Why Prostate Cancer Patients Should Consider Participating in a Clinical Trial

Why Prostate Cancer Patients Should Consider Participating in a Clinical Trial from Patient Empowerment Network on Vimeo.

Dr. Sumit Subudhi explains why prostate cancer patients should consider participating in clinical trials, the role they play in treatment options for prostate cancer and resources available to find trials. 

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

 

Targeted Prostate Cancer Therapies vs. Chemotherapy: What’s the Difference?

The Link Between Prostate Cancer and Inherited Mutations

Prostate Cancer Staging: What Patients Should Know

 


Transcript:

Katherine:                   

What would you say to patients who are nervous about participating in a clinical trial?

Dr. Subudhi:                 

Yeah. This is a common question that I deal with in clinic, because we tend to have a lot of trials at MD Anderson. And the first thing, for me, is to understand why they’re nervous, because there’s different reasons why people are nervous.

Some people have heard of placebo trials, where the experimental drug that they’re hoping to get is only given to a portion of the patients and not all. And so, patients are worried what if they get on the placebo arm. And so, what I tell patients in that case is that please note that you’re going to be monitored very closely – more than usual, and so I’ll be seeing you in clinic more often. And if there’s any signs of progression, I will take you off the study. But I also always have a back-up plan. So, I tell them this is the next drug I’m going to give you if you progress, so don’t worry, I’ve got a plan for you. So, that’s one thing.

The other thing that people get concerned about are experimental drugs – just the fact that they are experimental. And I have to remind them that all these standard therapies that we have for prostate cancer were all experimental at one point. And it was the courage of the other patients that went through clinical trials that helped bring it as standard of care. And then sometimes some people have issues with travel, and those are more logistical issues. And especially now with the COVID era, we have to think about that. And so, we’re also trying to find and use networks to see if there’s other trials that are more amenable for patients so they don’t have to travel far.

Katherine:                   

How can patients find out about clinical trials that may be right for them?

Dr. Subudhi:                 

Yeah. So, one way is using clinicaltrials.gov. And that’s a website that allows you to search for specific trials either by drug name or by disease type – so, for example, prostate cancer. So, that’s one resource. And the others are cancer societies like the American Cancer Society or ASCO or Prostate Cancer Foundation. They also have links to clinical trials that are exciting. 

Prostate Cancer: How to Know If Your Treatment Plan Is Working

Prostate Cancer: How to Know If Your Treatment Plan Is Working from Patient Empowerment Network on Vimeo

How do you know if a prostate cancer treatment plan is effective? Dr. Sumit Subudhi, a Medical Oncologist, explains how a patient’s treatment response is monitored for its effectiveness.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

 

Prostate Cancer Staging: What Patients Should Know

The Link Between Prostate Cancer and Inherited Mutations

Targeted Prostate Cancer Therapies vs. Chemotherapy: What’s the Difference?

 


Transcript:

Katherine:                   

How can you tell if treatment is working?

Dr. Subudhi:                 

So, I actually use three criteria to figure this out. One is the patient’s self, their symptoms. So, some patients’ symptoms are related to the urinary tract system, such as they may have frequent urination, or they can have pelvic pain in that area or blood in the urine or problems with ejaculation.

Other patients have pain because they have metastasis to the bone, and so the bone pain can be a symptom. And when a treatment is working, these things will actually start resolving. And so, you’ll see that these symptoms start disappearing without pain medications or other things. So, symptoms is No. 1.

No. 2 is in prostate cancer, unlike many other cancers, we actually have a serum test, or blood tests, that we can follow, which is the PSA. And usually when that’s going down, that’s reassuring.

The third is scans – radiographic scans, such as CAT scans and bone scans, help us monitor the disease. In an ideal world, all three will be going in the same direction. Meaning if the treatments working, the patient’s symptoms have improved, if they had symptoms. The PSA is going down and third, the scans show that things are improving. But the truth is we don’t live in an ideal world.

And to me, the patient’s symptoms always trumps. And I’ll give you an example. Early on in my career, I had a patient that was getting hormonal therapy, and their PSA was zero. And he started having right hip pain. He had a traditional scan – a CAT scan and bone scan – done which showed that everything was stable. And remember, the PSA was zero. And so, I told him, I looked at your history carefully, and you had a right hip repair 10 years ago. I have a feeling that that’s probably what’s causing it.

So, he went to go see his orthopedic surgeon. And he comes back, and he says, no, the orthopedic surgeon says it’s your fault. So, I did an MRI, and the patient and the surgeon were absolutely right. So, I got tricked, because I fell in love with the PSA. And ever since then, the patient’s symptoms trumps everything else. It’s my job to figure out and rule out that this is not prostate cancer. So, my point is don’t fall in love with the PSA, because even if it’s zero, that doesn’t mean that you’re in the clear.

Katherine:                   

How long do you monitor a patient before you make the decision that the current treatment not working, let’s move on to something else?

Dr. Subudhi:                 

Yeah, good question. So, for each type of treatment and for each patient, I personalize how often I will see them.

For example, if someone is having significant pain, then I’m more likely to see them more often in clinic to make sure the pain is under control, but also to monitor how their treatment is going. And that means I’ll also scan them or do radiographic scans with the CAT scan and bone scan more frequently. Now, someone that’s more asymptomatic, you’ll see the intervals are longer. So, it’s really personalized for each patient. And the type of treatment they’re receiving, as well. So, it depends if they’re getting chemotherapy versus hormonal therapy versus a PARP inhibitor. So, all these play a factor, so it’s not a one-size-fits-all.

Targeted Prostate Cancer Therapies vs. Chemotherapy: What’s the Difference?

Targeted Prostate Cancer Therapies vs. Chemotherapy: What’s the Difference? from Patient Empowerment Network on Vimeo

Targeted prostate cancer therapies and chemotherapy are both available options to treat patients with prostate cancer. Dr. Sumit Subudhi discusses the differences between these two forms of treatment, including their effectiveness and side effects.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

 

Prostate Cancer: How to Know If Your Treatment Plan Is Working

Why Prostate Cancer Patients Should Consider Participating in a Clinical Trial

Promising Prostate Cancer Treatment and Research News

 


Transcript:

Katherine:                   

Let’s turn to targeted therapies. How exactly do they work?

Dr. Subudhi:      

Yeah. So, this is a form of personalized medicine. So, what you’re doing is you’re looking at the patient’s cancer, either their inheritable cause of genetic causes or the somatic. And then you’re saying, oh, wait, they have a genetic defect in a DNA machine. So, let’s use the PARP inhibitor, which also targets the DNA machinery.

And these are the cancer cells that are most likely to be susceptible to PARP inhibition. And actually, the cancer cells will die from it. Whereas if a patient has a normal DNA machinery, the PARP inhibitors will actually not have any effect on the cancer. 

They’re given, actually, orally twice a day. The two drugs are rucaparib and Olaparib that have been FDA approved for this indication.

Katherine:                   

How do these newer treatments differ from traditional chemotherapy?

Dr. Subudhi:                 

So, with chemotherapies, at least in prostate cancer, they’re given intravenously every three weeks. And the goal of the chemotherapies, they are actually designed to kill any actively dividing cell in the body.

And the problem is it’s not just cancer cells that are actively dividing in our body. For example, with the chemotherapy such as docetaxel or cabazitaxel, that’s used in prostate cancer – their brand names are Taxotere and Jevtana – these chemotherapies will also affect hair loss. Why? Because hair grows really fast. And in fact, I need a haircut every three to four weeks, which my wife has been helping me with.

So, the chemotherapies are targeting all actively dividing cells, and that’s why you also get nausea vomiting, because the cells of our GI tract are also affected by that. So, chemotherapies are not personalized. They’re there to kill actively dividing cells. Luckily prostate cancer divides a lot more quickly than any other cell in our body, and that’s why they’re susceptible to chemotherapy.

