Implementing Triplet Therapy for mHSPC: Collaboration, Patient Communication, and QOL Considerations

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 third segment of the roundtable series, the panel delves into the implementation of triplet therapy for metastatic hormone-sensitive prostate cancer (mHSPC), highlighting the significance of effective communication with patients about the benefits and logistics of the ARASENS regimen, the collaborative efforts between urologists and medical oncologists, and the need for ongoing attention to patient quality of life throughout long-term treatment.

View the next segment of the roundtable series: Chemotherapy Eligibility and Drug Access in Metastatic Prostate Cancer Treatment.

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Dr. Parikh: Let us move on to the next stage where we have a patient with mHSPC who is about to start treatment. We have excellent data from the ARASENS trial, which investigated the triplet combination of ADT, chemotherapy, and the addition of darolutamide. This data is exciting because it shows that triplet therapy significantly improves survival and several other endpoints.

Based on the ARASENS trial, at least in my practice, we have started using the triplet or what we call intensified therapy for some of these patients. I would like to ask how you approach this, especially since you need to involve a medical oncologist for the chemotherapy component. As I understand it, most urology practices do not administer chemotherapy, so I am interested in your experience and how you collaborate on this matter, Dr. Perkel.

Dr. Perkel: Regarding communication, when I meet with a patient and determine that they will benefit from triplet therapy, I discuss this upfront. I inform them that I am referring them to a medical oncologist and explain that they will discuss specific details. I provide the patient with this information and let them know that the medical oncologist will guide their treatment. We are all following the same guidelines and data, so this is typically what they will encounter.

I also offer a pep talk, reassuring them that patients who have undergone this therapy generally do very well. I explain in layman’s terms that blocking testosterone weakens the cancer, allowing chemotherapy to be more effective. This combined approach provides a survival advantage of approximately 30% to 32%. It is important that patients feel optimistic about receiving an effective treatment.

Often, patients come to our office without knowing the full details, but they remember key points about their treatment options. Depending on the patient, timing, and prior authorization needs, I may start the ADT injection during the initial consultation or shortly thereafter.

Fortunately, there is not a significant delay with our medical oncologists. They can usually schedule patients within one or two weeks. Unless the patient is experiencing severe symptoms, this timing does not generally affect the outcome. We collaborate closely; if we administer ADT, sometimes we continue it, and other times we transition it to the medical oncologist, who then provides the second shot. This is done on a case-by-case basis.

At one point, I would have started the oral medication myself, but with the specialty pharmacy and our medical oncologists having their own specialty pharmacy, it is easier for them to handle it. By the time I complete the paperwork, they have already administered the drugs. This also alleviates some of the administrative burden from my medical assistant.

Dr. Parikh: It appears that you have established effective collaboration with your medical oncologists, which is crucial. Dr. Laungani, the other aspect I want to address is the quality of life. These patients will be on treatment for an extended period, often years. Could you provide more insight on how you incorporate quality of life considerations and handle them?

Dr. Laungani: I emphasize to my patients that this is a marathon, not a sprint. Completing the treatment is more important than the speed at which it is completed, and everyone earns a medal for finishing. As Dr. Perkel mentioned, we are not just transferring patients back and forth between medical oncology and urology; instead, we are engaged in a shared care approach.

It is important to reassure patients that this is part of their journey and treatment, which we believe offers the best chance for overall survival. This approach is particularly reassuring when administering triple therapy. As Dr. Bear noted, patients view us as the quarterback. We need to coordinate the play and determine what is best for the team, in this case, the treatment team.

We inform patients that they will benefit from seeing the medical oncologist. I will call the oncologist immediately after the consultation to ensure the patient is scheduled for follow-up. We then discuss options such as Lupron, Orgovyx, or other novel oral therapies.

For managing advanced prostate cancer, it is essential to keep the medical oncologist on speed dial. This allows us to coordinate treatment effectively and ensure timely patient care.