HSPC: Navigating Risk and Management
Transcript: Patient-centric approach to care
Daniel George, MD
All transcripts are created from interview footage and directly reflect the content of the interview at the time. The content is that of the speaker and is not adjusted by Medthority.
Hi, I am Dr. Dan George, I chair the Urinary Medical Oncologist from the Duke Cancer Institute in Durham, North Carolina. Here are my disclosures, and I am happy to present to you a short presentation on a patient-centric approach to care. So you heard earlier from Dr Morgans about the multidisciplinary care teams, and you've seen this slide, but I want to emphasize that the patient is in the center of this discussion, that at the end of the day, all of these various specialists are focused on directly interacting, either with the patient or with their data and results. And the key here is even though we're all facing the patients, the patient isn't coordinating the care, we are. So it's not a perfect visual of how the workflow is. What's most important is to recognize that we all share a role in communicating with patients directly, and we need to do it in a fair and balanced way so we don't contradict each other and confuse patients with different recommendations and advice. Now, if we apply this approach into the non-metastatic hormone-sensitive prostate cancer setting, there's various disease states that this applies to. And I'm gonna look at three of them with you here in this slide. The first is locally advanced, or patients with localized prostate cancer, what we might term non-metastatic hormone-sensitive prostate cancer or localized disease. The most important thing is to recognize that we want to deliver our messages in a tone and in a language that patients can relate to.
Our work is very technical, our work is very scientific-based. Our patients are not. It's important for us to be able to understand at what level of healthcare literacy these patients are coming in with and how to present that data so they can understand it. The next important thing is to understand what information is most important to a patient at this stage of disease, because we know a lot about prostate cancer and they don't need to hear a one-hour lecture. They want to hear something tight. So it'll be important for us to be able to speak here specifically about risk stratification, where they are in low, intermediate, or high risk for disease progression, what that means, the various components of Gleason score, or grade group, of PSA levels, of clinical stage, and of imaging. When we get into the relapse patient, these are patients that have undergone localized therapy and now have evidence of biochemical relapse, PSA rise. Many of these patients are now have a working knowledge of prostate cancer. They understand more about their disease. They're also concerned, this was a stage they were hoping to avoid, and yet here they are. This is non-metastatic, so presumably these patients have had imaging done that doesn't show any clear metastasis. That may be standard imaging or PET imaging. Either way, it's something we're gonna want to go over and explain to patients and reassure patients.
The most important things for patients to understand, number one is prognosis. The goals of care here are dependent on prognosis, and these patients can have quite a good prognosis or a relatively concerning prognosis based on the PSA doubling time and helping them understand how that factor differentiates its prognostic from other factors. Independently predicting for survival is really important. The next important thing for patients to understand is that even though we call this non-metastatic hormone-sensitive prostate cancer, we do believe most of these patients harbor microscopic metastatic disease. It's a bit of a contradiction. It's important for patients not to get confused by that. And then finally, there's metastatic hormone-sensitive prostate cancer, whether this is de novo or recurrent, these are patients now that have quite a different prognosis from the first two settings. In the first two settings, in the non-metastatic hormone-sensitive prostate cancer settings, they're more likely to die from other causes than prostate cancer. And if they do die from prostate cancer, it's 10 or 15 years down the road or more. Here, we're looking at a patient population that has a life expectancy that could be five years or less, depending on their prognostic features, their volume of disease, their graded disease, and other prognostic indicators. In addition, understanding that in this setting now, it's very important for us to understand the genetic underlying characteristics of their cancer. These are patients that we absolutely need to do genetic testing in to look for precision medicine targets such as HRR or BRCA defects, AKT alterations, or for MSI high microsatellite instability. So a lot to cover in this setting, in this disease state. The most important things for patients to understand, again, are their prognosis based on these features.
On our standard treatment options are hormonal therapy, particularly combined hormonal therapy with ADT and ARPI, and for them to understand why we use those drugs in order to prolong their survival and prevent death from prostate cancer. Very, very important goals. Along the way, in addition to prolonging their life, is their quality of life. And it's so important to recognize that this disease causes a decrease in quality of life as well as significant physical complications through skeletal involvement. Particularly, decreases in quality of life can happen from sexual function, urinary incontinence, changes in bowel functions, some of that is from our localized disease treatments, some of that can be from localized disease progression. In addition, patients develop metastatic complications from disease, including skeletal metastasis that can cause symptomatic skeletal events like core compressions or pathological fractures. And they can also get localized complications like your ureteral obstruction or other complications from extra skeletal disease. They can also develop constitutional symptoms, weight loss, loss of appetite, fatigue, muscle loss, et cetera. These can be somewhat compounded by the treatments we use, but those are reversible, those are treatable. The cancer complications are much harder to reverse and manage, and preventing those is critical. PET scans are really helpful in understanding how we manage these patients and really assess their disease, where it is and where it isn't. What's important to know is that the reliability, the specificity of PET scan increases as the PSA rises. And so if you're measuring a PET scan in someone with PSA less than 0.5, our sensitivity, but specifically, the specificity decreases, and so we can get false positives, and that's important to know. As this rises up to PSAs over one or higher, our specificity is very good, and here's where we can have confidence that these are indeed metastatic sites of disease. The ability to detect and treat all metastatic lesions can improve outcome, particularly in patients who have oligometastatic or a few metastasis, five or less. And these patients, particularly with the elevated PSAs that we feel confident in, we can, randomized studies have shown that the use of stereotactic body radiotherapy or tumor-directed, metastasis-directed radiotherapy to these individual sites can improve the distant metastasis-free survival, the appearance of new lesions from 6 months to 29 months. So really changing the natural history of patients who have this kind of particular low-volume metastatic pattern.
And finally, monitoring and managing the side effects of androgen deprivation therapy, androgen receptor pathway inhibitors is really critical. These drugs, this combination approach can have effects on their cardiovascular health. It can increase the risk of fractures, falls, and these symptomatic skeletal events and add to generalized fatigue and weakness. Monitoring can help with cardiovascular and partnering, coordinating with their cardiologist is critical. Supplements and exercise can really help with the prevention of fractures and skeletal events, as well as preventing falls and maintaining good bone and muscle health is critical for both quality of life and for prevention of complications. And then lastly, making the decision in metastatic hormone-sensitive prostate cancer is really a critical one that has to involve the patient in the individual patient factors, patient preferences, what are their financial liabilities and limitations, the safety and what they can tolerate, what they're willing to tolerate for toxicities, the effect of these drugs and what, how beneficial they can be depending on how high a volume and how risky their disease is for complications, and what is the quality of life impact. Some of these assessments are made up front, some of them are on treatment assessments. And so this decision on how to manage this patient really comes down to this balance and whether to intensify with chemotherapy and whatnot in this setting. Really involves an open discussion with patients and helping them to decide with us, together in a shared model, what is in fact, the best management for them. Thank you.
Updates in your area
of interest
of interest
Articles your peers
are looking at
are looking at
Bookmarks
saved
saved
Days to your
next event
next event
This educational program has been developed by EPG Health in partnership with the sponsor, Astellas. Indications and availability of products discussed in this educational program may vary in different countries. Please refer to the local summary of product characteristics / prescribing information for details. Astellas prohibits the promotion of unapproved uses and complies with all applicable laws, regulations, and company policies. In expert interviews, podcasts, and panel discussions, the views, thoughts, and opinions expressed belong solely to the speaker(s) and are subject to change without notice. This content is intended for healthcare professionals (HCPs) only. Non-HCPs should not view this educational program and should exit the program as soon as possible.
MA-MM-19264, March 2026.