Katherine:                   

And as far as the targeted therapies, Dr. Subudhi, are there side effects with those?

Dr. Subudhi:                 

Yeah, there are. One of the most predominant side effect is actually anemia. And so, that’s when the red blood cells in our body are lower than usual. And so, that’s one of the major side effects for PARP inhibitors. But in addition, you can have nausea, vomiting, and diarrhea as other side effects with the PARP inhibitors.

The Link Between Prostate Cancer and Inherited Mutations

The Link Between Prostate Cancer and Inherited Mutations from Patient Empowerment Network on Vimeo

How can inherited genetic mutations affect the course of your disease? Dr. Sumit Subudhi explains the link between inherited mutations and prostate cancer and how these mutations affect disease progression in patients with prostate cancer.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

Prostate Cancer Testing: What Tests Should You Advocate For?

How Can You Access Personalized Prostate Cancer Treatment? Resource Guide

How to Become a Partner in Your Own Prostate Cancer Care

 


Transcript:

Katherine:                   

Dr. Subudhi, what is the link between inherited mutations and prostate cancer?

Dr. Subudhi:                 

Yeah, so in approximately 10% to 15% of patients with prostate cancer, they have an inheritable cause for their cancer. And so, this predisposes them to not just having prostate cancer, but potentially to other cancers, but also their family members.

In regards to the inheritable causes, the BRCA mutations – BRCA2 and BRCA1 – are very common. In fact, BRCA2 is more common than prostate cancer than BRCA1. In addition, there’s CHEK2 and ATM which are common inheritable mutations. And the other ones are the mismatch repair genes. Again, all these play an important role in repairing DNA. So, if you’re mutated in these genes, then your ability to repair DNA has been significantly diminished, and you’re more likely to gain more mutations.

Katherine:                   

How do these mutations affect disease progression?

Dr. Subudhi:                 

Yeah. So, what they can do is they can lead to mutations that make the cancer grow more. And there’s two ways to do it. You can have a mutation in what we call an oncogene, a gene that when it’s active, it’s going to just promote the cancer.

And then we have other genes called tumor suppressor genes. Their normal function is to prevent the cancer from growing. But if the tumor suppressor gene gets mutated so it’s no longer functional, then the cancer can then take off, because it’s no longer suppressed. So, those are how these genes can actually affect the prostate cancer.

If you have either an inheritable mutation in these genes or a somatic mutation, then there’s a chance that the PARP inhibitors could actually work for you. And the PARP inhibitors, they actually target cancers where there’s a defect in the DNA repair pathway.

Now, there’s one thing that I want to point out that a lot of people sort of are missing, and it’s not a subtle point. Not all inheritable mutations are made the same – or even somatic mutations. Meaning, what we’re learning is the PARP inhibitors seem to be more active with the “Braca,” or BRCA, mutations and the ATM mutations. Whereas, they’re less active with other types of DNA repair mutations. So, the point is not all mutations are made the same.

Prostate Cancer Testing: What Tests Should You Advocate For?

Prostate Cancer Testing: What Tests Should You Advocate For? from Patient Empowerment Network on Vimeo.

Genetic testing results can influence a prostate cancer patient’s treatment options and provide a more in-depth understanding into their disease. Dr. Sumit Subudhi reviews specific tests that prostate cancer patients should advocate for.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

Prostate Cancer Staging: What Patients Should Know

The Link Between Prostate Cancer and Inherited Mutations

How Can You Access Personalized Prostate Cancer Treatment? Resource Guide

 


Transcript:

Katherine:                   

What is the role of genetic testing in prostate cancer?

Dr. Subudhi:                 

That’s a great question, because this is something that wasn’t really available when I was training and understanding prostate cancer. But over the last few years, this has actually hit the mainstream, and it’s very important. And I see it having three roles. The first role is whether or not you can receive a certain type of targeted therapy or systemic therapy known as PARP inhibitors. So, if your genetic test is positive for certain markers – that I think we’ll cover later – then it can help give you more treatment options. The second is that generate testing can give you also risk of other cancers besides prostate cancer. For example, if you have the BRCA mutation, you’re 15% to 20% more likely to get breast cancer in men.

The third is that because the genetic testing is looking for inheritable mutations in your genes, that means you can pass it along to your kids. And this could have a tremendous impact on the screening strategies your children want to use in the future.

Katherine:                   

Would you mind going into that a little bit?

Dr. Subudhi:                 

Yeah.

Katherine:                   

For instance, my ex-husband had early prostate cancer. My 22-year-old son is worried now about also getting prostate cancer. His grandfather had prostate cancer.

Dr. Subudhi:                 

Yeah, great question. So, it’s not just about prostate cancer. So, prostate cancer, genetically, is linked to other cancers, as well.

So, in your case, you’re turning by your son. But if you have daughters or any female members in the family, consideration needs to be given to breast and ovarian cancer. And for both men and women, we also have to think about melanoma and pancreatic cancer. So, it’s not just prostate cancer that we’re thinking about when you have these genetic risks. And that’s very important, because each of these different cancers can have different screening modalities.

Katherine:                   

Oh. Well, how is the testing administered then?

Dr. Subudhi:                 

The testing is actually a blood test, so very simple.

Katherine:                   

Have there been any major advances in testing?

Dr. Subudhi:                 

Yeah, so when we’re talking about the inheritable testing, that’s just a simple blood test. And the reason why it can be done simply through the blood is because every cell in your body has it. So, when they collect the blood, they can just take any cell from there and do genetic analysis. And if that gene is mutated or missing, it will be captured.

Now, there’s another type of testing where they test your tumor tissue itself – so, your cancer tissue – whether you got it by biopsy or surgically removed. And so, that’s a different type of testing. That’s looking for what we call somatic mutations. These are not inherited mutations. These are mutations that are specific for your prostate cancer. Again, in contrast, the inheritable mutations are in every cell in your body – not just your prostate cancer cells, but every cell in your body. And the somatic, it’s just in your prostate tissue itself.

And so, sometimes with prostate cancer, it’s difficult to get the tissue. And what’s happened more recently – and to answer your question – is that the advances have been in what we call liquid biopsies, where they are able to use your blood and get the DNA from the tumors and actually genetically test the cancers that way. And so, that’s where the future is going.

Katherine:                   

Oh, that’s amazing. Are there specific tests that patients should ask their doctor for following the diagnosis?

Dr. Subudhi:                 

Yeah. So, if inpatients with high risk or metastatic prostate cancer, they should definitely be considering tests to see if they have mutations in what we call the DNA damage repair pathway or homologous recombination DNA pathway. And I know they’re fancy terms. What these genes are, they’re genes that help the body repair their DNA, and DNA is very important. And so, when there’s defects in the DNA repair pathway, then mutations occur. And these mutations can actually help the cancer grow.

 Now what’s happening is that what they’re looking for in these genetic tests – whether it’s the inheritable test or the somatic mutation test that’s looking just within the tumor itself – they’re looking to see if there’s any DNA damage machinery that’s defective. And if it is, then you’re more likely to benefit from PARP inhibitors, which are oral drugs that specifically target the DNA repair pathway.

How to Become a Partner in Your Own Prostate Cancer Care

How to Become a Partner in Your Own Prostate Cancer Care from Patient Empowerment Network on Vimeo

Staying up-to-date about prostate cancer can help patients become partners in their own care. Dr. Sumit Subudhi explains how self-advocacy can play an essential role in helping patients become an active participant in their care decisions.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

 

Prostate Cancer Staging: What Patients Should Know

Prostate Cancer Testing: What Tests Should You Advocate For?

The Link Between Prostate Cancer and Inherited Mutations

 


Transcript:

Katherine:

Dr. Subudhi, what advice do you have for patients who may be hesitant to speak up an advocate for themselves when it comes to their own care and treatment?

