiation-based therapies.  

Unfortunately, not all are curable, and some will recur despite these curative intent treatments, and others might just be inherently more aggressive biologically, and they could even present with metastatic disease or stage IV disease having spread to other sites outside of the prostate gland, even at diagnosis. 

When prostate cancer metastasizes or spreads, it commonly spreads by lymphatic vessels or by the bloodstream and most commonly, they tend to go to either lymph nodes or bones or some combination of both. More common areas of lymph node spread are in the pelvic areas, kind of near where the prostate gland is, or deep in the abdomen in an area called the retroperitoneum. And then bones more commonly could be in sort of the back or spine bones or in the pelvic bones, but it could go to other areas less common as well. 

Advanced Prostate Cancer: How to Access the Best Care and Treatment for YOU

Advanced Prostate Cancer: How to Access the Best Care and Treatment for YOU from Patient Empowerment Network on Vimeo.

Progress in advanced prostate cancer has led to more personalized treatment options and individualized care for people with this diagnosis. Dr. Xin Gao discusses how the results of essential testing can help guide a patient’s prognosis and treatment path, reviews available therapies, and shares advice for self-advocacy.

Bio:
Dr. Xin Gao is a Medical Oncologist at Massachusetts General Hospital. Learn more about Dr. Gao.

Download Resource Guide

See More From INSIST! Prostate Cancer

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What Are Current Prostate Cancer Treatment Options?


Transcript:

Katherine:

Hello and welcome. I’m your host Katherine Banwell. Today’s program focuses on how people with advanced prostate cancer can access the best treatment in care. We’ll review essential testing, discuss the latest research, and share tips for self-advocacy. Before we meet our guest, let’s review a few important details. The reminder email you received about this program contains a link to a resource guide. If you haven’t already, click that link to access information to follow along during the webinar. At the end of this program, you’ll receive a link to a program survey. Please take a moment to provide feedback about your experience today in order to help us plan future webinars.  

Finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you. Well, let’s meet our guest today. Joining me is Dr. Xin Gao. Dr. Gao, welcome. Would you please introduce yourself? 

Dr. Gao:

Yeah. Thank you very much for having me. My name is Xin Gao. I’m a medical oncologist at Mass General Cancer Center in Boston, Massachusetts. I focus on prostate cancer and other cancers involving the urinary system. I’m also involved in our clinical trials program where we’re studying newer and what we hope are better treatments for these types of cancers.  

Katherine:

Well, thank you so much for joining us today. I know you’re a busy guy.  

Dr. Gao:

I’m happy to be here.  

Katherine:

Good. Dr. Gao, this program is focusing on advanced prostate cancer. Would you walk us through how the disease progresses in each stage? 

Dr. Gao:

Sure. I think advanced prostate cancer can mean a lot of different things, but in general, it means a prostate cancer that has either spread out from the prostate gland itself to other areas of the body or has recurred despite either surgery or radiation-based therapy to the primary prostate tumor. 

In each of these situations, typically the focus would on medication types of treatments and we think about advanced prostate cancer as either hormone-sensitive or hormone-resistant, or the other term in the field for it would be castration-resistant, meaning that the prostate cancer is either sensitive to hormonal therapies or perhaps it’s no longer sensitive to the most common type of hormone therapy called androgen deprivation therapy. So, those are sort of the ways that the cancer can progress, and typically all these cancers start as hormone-sensitive prostate cancers and over time, they may evolve and become resistant and become what we call castration-resistant prostate cancer. 

Katherine:

Okay. So, they’re not numbered as in a lot of other cancers, like stage I, stage II?  

Dr. Gao:

Meaning by stage, oh. So, there are stages. All advanced prostate cancers are by definition stage IV. All advanced cancers, in general, are stage IV but advanced prostate cancer would be stage IV. Most prostate cancers actually present as localized prostate cancer, stage I, stage II, even stage III prostate cancers and the majority of localized prostate cancers are actually fortunately quite curable with either surgery or radiation-based therapies.  

Unfortunately, not all are curable and some will recur despite these curative intent treatments and others might just be inherently more aggressive biologically and they could even present with metastatic disease or stage IV disease having spread to other sites outside of the prostate gland, even at diagnosis. 

