Prostate Cancer: The VISION Trial - Episode 9

Clinical Pearls for the Management of mCRPC

Scott T. Tagawa, MD, FACP, shares clinical pearls and advice for the management of mCRPC.

Scott T. Tagawa, MD, FACP: As far as advice for the average clinician who has prostate cancer as part of their practice, No. 1 is you’re not alone. Reach out to colleagues or friends. That may be someone within your practice who you may have trained with, or it may be someone at your local academic center, or across the world. Now that we’re so connected, whether that’s phone, email, or other, it’s important. Generally speaking, sometimes these curbside consultations are difficult on either end. I’m sure it’s happened to all of us. But sometimes it’s a simple question, and sometimes we’re able to do formal evaluations of individual patients. That’s one important fact to learn.

Another is that we have a number of different drugs. Some of them are similar. But we don’t have a lot of head-to-head comparative data. For instance, an AR [androgen receptor] signaling inhibitor or a PARP inhibitor will have different labels, but some of them are overlapping. Learn to use at least one of them well. The PARP inhibitors may be used in other cancers, so maybe there’s expertise already. As long as the data are reasonable, using that one as preferred to others is absolutely fine because it’s probably better to use a drug correctly with some data than use another one incorrectly that may have a higher level of data. That’s important, and a factor.

Also, keep up. I’m not saying keep up on the overall data, but at least looking at buckets; these may come from guidelines, review articles, or CME [continuing medical education]-type discussions. I’ll give you 1 specific example. Since the December 2013 press release, and 2014 ASCO [American Society of Clinical Oncology annual meeting] and beyond, we know that we can make a major improvement in overall survival by adding one of these drugs. I don’t believe chemotherapy is crummy, but as a naysayer, chemotherapy, docetaxel, doesn’t do so much for metastatic CRPC [castration-resistant prostate cancer]. That same drug with a few cycles has a major benefit for metastatic castration-sensitive, or noncastrate disease. There are now a lot of drugs that do that.

I’m not even going to mention doublets vs triplets, in part because through at least 2019, we know from data sets that a lot of patients are still getting old-fashioned therapy such as ADT [androgen deprivation therapy] alone or ADT plus a nonsteroidal or old-fashioned antiandrogen. This shouldn’t never happen, but it should happen in a very small minority. We want to make sure at least in principle that patients are getting the right therapy. There’s no way any specific doctor, including myself, can know all of the data. But as a patient is sitting in front of you, at least look up guidelines, phone a friend, or say something like, “This is your situation, and these are the general options that I see. I’m going to look into them a little more and then we’ll call you,” if it can’t be done in real time.

Transcript Edited for Clarity