Role of Multidisciplinary Management in mCRPC

Jorge A. Garcia, MD, FACP: To finalize, I think it’s important to remind our audience that the management of any cancer, specifically prostate cancer, cannot be done by 1 person alone. I do believe in the importance of putting the right team of people around the patient with 1 goal. One goal alone is it doesn’t really matter who is taking care of that patient at a given time. It’s just to make sure that we include the right team of people supporting those patients’ needs to maximize the outcomes.

In my practice for prostate cancer, it’s imperative and of paramount importance that we have a very close relationship with urology, with radiation oncology, with nuclear medicine, with the genetic counseling team, and certainly with palliative care medicine. It’s imperative for us to work on a multidisciplinary manner to ensure that the patient we’re seeing is getting the best of each of these groups. There is no doubt, through the natural history of prostate cancer, that patients will need someone’s help among those group of people.

Genetics is becoming part of the team nowadays, obviously with the DNA-repair deficiency data and the importance of germline testing. I think it’s super important for us. A lot of patients in America are getting a lot of different molecular platforms, NGS [next-generation sequencing] paneling and so on, that requires a different skill set to explain to the patients what those panels really mean. Lastly, I’d like to remind you that although we have done an extremely great job advancing the field of prostate cancer, we still see a significant number of patients dying from metastatic castration-resistant disease. Although we are moving many of the agents we use in the castration-resistant disease to the metastatic or castration-sensitive space—ENZA [enzalutamide], ABI [abiraterone], chemotherapy, and so on—the important point is that once you develop advanced prostate cancer, you are likely to die from your prostate cancer.

It’s very important to have the right approach and the right team of people supporting that patient, understanding the right sequence of events. Again it resides in that multidisciplinary approach to be able to provide the patient the best care that patient deserves. Patient access at my institution at Seidman Cancer Center has always been of paramount importance, but for me is of great relevance. As soon as we hear that someone needs to be seen, we’re making every effort for that patient to see our groups. Oftentimes, those advanced patients come from the medical oncology group, and we outsource those patients, to some extent, and get help from radiation oncology and urology. But the reality of it is that no matter how the patients enter the system, it’s imperative that multidisciplinary teams are seeing and taking care of men with advanced prostate cancer.

Transcript edited for clarity.

Case:A 69-Year-Old Man with Advanced Castrate Resistant Prostate Cancer

Initial presentation

• A 69-year-old man presented with intermittent back discomfort and loss of appetite
• PMH: hyperlipidemia controlled on a statin, no known family history of cancer
• PE: DRE revealed asymmetric, boggy prostate; otherwise unremarkable

Clinical Workup

• Biopsy with TRUS showed adenocarcinoma of prostate
  • Stage T2N0M0
  • Grade group 4
• Germline genetic testing: MLH1, MSH2, MSH6, PMS2, BRCA1/2, ATM, PALB2 and CHEK2
• Chest/abdominal/pelvic CT scan showed no evidence distant metastases or lymph node involvement
• Bone scan was negative
• PSA 24.9 ng/mL

Treatment and Follow-Up

• EBRT + ADT was started
• Follow up at 6 months, PSA 11.2 ng/mL
• At 12 months PSA 18.6 ng/mL
  • Patient reported increasing back discomfort and difficulty walking
  • Bone scan at that time showed multiple vertebral lesions at L3/L4
• Treatment with radium-223 dichloride was initiate
  • 6 infusions were completed, treatment was well tolerated