When prostate cancer metastasizes or spreads, it commonly spreads by lymphatic vessels or by the bloodstream and most commonly, they tend to go to either lymph nodes or bones or some combination of both. More common areas of lymph node spread are in the pelvic areas, kind of near where the prostate gland is, or deep in the abdomen in an area called the retroperitoneum. And then bones more commonly could be in sort of the back or spine bones or in the pelvic bones, but it could go to other areas less common as well.  

Katherine:

What are common symptoms of advanced disease, and how are the symptoms managed? 

Dr. Gao:

So, with advanced disease, the symptoms can present in a variety of different ways.  

They’re often related to where the cancer has spread to. If there’s a tumor in the prostate gland itself or next to it, some patients might experience urinary symptoms, urinary frequency, feeling of incomplete emptying or a weak urinary flow. Or even pain or discomfort of leading with urination. That’s sort of the primary prostate tumor itself. Bone metastases can cause bone pain and commonly this involves bones in the spine or back or in the pelvis.   

There’s also a heightened risk of fractures with bone metastases and obviously that can sometimes cause pain. However, I think I should mention, many bone metastases actually don’t cause pain. It’s not uncommon that we see a bone scan or a CAT scan that the cancer is in multiple bones, but the patient actually, you know, I think fortunately, doesn’t feel any pain from that. 

Lymph node spread, I would say, rarely causes symptoms early on, but if there’s significant enlargement of these lymph nodes or in risking anatomic areas, sometimes the lymph nodes can cause discomfort or pain. Sometimes they can compress upon major veins or blood vessels or on the ureters that drain the kidneys and cause either blood clots or lower extremity swelling if it’s the major veins or cause kidney dysfunction because the ureters aren’t draining the kidneys appropriately. And then, I think in general, as with any advanced cancer, advanced prostate cancer can commonly cause fatigue and cause patients to just kind of generally feel unwell in sort of a hard to pinpoint type of way.  

I think it’s sort of the general toll that the cancer – the burden of the cancer is causing on the body and maybe taking, you know, essential nutrients or other things away from normal body organs or body cells.  

Katherine:

How are some of these symptoms managed?  

Dr. Gao:

So, pain, if people have pain, it’s typically managed with analgesics and pain medications, whether it’s Tylenol or ibuprofen. Other NSAID types of medications. Opiates and narcotic pain medications are commonly used for advanced prostate cancers as well to control and manage and treat the pain. And patients with cancers involving the bones that have become resistant to standard hormone therapy, we also commonly give medications called bisphosphonates. 

Zoledronic acid is a common one. Or a related medication called denosumab to try to reduce the risk of fractures, to strengthen the bones a bit. And these medications can also help with bone pain to some extent. And sometimes we treat other symptoms of cancer with medications that might help improve energy levels and improve the fatigue, for example.  

So, methylphenidate or methylphenidate  (Ritalin) is a common medication that is used to try to help with energy levels or reduced energy in advanced cancer patients. Sometimes steroid medications can do that as well, could be helpful. Appetite, reduced appetite with advanced cancer is not uncommon, although I think for prostate cancer, we see it to a lesser extent compared to other advanced cancers. 

There are other medications, steroids being one of them, and medications like mirtazapine or Remeron can be used to help try to simulate the appetite a little bit more. In terms of other symptoms, urinary symptoms, let’s say from the primary prostate tumor, that’s often co-managed with my colleagues in urology. There are medications that can be used to try to help with the urinary flow or stream in some situations or perhaps procedural interventions that might be able to help open up the urinary outlet a little bit more. Those things can be considered as well.  

Katherine:

I’d like to talk about what goes into deciding on a treatment pass. What testing is used to understand a patient’s individual disease? 

Dr. Gao:

There is a lot of testing that we do for – to try and characterize a patient’s individual disease and try to select an optimal management strategy for their specific cancer and their specific situation. 

We look at the biopsy, the pathology. The most common type of prostate cancer is called adenocarcinoma, but rarely we see certain other types under the microscope, things like neuroendocrine or small cell prostate cancers that tend to be treated in a different way. We look at things like the Gleason score.  

That tells us a bit more about sort of the aggressiveness of this cancer, as well as the PSA, you know, it’s a very good correlate for how the cancer is doing in general once somebody has been diagnosed with prostate cancer. For imaging tests, we commonly rely on imaging. We look at prostate MRIs to get an idea of the local extent of the prostate tumor. We get things like bone scans and CAT scans to look at the entire rest of the body to see if or where the cancer may have spread to.  

