Case 2: Local Control in Metastatic CSPC

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Jorge Garcia, MD:Ken, do you get patients asking you…For an oncologist, I’m pretty aggressive in the management of local disease. I think most oncologists, when we are fixated on distant metastases, lose sight of the importance of local control. There is nothing worse than to see a young guy or an older guy not develop CRPC [castration-resistant prostate cancer] distantly but develop CRPC in the prostate gland region, where these patients are often miserable because of pain, pelvic floor dysfunction, hematuria, obstruction, and so forth. I do believe local control, where you do it with the intent of cure, or delaying symptoms, palliatively in nature, is extremely important for our patients.

Kenneth Kernen, MD:Yeah, I think that’s 1 of the things we do see once in a while, obviously in more select patients. Again, I think you could offer them radical prostatectomy. But again, as Neal said, the pendulum is swinging the other way. I think more appropriately is radiation therapy, because you can radiate the primary, prostate bed, and lymph nodes and get benefit as well. And then there’s some thought about cryotherapy, with immunologic potential that happens during cryotherapy for local disease as well. But again, I think those are very specific patients.

Alicia Morgans, MD:There is still a lot for us to work out. I didn’t mean to cut you off, Jorge. We’d love to hear what your closing thoughts are. What’s the theme of metastatic hormone-sensitive prostate cancer, from your perspective?

Jorge Garcia, MD:What you stated earlier, Neal, right after the case…You know, I think it’s mind-boggling to me that in the United States of America, with the compelling data that we have—6, 7 trials—and that with a hazard ratio for survival, that you can tell a patient, “I can reduce your risk of death by almost half,” and then our patient population is still getting suppression of testosterone.

I just cannot understand why it happens. It may require us to go and educate or for us to teach, right? But I think at the end of the day, the standard of care should be, throughout the world… It’s suboptimal when you do ADT [androgen deprivation therapy] alone. I tell my patients that volume matters, intensification is needed, and if you don’t get intensified, you’re getting suboptimal care.

Alicia Morgans, MD:Absolutely.

Kenneth Kernen, MD:I would echo the same thing. That’s why I brought it up. I just think it’s critically important for people who are watching this to know. We talked a lot of subtleties. There are a lot of great data out there. The bottom line is that ADT as monotherapy is the wrong answer.

Neal Shore, MD, FACS:I totally agree. You guys summarized it perfectly.

Alicia Morgans, MD:Agreed. Ultimately, we owe it to our patients to have these conversations, to offer them combination therapy. And really, it is a rare patient for whom ADT alone is going to be the right answer. We really need to make sure we think about combination first, and ADT alone as a very, very, very, very, very distant second option. Perhaps it should not be thought of as an option at all. It shouldn’t be an option for many of our patients. Thank you.

Transcript edited for clarity.