Navigating mHSPC Care: Hormone Therapy, Patient Relationships, and Multidisciplinary Communication

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 second segment of the roundtable series, the panel shares insights on managing metastatic hormone-sensitive prostate cancer (mHSPC), emphasizing the importance of effective patient communication and the evolving role of novel therapies, while addressing the impact of hormone treatments on quality of life and the need for improved coordination between urologists and medical oncologists.

View the next segment of the roundtable series: Implementing Triplet Therapy for mHSPC: Collaboration, Patient Communication, and QOL Considerations.

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Dr. Parikh: Dr. Laungani, what has your experience been with metastatic prostate cancer patients?

Dr. Laungani: Typically, we see this very commonly in the post-prostatectomy setting. To your point, we will have individuals present with a PSA of 100, 200, 500 or more, where we anticipate bone metastases or lymphadenopathy on a CT scan or a PSMA scan that lights up. Generally, the patients we manage often have undergone a radical prostatectomy or robotic prostatectomy and exhibit poor prognostic features, such as T3b staging or Gleason 9 disease. We understand that progression is likely and discuss hormone therapy and ADT therapy with them. We now offer options such as an injection every three months or a daily pill, and we discuss potential side effects, including long-term effects documented with chronic use.

We discuss intermittent therapy and quality of life because we sometimes overlook the impact of medications like Lupron or Orgovyx on our patients. We administer these treatments and send them on their way, but we may not fully appreciate the mental health effects or loss of “their mojo.” These are significant concerns for men who may still have 10, 15, or 20 years of good living ahead of them. Addressing these issues is important.

Moreover, what used to be just hormone therapy followed by medical oncology for chemotherapy has evolved. We can now retain our patients for a longer period, offering them many novel therapies. Patients appreciate continuing their journey with us, and this ongoing relationship is valuable.

When patients hear “medical oncology,” they often fear that their prognosis has changed for the worse. Our ongoing relationship with them, addressing issues such as incontinence, erectile dysfunction, and previous treatments like surgery or radiation, is extremely valuable. The ability to continue that relationship with newer therapies is significant.

Dr. Parikh: Yes, you have highlighted some important aspects that we need to focus on. Dr. Bear, could you share your experience in this area?

Dr. Bear: I would like to build on what others have mentioned. First, regarding access to PSMA PET scans, it is a barrier, but it is improving. Comparing now to two years ago, when a new patient with a Gleason score of 8 and a PSA over 15 presented, insurance previously required treatment failure before approving a scan. Now, we can use PSMA PET scans earlier, which facilitates earlier diagnosis and discussions with patients.

This advancement accelerates the process of educating patients. It is crucial that we educate them and remain their first line of contact. Whether we provide treatment ourselves or involve a medical oncologist, informing patients about all available options is key. The treatments available today are excellent, and minimizing side effects with new medications is beneficial.

Furthermore, as Dr. Laungani mentioned, many patients view us as the quarterback and the medical oncologist as the wide receiver. Maintaining communication and assuring patients that we will support them through every step is essential. This relationship is crucial, even if we trust the medical oncologist completely.

Dr. Greenstein: The importance of communication cannot be overstated. As practicing physicians, we sometimes experience breakdowns in communication. Having a team effort and a multidisciplinary approach where everyone can communicate directly via cell phones is beneficial. For example, “Hey, Dr. Parikh, did you see him on Tuesday? Great, you saw him; that is good.”

Dr. Parikh: You are absolutely right. Communication is crucial. Although we have excellent EMR systems, they do not always integrate well, leading to gaps in information sharing. Physician-to-physician communication is vital to ensure that patients receive the best possible treatment in an appropriate manner.