And there are newer imaging tests like the PSMA PET scan, which we commonly use now, which is a much more sensitive test for detecting prostate cancer in 2023 compared to traditional scans like CAT scans and bone scans. I also commonly make use of genetic testing and molecular information.  

So, for any patient with an advanced prostate cancer, I do recommend both what we call a germline test, which is testing for inherited cancer genes that a patient could have gotten from the parents and pass onto their kids, as well as somatic testing, which is testing the cancer itself to see what genetic mutations or alterations might’ve developed within their cancer. And that can actually factor into certain treatments that the patient may or may not be more likely to benefit from if they have these genetic mutations.  

Katherine:

Dr. Gao, a patient sent in this question prior to the program. What other genetic testing, beside BRCA markers, are important for deciding future targeted therapies and how are each of them used? 

Dr. Gao:

Yeah, that’s a great question. Targeted therapies have been used in a lot of different cancers and it’s only really within the past few years that we’re using them as a standard of care routinely in prostate cancers. So, BRCA II and BRCA I mutations are some of the more common mutations or genetic alterations that are targetable in prostate cancer. Recently, there have been multiple FDA approvals of different drugs that are called PARP inhibitor, which are able to target the cancer if they have BRCA II or BRCA I mutations.   

Beyond BRCA2 and BRCA1, there’s a panel of what’s called homologous recombination repair genes and that’s defined differently in varying extents, depending on the specific drug. That has been FDA approved, but in general, it’s about 12-14 genes total and they actually include the BRCA2 and BRCA1 genes.  

So, some of the ones that have been…it seems like the data shows maybe more activity or better efficacy with these PARP inhibitors include a gene called PALB2, P-A-L-B 2. It’s not a very common mutation that we see, but it is something that we should look for because even if it’s not common overall for the patient who has it, it could be a very helpful and useful gene to know that that they have and it certainly would warrant treatment with a PARP inhibitor. 

The other sort of dozen  or so…10-12 genes in this homologous recombination repair pathway, the data, I would say, is still early and it is still somewhat limited in terms of how much people with those gene mutations truly benefit from these PARP inhibitors, but I do think it’s important to look for them, to know that if they do have one of these genetic mutations that it does make a PARP inhibitor an option for them. And then, beyond these HRR genes, I always look for something called a microsatellite instability or mismatched repair deficiency. These are sort of genetic features or really a panel of about four genes involved in a cellular process called – a DNA repair process called mismatch repair.  

For those patients that have either mismatched repair deficiency or microsatellite instability high cancers, I do recommend that they consider an immunotherapy medication called pembrolizumab which is FDA-approved regardless of cancer type for any MSI high or mismatched repair cancer and they’ve shown pretty solid activity for those kinds of cancers.  

Katherine:

Dr. Gao, now that we know what goes into understanding a patient’s disease, I’d like to talk about treatment, starting with treatment goals. How do goals vary by patient, if they vary at all? 

Dr. Gao:

Sure, yeah. I do think they vary and I think it is important to be clear about what the realistic goals of treatment might be so that the patient can make an informed decision on how the prostate cancer should be treated or managed. 

Some prostate cancers are highly curable, although there isn’t anything that’s 100 percent, right? And others are curable, but we acknowledge that there may still be a significant risk of relapse despite treatment. And maybe that rough percentage, the probability of cure and sort of the potential downsides or side effects of treatment, that’s something that the patient has to weigh in terms of whether they want to proceed with that treatment or not.  

And then, there are cancers, especially with advanced prostate cancers, that are unfortunately not curable, but yet treatments have the ability to significantly prolong somebody’s life, to slow the cancer progression down or even to shrink it, and to improve cancer-associated symptoms and other sources of distress that we talked about earlier. 

And so, with each patient, I think it is important to talk about these treatment goals because it may not be readily clear, is this a curable cancer or not? And it might not be clear how much benefit they might expect with treatment or are we talking about a marginal benefit? And then that way, you know, they can think about it, talk about it with their family, and kind of factor into their overall benefit risk calculation about whether to do something or not.  

Katherine:

Would you provide an overview of current treatment options for advanced disease? 

Dr. Gao:

Sure. So, it’s a big, very open-ended question, I think.  