Dr. Subudhi:

Yeah, I’d say that it’s interesting because we all do this ourselves. And when it comes to our car – let’s say a car breaks down, or if we’re trying to buy furniture – we’ll get three, four different opinions. But for ourselves, for our own body, we don’t do that. And when you watch – we were talking earlier about Major League Baseball – and these players, when they get injured, they get the three best specialists in the world to evaluate them. And they’re seeing the best of the best.

And so, we owe it to ourselves and the patients owe it to themselves to actually get second opinions. I encourage it. I encourage my patients to get second opinions, even if I’m the first doctor they see, because I want them to feel comfortable with their decision.

And it’s important to understand that just because you’re seeing a doctor doesn’t mean that it’s a one-size-fits-all. You will get different opinions from different doctors, and you have to go with the one that makes you feel most comfortable.

Katherine:                   

We have a question from the audience, Dr. Subudhi. Amy is saying she’s the daughter of a prostate cancer patient. And she’s curious to know how she goes about getting genetic testing, and if her children should be tested, as well.

Dr. Subudhi:                 

Yeah. So, one of the things is that family history is very important in determining who should get genetically tested. So, if you’re a prostate cancer patient and you have metastatic disease, you should get genetically tested. And the reason for that is because we have a new set of drugs, the PARP inhibitors. But if you’re a family member that’s wanting to know whether you have a loved one has inheritable cancer that you may end up inheriting, that requires more understanding of the family history.

For example, did the grandfather have prostate cancer? Did the uncle have prostate cancer? And as I mentioned earlier, it’s not just prostate cancer. Is there a family member with breast cancer or ovarian cancer? These things play out in the decision-making of who should be genetically tested.

Prostate Cancer Staging: What Patients Should Know

Prostate Cancer Staging: What Patients Should Know from Patient Empowerment Network on Vimeo

Dr. Sumit Subudhi provides a brief explanation of the stages of prostate cancer, the role of staging in determining a prostate cancer patient’s treatment path, and how patients can advocate for a precise diagnosis.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

Prostate Cancer Testing: What Tests Should You Advocate For?

How to Become a Partner in Your Own Prostate Cancer Care

How Can You Access Personalized Prostate Cancer Treatment? Resource Guide

 


Transcript:

Katherine:                   

Well, Dr. Subudhi, I’d like you to begin with a brief explanation of the stages of prostate cancer.

Dr. Subudhi:

We use stages, and there’s four – Stage I, II, III, and IV. And we use it to help us determine what treatments the patients need for their prostate cancer. In general, Stage I is localized prostate cancer, and it’s localized only to the prostate. And when we do a digital rectal exam, we cannot feel or palpate the prostate.

And the treatment for Stage I prostate cancer is either active surveillance, where you’re not trying to cure the cancer, you’re just actively watching it, and you’re using a PSA imaging studies, prostate biopsies, and digital rectal exams at regular intervals to follow the patients. But other patients with Stage I prostate cancer can actually get definitive treatment for curative intent with radiation therapy or surgery. Stage 2 prostate cancer is also localized, but on physical exam, we can actually palpate or feel the prostate cancer. And this also can receive definitive treatment for the prostate to cure it, and that, also, you can use radiation therapy and surgery.

Stage III is what I consider locally advance. This is where the prostate cancer is now starting to leave the prostate. And it still can be cured by radiation and surgery, but most likely needs a multidisciplinary approach, where you might need both or maybe even in addition of a systemic therapy. Stage IV is the last stage that I’ll talk about, and it has distant metastases. And here we’re not looking for a curative approach; we’re actually looking for palliation, which means that we’re trying to treat the prostate cancer as a chronic disease.

Katherine:

I understand that there are many types of prostate cancer that have been identified. How can patients advocate for a precise diagnosis?

Dr. Subudhi:

Yes, you’re absolutely right. There are many types. So, we have historically used histological classification. And when I say histological, that means when we look at the cancer under the microscope, we can look at the different structures within the prostate cancer and classify them.

And there are multiple types such as adenocarcinoma, neuroendocrine, small-cell, mucinous, etc. But more recently, with the advances in genetic and molecular testing, we now can look at the genes inside the prostate cancer, and that has also helped us better classify the cancer. Now many of these types of approaches are best done at major cancer centers, where they have experienced pathologists who actually evaluate both histologically and molecularly the cancer.

So, I recommend to my patients, or family and friends, that have been diagnosed with prostate cancer that they don’t necessarily have to go to the major cancer centers. They can have their local doctor send the tissue from the biopsy to the advanced cancer centers to get a second opinion.

Promising Prostate Cancer Treatment and Research News

Promising Prostate Cancer Treatment and Research News from Patient Empowerment Network on Vimeo

Are there advances in prostate cancer treatment that patients should know about? Dr. Sumit Subudhi shares prostate cancer research news and discusses highlights from this year’s American Society of Clinical Oncology (ASCO) meeting.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

See More From INSIST! Prostate Cancer

Related Resources

 

Prostate Cancer Staging: What Patients Should Know

Prostate Cancer Testing: What Tests Should You Advocate For?

The Link Between Prostate Cancer and Inherited Mutations

 


Transcript:

Katherine:

As a researcher in the field doctor, Dr. Subudhi, what would you like to leave patients with? Are you hopeful?

Dr. Subudhi:

Yeah, I’m very hopeful. It’s a really interesting time, because with the technological advances and scientific advances – Traditionally, prostate cancer has always been treated just with hormonal therapies from the 1930s all the way to early 2000. Then in 2004, chemotherapy became the next thing. And then after chemotherapy, we’ve now got a dendritic cell vaccine; we’ve also got a radiopharmaceutical agent. And so, what the point is now we have a lot more different FDA-approved agents. And now, experimentally, the PARP inhibitors have now become a standard of care for those patients with mutations in the BRCA1, BRCA2, or ATM.

And then, in addition, we have many other types of technologies, such as BiTE and CAR T cells, that are coming out that are showing in early studies to be exciting. And so, I feel like that these therapies in combination may actually lead us to cure the cancer.

Katherine:                   

ASCO happened in June. Was there any news that patients should know about?

Dr. Subudhi:                 

Yeah, so the PARP inhibitors got a lot of press during ASCO, as they should, because this is a new class of drugs that is the first personalized version of medicine that we have in prostate cancer. Now, personalized medicine has been around for a long time in cancers such as breast and lung cancer. But for first time, we actually have it in prostate cancer.

Katherine:                   

Dr. Subudhi, I want to thank you so much for joining us today.

Dr. Subudhi:

Thank you for your time. I really appreciate it.

Katherine:

And thank you to all of our partners. To learn more about prostate cancer and to access tools to help you become a more proactive patient, visit powerfulpatients.org. I’m Katherine Banwell.

What Do Prostate Cancer Patients Need to Know About COVID-19?

What Do Prostate Cancer Patients Need to Know About COVID-19? from Patient Empowerment Network on Vimeo

Due to COVID-19, many patients with prostate cancer must follow new guidelines to receive care. Dr. Alicia Morgans, a hematology and oncology specialist, explains precautions patients should take and the role telemedicine plays in prostate cancer care.

Dr. Alicia Morgans is an Assistant Professor of Medicine at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

See more from The Pro-Active Prostate Cancer Patient Toolkit

Related Resources

 

Are You Prepared for Your Prostate Cancer Appointment? Expert Tips

Prostate Cancer Research News

Prostate Cancer Treatment Decisions: Which Path is Best for YOU?

 


Transcript:

Dr. Alicia Morgans:

Men with prostate cancer, like every patient with cancer, do need to take precautions because of COVID, but the degree of caution that they need to take really depends on a couple of factors. One is probably that individual’s age, with older people being more susceptible to having severe complications related to COVID, especially if they have other medical conditions like COPD or lung disease or heart disease with a history of things like heart attack or stents in the heart. Things like diabetes can even increase the risk of having complications, according to some studies, for people with cancer. So, these are things to think about. Comorbid illness and certainly advancing age.

