Chemotherapy Eligibility and Drug Access in Metastatic Prostate Cancer Treatment

A roundtable discussion, moderated by Jigarkumar Parikh, MD, MBBS, highlighted the evolving landscape of prostate cancer treatment through the integration of multi-specialty collaboration, the introduction of new therapies and their challenges, and the crucial role of molecular and genetic testing in personalizing patient care and improving long-term outcomes. Dr. Parikh was joined by Joshua Perkel, MD; Rajesh Laungani, MD; Joseph Bear, MD; and Marc Greenstein, DO.

In the fourth segment of the roundtable series, the panel considers the decision-making process for chemotherapy eligibility in metastatic hormone-sensitive prostate cancer (mHSPC), emphasizing the role of initial patient education, the importance of collaboration with medical oncologists, and the benefits of darolutamide, particularly regarding its side effect profile and the support provided by the industry for medication access and patient care.

View the next segment of the roundtable series: Future Directions in Metastatic PC: Exploring Monotherapy, Novel Therapies, and Strategic Sequencing.

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Dr. Parikh: Another aspect of decision-making is related to chemotherapy eligibility. Dr. Bear, can you tell the group how you address chemotherapy eligibility with patients? Do you leave that decision solely to the medical oncologist, or how do you approach it?

Dr. Bear: In my practice, which is solo, I usually try to discuss expectations with the patient, including the use of docetaxel, triple-line therapy, and androgen receptor inhibitors. Having a comprehensive treatment protocol can be overwhelming for certain urologists, especially if they lack the ancillary staff for prior authorizations. However, in my practice, we can at least start the process with treatments such as Lupron or Eligard.

If you are managing advanced prostate cancer in your practice, it is beneficial to do as much as possible before involving an oncologist. In my practice, I initiate the process, set expectations, and discuss potential side effects to ensure that the patient is well-prepared. It is crucial to prepare the patient thoroughly; if they experience symptoms, at least they will be aware and prepared. If we over-prepare and the patient does not experience the symptoms, we have still done our part.

I establish strong relationships with several medical oncologists who specialize in prostate cancer. A brief phone call can significantly advance the process.

Dr. Parikh: These are great insights. We are benefiting from new drugs, and ultimately, the patients are the beneficiaries. We must prioritize their interests. This collaboration is very promising. Moving forward, the ARASENS trial has demonstrated that triplet therapy significantly improves overall survival when combined with chemotherapy. This has become the new standard of care for mHSPC. In our practice, we have a similar understanding with our urology colleagues, where they start patients on ADT, which could be Lupron or Eligard, and then proceed with genetic testing and chemotherapy.

This approach has worked well in our practice. It seems you all have a solid understanding with community oncology practices. Do you have any experience with darolutamide, particularly regarding side effect management? Could you share your experiences?

Dr. Greenstein: Darolutamide is a newer medication, so our experience with it is somewhat limited. Our practice handles various conditions such as prostate cancer, kidney stones, kidney cancer, and bladder cancer. Darolutamide is generally well-tolerated, and we have successfully obtained it through insurance, which has been beneficial. So far, we have not encountered significant issues.

Dr. Parikh: Have you had any issues with insurance access for darolutamide?

Dr. Greenstein: Not yet. I do not recall having to make a substitution for it.

Dr. Laungani: The side effect profile of darolutamide is one of its most attractive aspects compared to other medications in this category. Industry support is also crucial because, although we prescribe the medication, we do not handle the paperwork or ensure the patient receives it through third-party pharmacies. Having appropriate industry support is essential for addressing issues such as prior authorizations and ensuring timely medication access.

Industry support is vital, especially with new medications. Not all urologists are comfortable prescribing them, so having a helpline or contact for support is very important. Without this support, patients may experience delays and complications in accessing their medications.

In my practice, having a medical assistant who can contact industry representatives for assistance has been very helpful. They can quickly address issues like obtaining samples or resolving authorization delays, which significantly benefits patient care.

Dr. Parikh: Indeed, having drugs available to patients is crucial, and it seems that the industry is doing its part to assist both physicians and patients in accessing these medications.

Dr. Laungani: Access is indeed the most important factor.