So, I think you can divide it up into sort of the major treatment modalities, so things like radiation or radiation types of therapies, chemotherapy, hormonal therapies which are the mainstay of prostate cancer treatments, targeted therapies, and immunotherapies.   

Starting with hormonal therapies which are the backbone of prostate cancer treatments, for advanced prostate cancer, androgen deprivation therapy or ADT is often given indefinitely as the typical standard of care treatment and there are various forms of ADT, most commonly in the form of long-lasting injectable medications – leuprolide (Eligard/Lupron Depot), goserelin (Zoladex), sometimes degarelix (Firmagaon)  is used. And then more recently, there was an FDA approval a couple years ago of an oral pill called relugolix (Orgovyx), which is also a form of ADT or androgen deprivation therapy.   

These medications block the body’s ability to make testosterone which is important for prostate cancer survival and spread. In addition, abiraterone is an oral medication that is also considered a hormonal therapy. It blocks the production on androgens or male sex hormones outside of the testes. That includes the adrenal glands and some other tissues such as prostate cancer itself. And abiraterone (Zytiga) is commonly used in advanced prostate cancer management, in addition to androgen deprivation therapy whereas ADT blocks the testes from making testosterone and androgens, abiraterone blocks the production of androgens outside of the testes. 

And then finally, oral anti-androgen medications that block the prostate cancers from being able to detect androgens or male hormones and to block the androgen receptors on prostate cancers from sending cellular signals for growth and survival are also very commonly used.  

There are older anti-androgen medications like bicalutamide (Casodex), flutamide (Eulexin), lutamide, and there are newer ones, stronger versions, called enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa). For most patients who present with advanced prostate cancer, I think this is much easier, ADT along with either abiraterone or one of the newer, stronger anti-androgens, is the standard of care for most advanced prostate cancer patients with metastatic disease.  

And then, sometimes for patients with higher volume or more aggressive cancers even in the group with metastatic disease, we even add on another treatment, usually chemotherapy, something called docetaxel for what we call triple therapy. And then, maybe that’s a segue to chemotherapy, so docetaxel chemotherapy is a common chemotherapy used for prostate cancer, certainly advanced prostate cancers. Cabazitaxel (Jevtana) is also a common chemotherapy in this situation. These two are related drugs in a family of drugs called taxane chemotherapies and basically they kind of block the trafficking of important components within cancer cells and cause the cancer cell death.  

Docetaxel (Taxotere) is the more commonly used one. It’s typically used earlier, before cabazitaxel. And like I said earlier, for certain patients with what we call high volume metastatic prostate cancer, it’s often used in combination with hormonal therapies early on, what we call upfront therapy for six cycles. If a patient doesn’t receive docetaxel up front, docetaxel is commonly used after progression, after the cancer has progressed on ADT and one of the oral hormone medications.  

Cabazitaxel is more commonly used after a patient has previously received or progressed on docetaxel. Both drugs have been evaluated in randomized Phase III clinical trials and have shown to provide efficacy for patients with advanced prostate cancers. 

In addition to these taxane chemotherapies, platinum chemotherapy, such as carboplatin or cisplatin, are sometimes used for advanced prostate cancers as well, especially for certain neuroendocrine or small cell prostate cancers. These are rarer cancers, but they tend to respond better to platinum-based chemotherapies.  

Or for certain what we call aggressive variant prostate cancers, these platinum-based chemotherapies are also used in combination with either one of the taxanes or with another chemotherapy drug called etoposide. In terms of other treatment modalities, I think recently what we call radiotherapeutics or radioligand therapies have gotten a lot of press with the approval of a new medication called lutetium PSMA or 177 lutetium PSMA 617 (Pluvicto). 

The brand name for that in the U.S. is Pluvicto and what this is is a drug that’s a small molecule that binds to PSMA, which is a protein highly expressed in close to 90 percent of prostate cancer, advanced prostate cancers. And the small molecule will home to the cancer and it’s linked to radioactive lutetium and the lutetium will decay in that area and lead to cancer cell death.  

So, Pluvicto or lutetium was FDA approved in spring of 2022 based on randomized Phase III trials that show significant efficacy for patients with metastatic castration-resistant prostate cancer who have previously received a second-generation androgen receptor pathway inhibitor, such as abiraterone and enzalutamide, as well as a taxane chemotherapy, like docetaxel or cabazitaxel.  