The other thing that I always think about is what kind of therapy are you getting as a man with prostate cancer? Are you getting something that really is only affecting hormones, like lowering testosterone levels or blocking testosterone signaling? That’s the male hormone. Hormonal treatments don’t suppress a person’s immune system. So, they don’t change the way that an individual’s immune system can attack the COVID virus and protect them from that illness. And those kinds of treatments are not as dangerous to use in a pandemic like we’re experiencing now, because they don’t affect a person’s ability – their innate and normal ability – to fight off the disease.

Things like chemotherapy, on the other hand, do suppress the immune system. They make it difficult for the immune system to fight things like that SARS virus, SARS-CoV-2, that causes COVID-19, because it suppresses the immune system such that a patient can’t mount the normal response that he would have against that virus if it came into his body.

When we don’t have an immune system, we can be more susceptible to things like that SARS-CoV-2 virus that causes COVID-19, but we can be susceptible to things that we would find in our normal environment and sometimes even to infections from bacteria that live in our body all the time. So, things like chemotherapy can be challenging whenever you take them. They can be incredibly effective against cancer. And so, it’s always this trade-off.

And if it’s recommended to you, you can get it safely, but taking extra precautions with, of course, washing hands, wearing masks, but also, probably, really still socially distancing even though some of the restrictions in most of the United States have lessened. If you’re on chemotherapy, I would still recommend social distancing and staying out of public places, because you do not necessarily have the immune system that you would normally have to protect yourself from the virus.

Telemedicine has been great for men with prostate cancer when they don’t necessarily need to come in to be seen. This can be really helpful, especially between visits where people are getting injections that they get to lower testosterone as androgen deprivation therapy. If that injection is due every three months or four months, but your doctor wants to check in on you every six weeks or eight weeks, having a telemedicine visit at that interim visit can be really useful so you don’t have to come all the way into the clinic to see the provider.

They can even be useful if you do need to get the injection or you do need to get lab work, because you can get those procedures and then go home and still be safe not sitting in a waiting room, not sitting in a doctor room. And the doctor can usually call and have that telemedicine visit.

For men who have been treated and are simply having their PSA followed because they’ve had a prostate surgery or have had radiation to the prostate and are believed to be cured, as long as they can get that lab work done, the telemedicine visit gives them the opportunity to get the guidance of their doctor who has looked at their lab work, without actually going in to see that doctor in person and potentially put themselves at risk of getting an infection in the in the clinic or the hospital setting.

So, telemedicine is a way for us to really protect our patients and stay engaged while we’re not seeing them in person. But it is still important to do the telemedicine and not just say I’m not going to do anything. And it will be important at some points for many men with prostate cancer to come in at least to do lab work or to get their injections if that’s part of their treatment plan to make sure that they are still being monitored despite the pandemic.

Prostate Cancer Research News

Prostate Cancer Research News from Patient Empowerment Network on Vimeo

Are there developments in prostate cancer research that patients should know about? Dr. Alicia Morgans discusses highlights from the 2020 American Society of Clinical Oncology (ASCO) meeting.

Dr. Alicia Morgans is an Assistant Professor of Medicine at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

See more from The Pro-Active Prostate Cancer Patient Toolkit

Related Resources

Are You Prepared for Your Prostate Cancer Appointment? Expert Tips

What Do Prostate Cancer Patients Need to Know About COVID-19?

Prostate Cancer Treatment Decisions: Which Path is Best for YOU?

 


Transcript:

Dr. Alicia Morgans:

Just recently in June, ASCO, which is our American Society of Clinical Oncology, meeting was held here in Chicago, and it was a virtual meeting. It was actually very exciting for people who take care of prostate cancer and for men who have prostate cancer in several advances. Some of those advances were around imaging and new strategies that we’re going to have, I think, in the relatively near future using PSMA-targeted imaging for men who have prostate cancer that is high-risk before they go through things like surgery or radiation, or for men who have a rising PSA after they’ve had their initial treatment for prostate cancer.

We also learned the survival data that was associated with three agents that we now have to treat non-metastatic castration-resistant prostate cancer. And this is prostate cancer where we have had a group of men who have already had treatment of their prostate, but now have a rising PSA blood level despite having imaging that doesn’t really show any areas of cancer on the scans. And there are three drugs that we have to use for men with this particular stage of prostate cancer, or state of prostate cancer, and we learned that those drugs not only prolong the time until men develop metastatic disease or disease that we can see on those scans, but they also help men live longer.

And this tells us that if we move those therapies earlier on in the stage of treating prostate cancer, we can actually, probably bend the curve of that man’s survival for the rest of his life. Intervening early, at our earliest opportunity, in this particular situation may be so helpful for men over the rest of their journey, no matter what their next treatments might be.

And finally, we learned information about a drug called lutetium, which is not yet approved for the treatment of prostate cancer, but was tested in a clinical trial for men with more advanced prostate cancer and called metastatic castration-resistant prostate cancer. And we learned that this drug can be both tolerable and potentially as effective, or perhaps more effective, than the chemotherapy that we have traditionally used in this state. So, lutetium is a drug that we expect will eventually be approved for the treatment of prostate cancer, pending some clinical trial data that we are still waiting for. And that was real exciting, to learn about the upcoming advances with this particular drug.      

Why You Should Consider a Prostate Cancer Clinical Trial

Why You Should Consider a Prostate Cancer Clinical Trial from Patient Empowerment Network on Vimeo

Dr. Alicia Morgans, a hematology and oncology specialist, explains the importance of prostate cancer patients of different geographic locations participating in clinical trials and the role trials plays in clinical care.

Dr. Alicia Morgans is an Assistant Professor of Medicine at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

See more from The Pro-Active Prostate Cancer Patient Toolkit

Related Resources

 

Are You Prepared for Your Prostate Cancer Appointment? Expert Tips

Prostate Cancer Research News

Prostate Cancer Treatment Decisions: Which Path is Best for YOU?

 


Transcript:

Dr. Alicia Morgans:

From my perspective, I think any time in a prostate cancer journey is a great time to think about a clinical trial if that trial is available where you live or is available at a place where you would be willing to travel. We have so much to learn about prostate cancer, about how to continue to provide options to patients, and about how to support men as they go through their treatment. And the only way we can learn those things is if men participate in clinical trials. So importantly, also, we need to have men of diverse backgrounds of diverse races from geographic diversity.

Because if we only study certain people from the city of Chicago, for example, where I live, we’ll really only know what we know about those men. And we won’t necessarily know if we can apply our findings to men who live in Atlanta and are Black. It’s going to be the kind of thing where we have the data, but we don’t necessarily know if it’s going to be the right data for you.

So, the more men of color, the more men from different geographic locations that we can encourage to participate in clinical trials, the more we learn for every patient and the more we are able to take care of the specific and unique needs of you as an individual, which is really a critical part of what we do and why we do what we do. So, participating in clinical trials, no matter who you are, if you’re able, and if you’re willing, is really a great service to you to get, hopefully, better outcomes for you, but also a great service to your community of men with prostate cancer.  

Prostate Cancer Treatment Decisions: Which Path is Best for YOU?

Prostate Cancer Treatment Decisions: Which Path is Best for YOU? from Patient Empowerment Network on Vimeo.

Which prostate cancer treatment path is best for you? Dr. Alicia Morgans discusses how multiple factors, including disease progression and patient goals, determine which treatment path is best to help improve a patient’s outcome and overall quality of life. 

Dr. Alicia Morgans is an Assistant Professor of Medicine at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

See more from The Pro-Active Prostate Cancer Patient Toolkit

Related Resources

 

What Do Prostate Cancer Patients Need to Know About COVID-19?

