This program provided a forum for Canadian clinicians and allied health care professionals to learn and connect with Canadian experts and peers.
The goals of the meeting:
- To highlight key research that informs current standards
- Promote interactive discussion on implementing nmCRPC best practices
Additional Resources – Case Discussion Series
Dr. Srikala Sridhar
Princess Margaret Cancer Centre
Dr. Cal Andreou
Surrey Memorial Hospital, BC
Dr. Ilias Cagiannos
The Ottawa Hospital
Dr. Geoffrey Gotto
University of Calgary
Dr. Krista Noonan
Video Guide & Discussion Highlights
0:00 — Welcome & Opening Remarks
2:20 — nmCRPC Treatment in 2022: Presentation
12:20 — Interactive Panel Discussion
1:12:33 — Closing Remarks
Panel Q&A Video Discussion Guide
12:34 — What do you think about the SPARTAN, PROSPER, and ARAMIS studies in the nmCRPC space?
- Given efficacy and safety shown in these trials, these agents should be standard of care in the high-risk population (PSA doubling time of less than or equal to 10 months).
- It is nice to see the consistent benefit across three independent trials. This really reinforces that this class of drugs has a highly significant impact in this patient population.
- All the trials show that earlier treatment is better.
14:55 — Are you looking for high-risk nmCRPC more closely, or following PSA doubling time more precisely since having these data available?
- Now that we have treatment options that are approved specifically in patients with doubling times less than 10 months, it’s important to pay attention and monitor PSA closely.
16:33 — How has your practice changed with the introduction of these agents?
- A shift in mentality/thinking in our practice is required to identify patients within the window before they become metastatic.
18:50 — Is your real-world experience similar with these agents similar to the outcomes seen in the clinical trials?
- Yes, these agents are generally well tolerated (as suggested in the trials) and patients are often pleased to see the PSA response.
20: 36 — What to do you when patients come to you already on therapy (i.e. impact on downstream treatments)?
- When you see progression on these agents, chemotherapy as the next line of treatment is preferred.
- Cross-resistance between the AR PIs creates a challenge in patients who are chemo-ineligible.
- Another thing that we worry about is whether we’re selecting out an aggressive phenotype with earlier treatment. Looking at PFS2 in the SPARTAN study and seeing that it was also improved provides some solace.
23: 34 — Do you anticipate some of the agents used currently in later lines will find their way into the nmCRPC setting?
- There are ongoing trials for PARP inhibitors in the metastatic castration sensitive prostate cancer space
- Another trial is looking at neoadjuvant therapy with apalutamide prior to radical prostatectomy (currently enrolling patients)
28:08 — Outside of clinical factors, are there other things that you discuss with patients to help determine what the best option for them is?
- I consider all three options and then look for a reason not to pick a specific drug. This usually comes down to drug-drug interactions or seizure history, hypothyroidism, psoriasis etc.
- It is also important to try to mix it up a little to get experience with all three agents
30: 45 — In your clinics, what role do nurses play in nmCRPC patient care?
- This really depends on individual practice- not all have nursing support or a pharmacy on site.
- While this could be one of the reasons that urologists in the past have shied away from some of the treatment options in this setting, these drugs are well tolerated and when issues do occur, they are usually easily managed.
- We must acknowledge that the family doctor is our friend, and having them involved to counsel the patient at the beginning to reinforce monitoring practices (i.e. checking blood pressure at home) will help prevent phone calls to your clinic and potentially having to adjust medications
36:45 — How important is tolerability of the agents used in this setting in terms of the impact on decisions made in later lines?
- It’s really important to select subsequent therapies based on their tolerance to prior therapies
- With so many new drugs available, it is now a question of how to sequence them to get the maximum number of treatments in. We want to use our best drugs first because we know there will be attrition to second and third line therapies.
- The key is to monitor and refer patients early enough to the medical oncologist if they’re progressing. Don’t hang on them on them for too long and prevent them from being eligible for other lines of therapy.
38:58 — At what point do you make the decision (as a urologist) to refer a patient onward (transfer care to the medical oncologist)?
- Multi-disciplinary care is linked to better overall outcomes. Initiating discussions about patients you suspect may be progressing early can ensure that care is transferred seamlessly, and in a timely manner.
42:30 — What does the shared-care model look like at your centre?
- It is possible to maintain continuity of care and as a urologist stay involved in the entire lifespan of the patient.
- If you can have a shared care model, the patient is going to benefit.
46:50 — How has COVID impacted your practice?
- COVID has changed many things in our practice (i.e. virtual, more home injections, etc.)
- Another issue we had to navigate during the pandemic was accessing lab testing. In patients where there was concern about PSA progression, it was often challenging to get them in to do adequate PSA monitoring.
- Positively, it’s taught us that we can be successful virtually, especially if we are watching the PSA every three months.
- The current (OMICRON) wave impacted as much as previous waves because everybody’s a lot more comfortable with things now.
53:45 — Have you had any challenges getting patients on clinical trials or getting patients switched to new therapies during the pandemic?
- Where it’s important to see patients in clinic (vs. virtual) is when you are making a treatment switch. For some people it’s quite emotional because it’s regarded as a sort of failure instead of being looked at as the disease progressing.
- There was a hold and accrual of clinical trials during the height of the pandemic
- It has been interesting to see how clinical trials gave allowances to allow virtual visits, meaning patients who otherwise would have never participated (i.e. those located in a far distance from the treatment centre) to get on to trial.
59:05 — Does the availability of the agents approved in this setting change when you institute ADT in the context of biochemical relapse?
- It hasn’t necessarily changed how we managed biochemical recurrence at this point other than that we’re more vigilant with monitoring PSA and testosterone levels while patients are on either intermittent or continuous hormonal therapy.
1:00:50 — What guidelines and/or tools do you use to inform treatment decisions in this setting?
- CUA DDI Virtual checklist: https://www.cua.org/sites/default/files/Flipbooks/CPD/DDI/mobile/index.html#p=1
- There are also tools available to calculate doubling time. It can be surprising sometimes how off our own estimations can be.
1:03:30 — What are your thoughts on metastases-directed therapy?
- Metastases directed therapy it not yet standard.
- If it is in just one area, or a few areas that you know you can actually target (i.e. with SBRT) and delay chemotherapy, it may be valuable to continue their current therapy before moving on to the next line. Selection is key.
1:08:30 — Any final comments that would be particularly helpful for those operating in busy community and/or rural centres?
- It can be immensely helpful to provide opportunities for collaboration and mentoring. Having someone to turn to when there are difficult patients or when they have questions makes it easy to treat these patients.
- Mentorships can be mutually rewarding mutually rewarding and is a really a great way establish a comfort level assessing patients, making an appropriate diagnosis, and treating appropriately.
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