The medication is given intravenously, once every six weeks, for up to six doses, and there are ongoing clinical trials, actually, that are trying to evaluate this medication in earlier settings where patients haven’t gotten prior chemotherapy before. There was a press release from about half a year ago stating that they’re seeing some early encouraging signs of efficacy with this drug, even in patients who had never received chemotherapy before, so it may be a medication that is going to be used more and more so in more patients even earlier in their course of disease. 

Katherine:

This actually leads me to my next question which is about research news. 

Prostate cancer research is evolving quickly, like so many other cancers. And it’s important for patients to stay up to date on developing news. So, are there research advances that patients should be aware of? 

Dr. Gao:

Yeah, I mean some of the treatments that I just mentioned, PARP inhibitors, pembrolizumab (Keytruda) for MSI higher and mismatch repair deficient tumors and lutetium. Those have come out of recent major clinical trials and have become the standard of care in a lot of different…in various different settings for patients. And there are always new research trials, clinical trials, that are going to either move some of these established treatments to earlier lines of setting, earlier lines of treatment, or using them in maybe combination with other drugs where we might learn that they’re more useful if we combine it with another drug or maybe combine it with hormone treatments earlier rather than later. 

So, there are always clinical trials for advanced prostate cancer. There are even newer trials, novel therapies, completely new treatments that have been studied in the laboratory in say petri dish models of cancer or animal, mouse models of prostate cancer, but have shown enough early exciting data to try to move them into human beings and hopefully help advanced prostate cancer patients. 

Katherine:

Dr. Gao, if a patient is feeling like they’re not getting proper care or if they’re just not comfortable with their care team, what steps would you recommend they take to change the situation? 

Dr. Gao:

Yeah, I think that’s a difficult question to answer and it depends on sort of what the specifics are, but I will always encourage people to be up front with their providers, with their oncologists and their oncology team. I think it’s… it really is a collaboration and it really needs mutual trust and open communication.  

And to be able to say these are the things that I wish could be a bit better or not that different or could you clarify this or answer this or what about this idea or this thing that maybe I heard about. See what their thoughts are. I think clear communication is always important and it shouldn’t – I tell my patients that I view my role as sort of advising them about what the reasonable treatment or management strategies might be in their situation and what the data shows and what is recommended. 

But ultimately, it is a shared decision and the patient is in charge of their own body and own health and they can make the decision on what makes sense for them. So, again, I think it’ s a two-way street and open communication is the most important thing.  

Katherine:

As we wrap up, Dr. Gao, I’d like to get your thoughts. How do you feel about where we stand with advanced prostate cancer care? 

Dr. Gao:

Yeah. I think there have been a lot of advances in advanced prostate cancer care in recent years. Newer and better treatment strategies seem to come along every couple of years and I think what we’ve seen for advanced prostate cancer patients over the past, really, since probably 2015 or so, is a significant improvement in outcomes, long-term outcomes like survival and slowing down of the cancer. 

And it’s… I think it’s important to acknowledge that and to acknowledge that the clinical trials in recent years have really led to a lot of improvements and really the hope that in the coming years, there’s going to be additional research, additional clinical trials, newer treatments hopefully, that will continue to improve outcomes for advanced prostate cancer patients. I also think that it’s really critical to evaluate the specific patients’ cancer characteristics, things like the genetic testing that I mentioned earlier, as well as their sort of life situations and other medical comorbidities to come to a shared decision about what makes the most sense in terms of their cancer management.  

Genetic testing might open up the option for certain FDA-approved therapies or consideration of certain targeted therapies that still might be in clinical trials. And clinical trials, again, are also an option for additional treatment strategies that otherwise would not be available. 

Katherine:

Dr. Gao, thank you so much for taking the time to join us today. 

Dr. Gao:

You’re welcome. Thanks for having me. 

Katherine:

And thank you to all of our collaborators. If you would like to watch this webinar again, there will be a replay available soon. You’ll receive an email when it’s ready. And don’t forget to take the survey immediately following this program. It will help us as we plan future webinars. To learn more about prostate cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for joining us. 

What Are Current Prostate Cancer Treatment Options?

What Are Current Prostate Cancer Treatment Options? from Patient Empowerment Network on Vimeo.

What treatment options are available for prostate cancer patients? Expert Dr. Channing Paller shares an overview of prostate cancer treatment options including surgery, radiation, combination therapies, hormonal therapies, and the PEACE-1 clinical trial.