Prostate Cancer Research News

How Does Prostate Cancer Staging Affect Treatment Approaches?

 


Transcript:

Dr. Alicia Morgans:

The main factors I think about when approaching a treatment plan for a patient is to understand is this treatment for cure. Are we able to cure this patient? Is that our goal? Or are we in a situation where we know that the cancer is going to be incurable, but we can prolong that individual’s life and improve the quality of life that he has?

That is a major breakdown or separation point in how we approach treatment. Once we figure that out, we can try to sort through among all the choices. If we’re going to use curative treatment to the prostate itself, what do we think is best for you as an individual man? And what do we think is possible from a medical perspective? Whether that’s radiation or surgery or even just watching and waiting with an active surveillance plan, there may be choices.

And similarly, with metastatic prostate cancer or advanced prostate cancer that’s incurable or not able to be cured, what are the medical treatments that we can use? And what are the choices that you as a man with prostate cancer want to make to really maximize your benefit – thinking through what’s important to you? What barriers do you have? And how do you want to go through your treatment sequence?

We’re actually really fortunate in prostate cancer care to have many choices, whether it’s in treating localized curable prostate cancer or in treating metastatic prostate cancer that we’re really trying to treat to prolong life and improve quality of life. In each setting, in most cases, there are multiple choices to make along the journey. Sometimes these choices would exclude other choices in the future, but sometimes they don’t. Sometimes you can choose A or B, because in a few months, you’re going to have the opposite option available to you. So, exactly what your choices are going to be are going to be important for you to speak with your doctor about.

But having those choices really empowers men to get engaged in each of these treatment decisions to explain this is my preference for that side effect or this particular toxicity, and I’m going to choose this treatment, because it works best for me because I can get to work or because it doesn’t lead to incontinence or because it doesn’t cause me to lose my hair or whatever the reason is. Men’s preferences can be so importantly incorporated into the treatment decision, because we have all the choices we have in treating prostate cancer.

How Does Prostate Cancer Staging Affect Treatment Approaches?

How Does Prostate Cancer Staging Affect Treatment Approaches? from Patient Empowerment Network on Vimeo

Every stage of prostate cancer stage requires different treatment approaches. Dr. Alicia Morgans explains prostate cancer staging and how it impacts treat options.

Dr. Alicia Morgans is an Assistant Professor of Medicine at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

See more from The Pro-Active Prostate Cancer Patient Toolkit

Related Resources

 

What Do Prostate Cancer Patients Need to Know About COVID-19?

Prostate Cancer Research News

Prostate Cancer Treatment Decisions: Which Path is Best for YOU?

 


Transcript:

Dr. Alicia Morgans:

Staging in prostate cancer is a way for people to understand how to best approach the treatment of the disease. To say this a different way, low stages – things like Stage I, II, and usually Stage III – can be treated with local therapies to the prostate itself with a goal of trying to cure the prostate cancer. And some patients who have Stage I disease may not even need active treatment, but could be followed on active surveillance as a way to monitor the cancer and prevent side-effects by simply monitoring until it would actually need treatment. Higher stage, like Stage IV, means that the cancer has spread outside of the prostate.

And it’s still prostate cancer. It just is cancer cells from the prostate that now live in the bones, or live in distant lymph nodes, or live in another organ or place in the body. Those cancer cells are still treated the exact same way we treat prostate cancer in terms of the medical therapies – the injections, the pills, the chemo agents potentially – that we would use to treat those cancer cells, whether they’re in the bones or in the prostate. But when they have spread outside of prostate, that typically means that there’s no longer an opportunity for us to cure that cancer. And we wouldn’t necessarily use things like surgery or radiation to the prostate if the cancer had spread.

I say “wouldn’t necessarily,” because that is certainly an area that’s evolving. And now even men with metastatic prostate cancer or Stage IV prostate cancer can be treated with radiation, in particular, to the prostate, and we know that can be beneficial. So, staging helps us understand how far the cancer has spread or not spread.

And it helps us understand if we can treat that patient with local treatments to the prostate to try to cure them, or if we need to use medical therapies as a major backbone of treatment rather than things like radiation or surgery to treat them for prolonging their life and improving quality of life but knowing that we can’t cure their disease.

How Can You Access Personalized Prostate Cancer Treatment?

How Can You Access Personalized Prostate Cancer Treatment? from Patient Empowerment Network on Vimeo.

How could genetic testing results affect your prostate cancer treatment plan? In this INSIST! Prostate Cancer webinar, Dr. Sumit Subudhi will discuss key prostate cancer tests, the latest targeted therapies and tools to help you advocate for a personalized treatment approach and insist on better care.

Dr. Sumit Subudhi is a Medical Oncologist at The University of Texas MD Anderson Cancer Center.

Download Program Resource Guide

Related Resources

 

 

Three Key Steps to Take Following a Prostate Cancer Diagnosis

 

 


Transcript:

Katherine:                  

Welcome to Insist Prostate Cancer, a program focused on empowering patients to insist on better care. Today we’ll discuss the latest advances in prostate cancer, including the role of genetic testing and how this may affect treatment options.

I’m Katherine Banwell, your host for today’s program. And joining me is Dr. Sumit Subudhi. Welcome, Dr. Subudhi. Would you please introduce yourself?

Dr. Subudhi:        

Hi, I’m Sumit Subudhi. I’m a medical oncologist at MD Anderson Cancer Center, and I specifically focus on prostate cancer.

Katherine:    

Excellent, thank you. Before we start, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team. Well, Dr. Subudhi, I’d like you to begin with a brief explanation of the stages of prostate cancer.

Dr. Subudhi:               

Yeah, that’s a great question. So, we use stages, and there’s four – Stage I, II, III, and IV. And we use it to help us determine what treatments the patients need for their prostate cancer. In general, Stage I is localized prostate cancer, and it’s localized only to the prostate. And when we do a digital rectal exam, we cannot feel or palpate the prostate.

And the treatment for Stage I prostate cancer is either active surveillance, where you’re not trying to cure the cancer, you’re just actively watching it, and you’re using a PSA imaging studies, prostate biopsies, and digital rectal exams at regular intervals to follow the patients. But other patients with Stage I prostate cancer can actually get definitive treatment for curative intent with radiation therapy or surgery. Stage 2 prostate cancer is also localized, but on physical exam, we can actually palpate or feel the prostate cancer. And this also can receive definitive treatment for the prostate to cure it, and that, also, you can use radiation therapy and surgery.

Stage III is what I consider locally advance. This is where the prostate cancer is now starting to leave the prostate. And it still can be cured by radiation and surgery, but most likely needs a multidisciplinary approach, where you might need both or maybe even in addition of a systemic therapy. Stage IV is the last stage that I’ll talk about, and it has distant metastases. And here we’re not looking for a curative approach; we’re actually looking for palliation, which means that we’re trying to treat the prostate cancer as a chronic disease.

Katherine:                  

I understand that there are many types of prostate cancer that have been identified. How can patients advocate for a precise diagnosis?

Dr. Subudhi:    

Yes, you’re absolutely right. There are many types. So, we have historically used histological classification. And when I say histological, that means when we look at the cancer under the microscope, we can look at the different structures within the prostate cancer and classify them.

And there are multiple types such as adenocarcinoma, neuroendocrine, small-cell, mucinous, etc. But more recently, with the advances in genetic and molecular testing, we now can look at the genes inside the prostate cancer, and that has also helped us better classify the cancer. Now many of these types of approaches are best done at major cancer centers, where they have experienced pathologists who actually evaluate both histologically and molecularly the cancer.

So, I recommend to my patients, or family and friends, that have been diagnosed with prostate cancer that they don’t necessarily have to go to the major cancer centers. They can have their local doctor send the tissue from the biopsy to the advanced cancer centers to get a second opinion.

