Prostate Cancer Multidisciplinary Management

Daniel J. George, MD:Prostate cancer is becoming very much a team sport in that we’re recognizing early on now that there are roles to play with primary care, with supportive care, and with medical oncologists, radiation oncologists, and urologists. The natural history of prostate cancer can range from a few years to more than 20 years. The care of these patients crosses all those disciplines. We are frequently working together as a team in our multidisciplinary clinic for newly diagnosed prostate cancer patients to make sure they get a fair, balanced, and as objective as possible description of their treatment options, so that we’re not sending everybody to surgery or radiation oncology. Not every approach is appropriate for every patient. There are risks and benefits associated with each of these therapies.

The same is true later on in the natural history of this disease, as patients progress into the metastatic and castration-resistant setting. It’s really important that they see a medical oncologist, but at the same time, that patient’s rapport and trust are predicated largely on the long-term relationship with their radiation oncologist or urologist. You can’t simply cut the cord from that. It’s really important that—for these patients to buy into concepts like chemotherapy, radium-223, sipuleucel-T, or even these hormonal therapies—they have trust and support from the physicians they know as well as some of the newer physicians becoming involved in their care. So, to me, multidisciplinary care is really critical.

And I think the last piece of that is palliative care and involving many of our palliative care team folks to help make sure we keep these patients in as good a functional status as possible while we go through a series of treatments. The care for prostate cancer patients has gotten enriched with all of these therapies, but it’s really required even more so than ever to have a collaboration of physicians to optimize outcomes.

Rajan T. Gupta, MD:Multidisciplinary care is at the real heart of cancer care today. The Duke Cancer Institute changed the way that they delivered cancer care a number of years ago, when we put the patient at the center and had everyone really rotate around that patient. We took a single cancer center approach, where we had disease-focused groups who came together and talked about patients, and I think that’s really the best way to deliver cancer care.

When you take a diagnosis like prostate cancer, one thing you really want to make sure you do is put all the key decision makers in that room with the most key decision maker, which is the patient. When you have the prostate radiologist, the oncologist, the medical oncologist, the radiation oncologist, the urologist, and everyone involved, you can make much more informed decisions and you can provide a lot more options to that patient. So, I think multidisciplinary care is really where cancer care is and should be in the future.

Multidisciplinary collaboration really comes down to communication. We have a great group of doctors that we work with at the Duke Cancer Institute who really trust one another and really value one another’s opinion, and I think that’s the key to administering really high-quality cancer care to our patients. We have tumor boards, where we discuss both straightforward as well as more difficult cases. We have radiologic-pathologic correlation conferences where we go through, “Is what we are seeing on the radiology concordant with what the pathology is seeing?” Then we can more appropriately inform decision making on the part of the surgical treatment or oncologic treatment. I think communication really is the thread that runs through any successful multidisciplinary team for cancer care.

Glen Gejerman, MD:The multimodality approach is very important, because we have to identify when this patient is at the point in their disease when they should receive radium-223 as opposed to the other therapies that they’ve already received. I think that all patients with prostate cancer should be evaluated by a urologist, urologic oncologist, and a radiation oncologist. After a full discussion of all the available modalities, these clinicians should be the ones to decide in what order to do the therapeutic layering.

Transcript edited for clarity.

December 2012

• A 65-year old gentleman presented to a urologist with urinary incontinence
• Digital rectal examination was unremarkable
• Serum prostate-specific antigen (PSA) level of 10.8 ng/mL
• Transrectal ultrasound and biopsy revealed adenocarcinoma of the prostate gland with Gleason score 7(3 + 4)
• Bone scan and CT showed no evidence of metastasis
• The patient opted for radical prostatectomy; pathology confirmed Gleason 7 prostate cancer with evidence of extracapsular extension and negative nodes; pT3aN0
• Immediately following surgery, his PSA level was undetectable (<0.1 ng/mL)

December 2014

• Two years later the patient developed disease progression
  • PSA level increased rapidly to 15 ng/mL
  • He was asymptomatic
• He was referred to an oncologist by his urologist
• Bone scan and CT were negative
• He was started on androgen deprivation therapy and had an initial response of PSA decline to 0.5 ng/mL

December 2015

• Over the next year, his PSA level increased to 35 ng/mL
• Repeat imaging studies were done:
  • Bone scan showed multiple boney metastases in the spine, pelvis, ribs, and femur
  • CT scan showed no visceral or nodal disease
• Within 3 months his PSA level rose to 145 ng/dL and he began complaining of fatigue and pain
• He was started on abiraterone and prednisone
• Additionally, he opted for therapy with radium-223
• After 3 infusions of radium-223 his PSA declined to <10 ng/dL; ALP remained stable
• After 6 cycles of treatment, CT and bone scan confirmed stable disease with no new metastases
• The combination was generally well tolerated; the patient experienced grade 2 anemia and fatigue