Dr. Channing Paller is Director of Prostate Cancer Clinical Research at Johns Hopkins Medicine. Learn more about Dr. Paller.

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Transcript:

Katherine:

What are other options that are available now, for patients? 

Dr. Paller:

For curative intent, the main two treatment options are surgery, radiation. Many people for very localized disease are trying other therapies, such as cryotherapy, and more focal therapies. But really, for curative, the standard is surgery or radiation. And as it gets more advanced, circling back to advanced prostate cancer, we are learning that combination therapy is better. So, adding pills like abiraterone, adding systemic therapies, help patients do better. 

So, there’s a big, long list of therapies upfront that we use for metastatic hormone-sensitive prostate cancer. There’s abiraterone, there is apalutamide (Erleada), there’s enzalutamide, and now, darolutamide (Nubeqa).  

And in fact, in fit patients that can tolerate chemotherapy for metastatic high-volume prostate cancer patients, we always recommend triple therapy, either with abiraterone, docetaxel, and ADT, or with darolutamide, docetaxel, and ADT, and these patients really seem to do better for longer. The other thing I would add is the PEACE-1 trial, which looked at abiraterone and docetaxel, found that patients would do best by adding growth factor support. And so, that is recommended. 

The other thing I want to point out to patients is, I know we’re all eager to get started when we find out we have a diagnosis of metastatic prostate cancer, but sometimes, these therapies are quite tough on the system when you have a lot of cancer in your body, and my recommendation to everybody is, one thing at a time. 

So, start the hormone therapy and wait at least 30 days, and in fact, in the PEACE-1 trial, they waited 45 days, right? That allows the testosterone levels to fall, it allows you to adjust to the side effects of hormone deprivation therapy, and it allows your body to be ready for the next line of therapy. And you can add the ADT to second line, such as abiraterone or daro during that time, but not adding the chemo all at once, that really makes a difference. 

I find, unfortunately, when patients and their providers don’t follow those strict criteria, as they did in the trial, meaning they start chemo and abiraterone and ADT on day one, the levels of chemotherapy get higher in the bloodstream because testosterone regulates that, and we’ve published on that before. And they end up with terrible side effects from the chemotherapy, such as neutropenic fever, which means you end up in the hospital with a bloodstream infection and a fever, and more neuropathy, meaning numbness and tingling in your hands and feet. 

And so, I really caution people to spread those therapies out over the first 90 days, and you’ll do better in terms of side effects, and just as well in terms of overall survival. 

Katherine:

Where does hormonal therapy fit into the treatment options, and have there been any advances in hormonal therapy? 

Dr. Paller:

Yes. So, hormonal therapy is the mainstay of how we take care of prostate cancer patients, whether we do this with surgical castration, which is not done very often anymore, or we do it with an LHRH agonist, or we do it with an LHRH antagonist. So, that means that we can do it with medicines that block the signaling, but that tells your body to produce testosterone in various ways. What’s really neat is we’ve made advances, that there are now oral options for some of these therapies. 

In particular, there’s a new therapy called Orgovyx, or relugolix, that is an oral LHRH antagonist that locks testosterone and allows us to stop prostate cancer growth. In addition, there are a variety of LHRH agonists that can be given as subcutaneous shots. 

Prostate Cancer Clinical Trials: What Are the Benefits?

Prostate Cancer Clinical Trials: What Are the Benefits? from Patient Empowerment Network on Vimeo

Prostate cancer expert Dr. Channing Paller shares an overview of what occurs in each clinical trial phase and discusses the role of surgery and radiation in patient care.

Channing Paller, MD is the Director of Prostate Cancer Clinical Research at Johns Hopkins Medicine. Learn more about this Dr. Paller.

Download Resource Guide

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Transcript:

Katherine:

Dr. Paller, let’s talk about what goes into deciding on a treatment path. First, what testing helps you understand the patient’s individual disease? 

Dr. Paller:

Great question. 

When I meet a patient, we talked about a few variables. First is, how do they feel? Are they in pain? Are they losing weight? Are they fatigued all the time? Are they able to do things that they enjoy, or not? So, that’s the most important, in terms of, how do they feel, and what are their symptoms? 