Katherine:    

But this would be an initial visit to a doctor. Is that right?

Dr. Subudhi:    

Good question. So, I’m presuming that the patient is actually being seen at a local center where they have a local doctor, and so they don’t have to come, for example, to MD Anderson Cancer Center to see me. They could actually have their tissue sent to our pathologists and get it reviewed, and they can still be at home. And especially in this era of COVID, that’s important.

Katherine:      

What is the role of genetic testing in prostate cancer?

Dr. Subudhi:     

That’s a great question, because this is something that wasn’t really available when I was training and understanding prostate cancer. But over the last few years, this has actually hit the mainstream, and it’s very important. And I see it having three roles. The first role is whether or not you can receive a certain type of targeted therapy or systemic therapy known as PARP inhibitors. So, if your genetic test is positive for certain markers – that I think we’ll cover later – then it can help give you more treatment options. The second is that generate testing can give you also risk of other cancers besides prostate cancer. For example, if you have the BRCA mutation, you’re 15% to 20% more likely to get breast cancer in men.

The third is that because the genetic testing is looking for inheritable mutations in your genes, that means you can pass it along to your kids. And this could have a tremendous impact on the screening strategies your children want to use in the future.

Katherine: 

Would you mind going into that a little bit?

Dr. Subudhi:  

Yeah.

Katherine:  

For instance, my ex-husband had early prostate cancer. My 22-year-old son is worried now about also getting prostate cancer. His grandfather had prostate cancer.

Dr. Subudhi:               

Yeah, great question. So, it’s not just about prostate cancer. So, prostate cancer, genetically, is linked to other cancers, as well.

So, in your case, you’re turning by your son. But if you have daughters or any female members in the family, consideration needs to be given to breast and ovarian cancer. And for both men and women, we also have to think about melanoma and pancreatic cancer. So, it’s not just prostate cancer that we’re thinking about when you have these genetic risks. And that’s very important, because each of these different cancers can have different screening modalities.

Katherine:                  

Oh. Well, how is the testing administered then?

Dr. Subudhi:               

The testing is actually a blood test, so very simple.

Katherine:                  

Have there been any major advances in testing?

Dr. Subudhi:               

Yeah, so when we’re talking about the inheritable testing, that’s just a simple blood test. And the reason why it can be done simply through the blood is because every cell in your body has it. So, when they collect the blood, they can just take any cell from there and do genetic analysis. And if that gene is mutated or missing, it will be captured.

Now, there’s another type of testing where they test your tumor tissue itself – so, your cancer tissue – whether you got it by biopsy or surgically removed. And so, that’s a different type of testing. That’s looking for what we call somatic mutations. These are not inherited mutations. These are mutations that are specific for your prostate cancer. Again, in contrast, the inheritable mutations are in every cell in your body – not just your prostate cancer cells, but every cell in your body. And the somatic, it’s just in your prostate tissue itself.

And so, sometimes with prostate cancer, it’s difficult to get the tissue. And what’s happened more recently – and to answer your question – is that the advances have been in what we call liquid biopsies, where they are able to use your blood and get the DNA from the tumors and actually genetically test the cancers that way. And so, that’s where the future is going.

Katherine:      

Oh, that’s amazing. Are there specific tests that patients should ask their doctor for following the diagnosis?

Dr. Subudhi:   

Yeah. So, if inpatients with high risk or metastatic prostate cancer, they should definitely be considering tests to see if they have mutations in what we call the DNA damage repair pathway or homologous recombination DNA pathway. And I know they’re fancy terms. What these genes are, they’re genes that help the body repair their DNA, and DNA is very important. And so, when there’s defects in the DNA repair pathway, then mutations occur. And these mutations can actually help the cancer grow.

Now what’s happening is that what they’re looking for in these genetic tests – whether it’s the inheritable test or the somatic mutation test that’s looking just within the tumor itself – they’re looking to see if there’s any DNA damage machinery that’s defective. And if it is, then you’re more likely to benefit from PARP inhibitors, which are oral drugs that specifically target the DNA repair pathway.

Katherine:    

All right. Dr. Subudhi, what is the link between inherited mutations and prostate cancer?

Dr. Subudhi:               

Yeah, so in approximately 10% to 15% of patients with prostate cancer, they have an inheritable cause for their cancer. And so, this predisposes them to not just having prostate cancer, but potentially to other cancers, but also their family members.

Katherine:                  

Would you give us an overview of common mutations in prostate cancer?

Dr. Subudhi:               

Yeah. So, in regards to the inheritable causes, the BRCA mutations – BRCA2 and BRCA1 – are very common. In fact, BRCA2 is more common than prostate cancer than BRCA1. In addition, there’s CHEK2 and ATM which are common inheritable mutations. And the other ones are the mismatch repair genes. Again, all these play an important role in repairing DNA. So, if you’re mutated in these genes, then your ability to repair DNA has been significantly diminished, and you’re more likely to gain more mutations.

Katherine:                  

How do these mutations affect disease progression?

Dr. Subudhi:               

Yeah. So, what they can do is they can lead to mutations that make the cancer grow more. And there’s two ways to do it. You can have a mutation in what we call an oncogene, a gene that when it’s active, it’s going to just promote the cancer.

And then we have other genes called tumor suppressor genes. Their normal function is to prevent the cancer from growing. But if the tumor suppressor gene gets mutated so it’s no longer functional, then the cancer can then take off, because it’s no longer suppressed. So, those are how these genes can actually affect the prostate cancer.

Katherine:                  

What about treatment options, what’s available?

Dr. Subudhi:    

Yeah. So, if you have either an inheritable mutation in these genes or a somatic mutation, then there’s a chance that the PARP inhibitors could actually work for you. And the PARP inhibitors, they actually target cancers where there’s a defect in the DNA repair pathway.

Now, there’s one thing that I want to point out that a lot of people sort of are missing, and it’s not a subtle point. Not all inheritable mutations are made the same – or even somatic mutations. Meaning, what we’re learning is the PARP inhibitors seem to be more active with the “Braca,” or BRCA, mutations and the ATM mutations. Whereas, they’re less active with other types of DNA repair mutations. So, the point is not all mutations are made the same.

Katherine:                  

Let’s turn to targeted therapies. How exactly do they work?

Dr. Subudhi:      

Yeah. So, this is a form of personalized medicine. So, what you’re doing is you’re looking at the patient’s cancer, either their inheritable cause of genetic causes or the somatic. And then you’re saying, oh, wait, they have a genetic defect in a DNA machine. So, let’s use the PARP inhibitor, which also targets the DNA machinery.

And these are the cancer cells that are most likely to be susceptible to PARP inhibition. And actually, the cancer cells will die from it. Whereas if a patient has a normal DNA machinery, the PARP inhibitors will actually not have any effect on the cancer.

Katherine:                  

Oh, I see. Just as a follow-up, how are these targeted therapies administered?

Dr. Subudhi:               

They’re given, actually, orally twice a day. The two drugs are rucaparib and Olaparib that have been FDA approved for this indication.

Katherine:                  

How do these newer treatments differ from traditional chemotherapy?

Dr. Subudhi: 

That’s a great question. So, with chemotherapies, at least in prostate cancer, they’re given intravenously every three weeks. And the goal of the chemotherapies, they are actually designed to kill any actively dividing cell in the body.

And the problem is it’s not just cancer cells that are actively dividing in our body. For example, with the chemotherapy such as docetaxel or cabazitaxel, that’s used in prostate cancer – their brand names are Taxotere and Jevtana – these chemotherapies will also affect hair loss. Why? Because hair grows really fast. And in fact, I need a haircut every three to four weeks, which my wife has been helping me with.

So, the chemotherapies are targeting all actively dividing cells, and that’s why you also get nausea vomiting, because the cells of our GI tract are also affected by that. So, chemotherapies are not personalized. They’re there to kill actively dividing cells. Luckily prostate cancer divides a lot more quickly than any other cell in our body, and that’s why they’re susceptible to chemotherapy.

Katherine:   

And as far as the targeted therapies, Dr. Subudhi, are there side effects with those?

Dr. Subudhi:     

Yeah, there are. One of the most predominant side effect is actually anemia. And so, that’s when the red blood cells in our body are lower than usual. And so, that’s one of the major side effects for PARP inhibitors. But in addition, you can have nausea, vomiting, and diarrhea as other side effects with the PARP inhibitors.

Katherine:  

What are you excited about in prostate cancer research right now?

Dr. Subudhi:  

So, to me, it’s the combination of treatments. So, not just treating with one PARP inhibitor or just one hormonal therapy, it’s combining these approaches, and especially with immunotherapies, so that we can potentially cure what’s considered incurable cancer. To me, that’s the most exciting.

Katherine:   

What would you say to patients who are nervous about participating in a clinical trial?

Dr. Subudhi:    

Yeah. This is a common question that I deal with in clinic, because we tend to have a lot of trials at MD Anderson. And the first thing, for me, is to understand why they’re nervous, because there’s different reasons why people are nervous.

Some people have heard of placebo trials, where the experimental drug that they’re hoping to get is only given to a portion of the patients and not all. And so, patients are worried what if they get on the placebo arm. And so, what I tell patients in that case is that please note that you’re going to be monitored very closely – more than usual, and so I’ll be seeing you in clinic more often. And if there’s any signs of progression, I will take you off the study. But I also always have a back-up plan. So, I tell them this is the next drug I’m going to give you if you progress, so don’t worry, I’ve got a plan for you. So, that’s one thing.

The other thing that people get concerned about are experimental drugs – just the fact that they are experimental. And I have to remind them that all these standard therapies that we have for prostate cancer were all experimental at one point. And it was the courage of the other patients that went through clinical trials that helped bring it as standard of care. And then sometimes some people have issues with travel, and those are more logistical issues. And especially now with the COVID era, we have to think about that. And so, we’re also trying to find and use networks to see if there’s other trials that are more amenable for patients so they don’t have to travel far.

Katherine:     

How can patients find out about clinical trials that may be right for them?

Dr. Subudhi:               

Yeah. So, one way is using clinicaltrials.gov. And that’s a website that allows you to search for specific trials either by drug name or by disease type – so, for example, prostate cancer. So, that’s one resource. And the others are cancer societies like the American Cancer Society or ASCO or Prostate Cancer Foundation. They also have links to clinical trials that are exciting.  

Katherine:                  

Do you recommend having patients see a specialist?

Dr. Subudhi:               

Absolutely. I think that if you have a metastatic disease, you need to have a medical oncologist on board that can still work with your urologist, who’s more surgically trained.

Katherine:                  

Right. Well, we’ve talked about COVID a couple of times, and I’d be remiss if we didn’t touch upon it now. What should prostate cancer patients be considering at this time, especially those with advanced disease?

Dr. Subudhi:               

Yeah, so what I don’t want are people to say, oh, I can wait a little bit longer to contact my physician, whether it’s primary care or a prostate cancer doctor, because of COVID. I think it’s very important that the medical team is up to date on a patient’s symptoms and what’s going on medically, whether it’s related to prostate cancer or not. And so, that’s one of the messages we’ve been trying to pass on to our patients.

And with every single patient, we try our best to see if we can provide medical care as well as expertise without having physically see them through telehealth, whether it’s through video or whether it’s just through a simple phone call. So, we’re trying to look at that with each individual patient. Now, sometimes when there’s treatment decisions that have to be made – especially like do we start chemotherapy? – it’s harder to do that over the phone. But sometimes what I’ll do for my patients that are in areas where COVID is really worrisome, I’ll work with the local medical oncologist and talk to them and basically see if we can develop a plan together so that the patient can be served best.

Katherine:                  

Is there a time when telemedicine is more appropriate than others?

Dr. Subudhi:               

I think that has to be a case-by-case basis. And that’s how we do it in clinic.

Every week, a week before hand, I go through my entire clinic list – I go through each patient’s case – and I say, okay, this is a patient that would be better served with telemedicine, this is a case that I really need to see the patient to get a better sense of what to do next.

Katherine:                  

If a patient has to go into clinic, what safety measures are in place for them?

Dr. Subudhi:               

Yeah, so I can only speak for our hospital and how we’re doing it. But there’s actually like a thermal scan where when you walk in the building, they actually measure your temperature without you even knowing it. But they delete it, so it’s not something that’s kept. And this is still kept private, so you don’t have to worry about public disclosure of your temperature. And so, they’re monitoring both the staff and the patients – their temperatures. The staff themselves have to go through screening questions that they have to answer every time, and they’re actually handed a mask that’s required to be used at all times.

As far as patients go, they are also getting their temperature measured. But in addition, they are asking questions about their exposures, whether it’s family members that are asymptomatic, or not symptomatic. And in addition, the new patients will get a COVID test done prior to seeing the medical team. And for the follow-up patients, they’re not required to get a COVID test unless there’s concerns of symptoms.

Katherine:                  

Unless they’ve been exposed to somebody?

Dr. Subudhi:               

Correct, that’s right. Thanks for pointing that out. In addition, all patients are asked to wear their masks at all times, especially if they’re going to be within 6 feet of a healthcare provider or a patient or anyone else. And so, these are the measures that we’re taking to keep our patients safe.

Katherine:                  

Oh, good. Dr. Subudhi, what advice do you have for patients who may be hesitant to speak up an advocate for themselves when it comes to their own care and treatment?

Dr. Subudhi:               

Yeah, I’d say that it’s interesting because we all do this ourselves. And when it comes to our car – let’s say a car breaks down, or if we’re trying to buy furniture – we’ll get three, four different opinions. But for ourselves, for our own body, we don’t do that. And when you watch – we were talking earlier about Major League Baseball – and these players, when they get injured, they get the three best specialists in the world to evaluate them. And they’re seeing the best of the best.

And so, we owe it to ourselves and the patients owe it to themselves to actually get second opinions. I encourage it. I encourage my patients to get second opinions, even if I’m the first doctor they see, because I want them to feel comfortable with their decision.

And it’s important to understand that just because you’re seeing a doctor doesn’t mean that it’s a one-size-fits-all. You will get different opinions from different doctors, and you have to go with the one that makes you feel most comfortable.

Katherine:    

We have a question from the audience, Dr. Subudhi. Amy is saying she’s the daughter of a prostate cancer patient. And she’s curious to know how she goes about getting genetic testing, and if her children should be tested, as well.

Dr. Subudhi:               

Yeah. So, one of the things is that family history is very important in determining who should get genetically tested. So, if you’re a prostate cancer patient and you have metastatic disease, you should get genetically tested. And the reason for that is because we have a new set of drugs, the PARP inhibitors. But if you’re a family member that’s wanting to know whether you have a loved one has inheritable cancer that you may end up inheriting, that requires more understanding of the family history.

For example, did the grandfather have prostate cancer? Did the uncle have prostate cancer? And as I mentioned earlier, it’s not just prostate cancer. Is there a family member with breast cancer or ovarian cancer? These things play out in the decision-making of who should be genetically tested.

Katherine:                  

Absolutely. As a researcher in the field doctor, Dr. Subudhi, what would you like to leave patients with? Are you hopeful?

Dr. Subudhi:               

Yeah, I’m very hopeful. It’s a really interesting time, because with the technological advances and scientific advances – Traditionally, prostate cancer has always been treated just with hormonal therapies from the 1930s all the way to early 2000. Then in 2004, chemotherapy became the next thing. And then after chemotherapy, we’ve now got a dendritic cell vaccine; we’ve also got a radiopharmaceutical agent. And so, what the point is now we have a lot more different FDA-approved agents. And now, experimentally, the PARP inhibitors have now become a standard of care for those patients with mutations in the BRCA1, BRCA2, or ATM.