The next thing we looked at is, what are their labs, right? We look at PSA, but we also look at, is the prostate cancer affecting their organs? Is it affecting their red blood cells, their platelets, their white blood cells? And very importantly, it tells us, by looking at their alkaline phosphatase, if it’s in their bones or not. And we also can look at their labs to see, is it affecting their liver or not. Another thing we monitor is their creatinine or kidney function. Is there a blockage of their important organs down there because the prostate cancer has grown? So, the labs tell me a lot about their body function, and making sure their body is still functioning well.  

After we do how they feel, and what their labs are, we also look at imaging. And then, the previous years, we’ve always looked at a standard nuclear medicine bone scan, and also, a CAT scan. And nowadays, we’re really moving towards PSMA, or prostate specific membrane antigen, to help us really identify, at a much more sensitive level, where prostate cancer cells are expressed. 

And after we do those main three key things, we start to look at diagnostic tests. We look at different ways of assessing what are their genes. So, one of the first things we do is looking at germline genetic testing to see, what were the genes they were born with? And can those genes help us learn more about their cancer, and how it might progress? And also, how we might treat it better if they have certain genes like BRCA. 

The other nice thing about genetic testing, or germline genetic testing, is looking at, if they do have a genetic mutation, or a pathologic variant like BRCA, we are always, always telling families that they should get cascade testing for their family, right? So, if they have a mutation, we recommend that their family members get tested to make sure that they’re not at risk for a cancer. And so, we have them meet with a genetic counselor. 

So, in addition to what you’re born with, we also want to know what your cancer has developed, because cancer cells are growing quickly, and they can develop a mutation. And so, we also test the cancer, get genomic testing of the cancer, to look for mutations that we can target with our multiple drugs that we’ve approved to target cancers in certain mutations. So, you have something called MSII, we have immunotherapy for you. If you have DNA repair mutations, we have PARP inhibitors for you, or even carboplatin (Paraplatin) can be added to target patients with DNA repair mutations as well. 

And so, there’s a whole variety of tests out there by a multitude of providers, that help us really better understand your cancer. 

Katherine:

And the treatment options, by the sounds of it. 

Dr. Paller:

And the treatment options. Yes, there is. There’s a whole variety of it. Yeah. 

Katherine:

So, what is personalized medicine, Dr. Paller? And how is it achieved? 

Dr. Paller:

Personalized medicine means many things to many different people. I find the most important thing is not forgetting the patient. The patient needs to be their own advocate, and have an advocate there with them, right? Because maybe the best treatment is chemotherapy, hormone therapy, radiation, etc., etc., but maybe you’re 92, and you’ve lived a good life, and you have heart disease, and you might not die of your prostate cancer. And so, overtreating people is just as dangerous as undertreating people. 

And so, precision medicine is a whole variety of things, of looking at the whole person, looking at their genes, looking at biomarkers their cancers produce, and looking at what comorbidities they have, right? If you have really bad diabetes, maybe you don’t want me to add steroids to your regimen. If you have a seizure disorder, maybe you don’t want me to add insulin. I wouldn’t, because there’s a seizure risk. If you have various problems, we just need to take those into account and find the best therapy for each individual. 

Katherine:

I think you’ve covered this, in a sense, but I’m going to ask you the question anyway. Why is it important that patients have a role in making decisions about their care? 

Dr. Paller:

Patients are different, just like everybody – let me start over. 

It is essential that patients have a role in their care so that they are taking ownership and being part of the team, to care for themselves, not to put extra weight or work on the patient, but really, so that they know they’ve made the right choice for them. 

Understanding a patient’s priorities are essential. Some patients may not want the side effects of hormone therapy, and they may say, “Hey, I have oligometastatic disease, meaning I just have one spot to my bones, and I’m 80 years old. And Dr. Paller told me that the sub analysis of this triple therapy, new trial, showed that, I’m over 75, I may not benefit as much. And you know what? I don’t want to have the side effects of hormone therapy. I don’t want to lose muscle mass. I don’t want to have hot flashes. I don’t want to have erectile dysfunction.” 

“I want to enjoy my life, even if it’s slightly shorter, and it might not be slightly shorter.” And so, I find, having a partnership with a patient to really understand their priorities makes life worth living more, right? So, maybe a patient’s priority is finding time with their grandchildren. Maybe a patient’s priority is getting a PhD. Whatever their patient’s priority is, it is important that we put that to the context of their whole being and helping them really find the best therapy for them, to help them do as well as they can, as long as they can.