And then, in addition, we have many other types of technologies, such as BiTE and CAR T cells, that are coming out that are showing in early studies to be exciting. And so, I feel like that these therapies in combination may actually lead us to cure the cancer.

Katherine:                  

ASCO happened in June. Was there any news that patients should know about?

Dr. Subudhi:   

Yeah, so the PARP inhibitors got a lot of press during ASCO, as they should, because this is a new class of drugs that is the first personalized version of medicine that we have in prostate cancer. Now, personalized medicine has been around for a long time in cancers such as breast and lung cancer. But for first time, we actually have it in prostate cancer.

Katherine:

Dr. Subudhi, I want to thank you so much for joining us today.

Dr. Subudhi:

Thank you for your time. I really appreciate it.

Katherine:

And thank you to all of our partners. To learn more about prostate cancer and to access tools to help you become a more proactive patient, visit powerfulpatients.org. I’m Katherine Banwell.

PCRI: Managing Side Effects of Chemotherapy

This video was published by the Prostate Cancer Research Institute on June 25, 2019 here.

 

Transcript

Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.

In the video today we want to cover how to minimize side effects from chemotherapy. Fortunately, chemotherapy is not often required with prostate cancer; hormonal therapy is very effective. We reserve chemotherapy for more advanced situations. Usually, men that have some sort of metastatic disease. We’re covering this particular section in Indigo, that is men that have enlarged lymph nodes. In particular, in High-Indigo studies are now showing that a short course of chemotherapy can improve cure rates and improve survival.

People enter into giving chemotherapy with more trepidation. Everyone hears that word and you think side effects: Hair loss, nausea, fatigue, and these are certainly issues. Fortunately, there are a number of measures that can be implemented that will reduce those side effects, and that’s what we want to cover in this video. We’ll be taking the various side effects one-by-one. In some cases, there isn’t a lot you can do, and in other cases, you can make a big difference.

So let’s jump in first and talk about the side effect of fatigue. This can already be an issue in men that are on hormonal therapy and adding chemotherapy such as Taxotere can make it worse. Over and over we stress when men are on hormone therapy that they should be exercising. This same fact is true for men on any kind of chemotherapy, and it also goes for radiation as well. The men who exercise and stay strong are going to do much better and have much less fatigue. So consider that a non-negotiable reality, although men on chemotherapy may be so tired they may feel that they’re incapable of exercising. If that’s the case, then men should simply go through the motions. Move their body around even without the weights. Continue to remain active and mobile. This will help people get through the fatigue that’s caused from treatment.

When we’re talking about reducing side effects there are a number of different ideas regarding reducing the dosing of the medicine, the frequency of the medicine, and I’ll just share a few thoughts along those lines. Taxotere, the most commonly used type of chemotherapy is given every three weeks. It is possible to give a smaller dose on a weekly basis, and studies show that the side effects are reduced. Of course, that’s greater inconvenience, more doctor visits, but the weekly dosing regimen is milder, so that’s one consideration. Another possible alteration is to reduce the number of cycles. We frequently ascribe to the standard study results would suggest that six cycles is optimal for getting the maximum benefit from giving Taxotere; however, most of the side effects occur in the fourth and fifth cycle, and probably most of the benefit occurs in the first four cycles. So men that are contemplating this type of treatment but want to try and minimize side effects can consider going with only four cycles rather than six. This is a bit unorthodox and perhaps the cure rates won’t be quite as good, but it certainly will cut back on side effects.

So what other things can be done to combat fatigue? Well, many doctors use daily cortisone with prednisone in conjunction with the Taxotere. That has some benefit. It also has some potential additional side effects. Many doctors consider that sort of standard. We don’t in our practice, but men that are having excess fatigue, the addition of some prednisone five-ten milligrams a day may be helpful.

Another thing to consider is a medicine that’s approved for the treatment of narcolepsy. It’s called modafinil or Provigil. It’s sort of an upper type medicine that may help counteract fatigue in a dose from 100-200 milligrams a day.

Another idea is to consider switching Taxotere to another type of chemotherapy called Jevtana (or cabazitaxel). Studies aren’t clear on this but in my own experience and the experience of other experts, it seems like Jevtana has fewer side effects than Taxotere. So men that are running into excess fatigue or other problems with Taxotere can consider switching over to Jevtana. The medicine is given a similar three-week type protocol just like Taxotere.

So fatigue is sort of the big issue with Taxotere. In the old days, we used to be worried about nausea, which is common with all types of chemotherapy, it turns out that modern anti-nausea medicines are incredibly efficacious now. Medicines such as Zofran—an oral agent or can be given intravenously at the time of the chemotherapy administration—usually eliminate nausea altogether. There are other new agents that can be used as a backup if the Zofran is not doing the job, and so these days, although nausea used to be a very prominent issue, we don’t encounter it much anymore.

What about hair loss? Hair loss is occurring in up to 50% of people that take these agents, Taxotere or Jevtana, and the hair loss is reversible but hair loss can be very bothersome cosmetically to people and there are new ice caps that can be worn during treatment. They aren’t FDA approved yet and so it may involve a significant out-of-pocket expense. The ice caps are applied an hour or two before the chemotherapy and because of the cold blood flow is shunted away from the scalp and hair loss, therefore, is avoided.

So hair loss, fatigue, nausea and vomiting, these historically have been the big problems with any kind of chemotherapy. There’s a list of some other issues we’ll quickly and shortly address because they’re mostly correctable.

Low blood counts from chemotherapy which can place people at risk for infection can now be counteracted with an injectable medicine called Neulasta or neupogen. Our policy is to give this type of medicine in everyone who gets chemotherapy. You might want to discuss this with your doctor because some centers wait until people get a serious infection before they initiate these medications. So policies vary from office to office, but waiting around for an infection to develop seems like a rather poor plan and my recommendation would be to talk to your doctors and ask them to administer these prophylactics at the time of chemotherapy.

Chemotherapy can cause an effect on the taste buds and making food taste bad or metallic. If people keep some ice in their mouth during the infusion and for about an hour after the chemotherapy infusion, the blood, again, is shunted away from that part of the body and the incidence of problems with the taste buds is dramatically reduced.

The same thing can be said for preserving fingernails. Especially with the weekly administration of Taxotere, damage to the fingernail growth can occur. The placement of the fingers on some ice—some blue ice for example—during the Taxotere infusion and shortly thereafter shunting blood away from that area and thus the exposure of the fingernails to the Taxotere in the blood will reduce the incidence of fingernail damage and in our experience eliminate the risk altogether.

Last but not least, and this is a more common side effect with the weekly Taxotere, and that is that the Taxotere can get into the tears and then irritate the lining of the tear ducts. In serious cases the irritation becomes bad enough it can cause some scarring or closure of the tear ducts. This is a situation patients will complain and say the tears are coming out of my eyes, obviously the tears aren’t draining through the tear ducts anymore. This is a sign that you need to visit the eye doctor and they can place a small little tube in the tear ducts, open it up again, and the drainage—normal drainage—will ensue. The problem is that if you don’t do that the scarring theoretically can become permanent. So anyone on Taxotere that starts to notice increased tearing should visit the eye doctor and have their tear ducts checked out so that a stent can be placed which can be later removed after the Taxotere treatments are over.

So the use of Taxotere or its backup Jevtana is becoming more common now that studies are coming out showing that there’s a survival advantage for men in the Indigo stage who have pelvic lymph node involvement. Better cure rates, better survival all justify implementing a medicine that does have some downsides, some side effects, but if these side effects are handled wisely many of them can be bypassed or at least minimized and made tolerable so that people can get through their protocol and get on with their lives.