HSPC: Navigating Risk and Management
Transcript: Optimizing care in the MDT
Alicia Morgans, MD, MPH
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I'm excited to talk to you today about "Optimizing care in multidisciplinary teams". So let's dive right in. These are my disclosures. When we think about using AR pathway inhibitors, particularly in this context, enzalutamide, we know that enzalutamide actually has an indication by both the FDA and the EMA across multiple disease states for prostate cancer. The FDA indication really focuses on both castration-resistant prostate cancer in the non-metastatic and metastatic settings, but it also focuses in the hormone-sensitive or castration-sensitive setting in both that non-metastatic castrate-sensitive setting, so a biochemical recurrence setting as well as in metastatic castrate-sensitive or hormone-sensitive prostate cancer. The EMA indication suggests that enzalutamide is indicated as monotherapy or in combination with ADT in the biochemical recurrent setting, similar to the FDA indication where it is also approved in the single agent or in combination with a GnRH agonist or antagonist. It's also approved in metastatic hormone-sensitive prostate cancer as well as non-metastatic and metastatic castration-resistant prostate cancer. So similar and broad definitions of when this particular agent is indicated and available. As we use this drug, enzalutamide, across the disease spectrum, it's important to remember the safety profile. Further details on that safety profile can be reviewed in the safety or the product brochure. When we think about multidisciplinary care, which is really the topic of this session today, I think it's important for us to cast a wide net or a broad understanding of who can be on a prostate cancer patient's team.
This, of course, would include medical oncologists like me and some of the other speakers as well as urologists and radiation oncologists who provide that real cancer control care for patients. But it also includes people who help patients in terms of their day-to-day management, including pharmacists and nurses who help patients think through side effects and how to mitigate those. It includes radiologists and pathologists who help with the diagnosis and with the ongoing monitoring of disease, as well as primary care doctors who integrate with our cancer directed teams, hopefully seamlessly, to deal with things like blood pressure, heart disease, medication management, and think about drug interactions. Of course, our pharmacist also helping there. As patients develop more advanced disease, our palliative care team can be critically important when it comes to managing things like appetite that may go down over time or certainly thinking about things like pain. And patient advocates, the support team for the patient, the family members, the caregivers are always critical members of the team as well.
So this team keeps growing. Nuclear medicine specialists are now there as well as we think about using radiopharmaceuticals, but it is wonderful to have such a group of individuals who participate in the care of our prostate cancer patients, and important for us to be in mind as we are really reaching to every individual to provide the specialization and the support that we know our patients need. The multidisciplinary team is especially important in the setting of localized and locally advanced prostate cancer where patients might be coming into care newly and having made decisions for the first time for a new diagnosis. In this setting, the urology team, the radiation oncology team, and often the medical oncologists get together to think about whether a patient should go on active surveillance, have a radical prostatectomy, have radiation as definitive treatment or some combination of these approaches. And understanding the disease risk stratification is one of the ways that this process happens. And then of course the shared decisions and the conversations around side effect profiles and how patients want to experience their post-treatment setting are really, really important. So that multidisciplinary care is necessary from the very beginning all the way through. And this is a very important setting, of course. When we think about what happens after definitive therapy, the multidisciplinary team remains important.
If the patient has PSA persistence or recurrence after primary definitive therapy, there are guidelines to help us think through how the team can approach this. If a patient has PSA persistence or recurrence after radical prostatectomy and has a more prolonged life expectancy of at least five years, we would typically use imaging, often a PSMA-PET scan to try to understand if this patient actually has M1 disease, so radiographic evidence of spread of disease outside of the pelvis, or if there may just be a local recurrence or even a negative PSMA-PET scan. If the patient has no evidence of spread of disease outside of the pelvis, we would typically recommend salvage radiation therapy. And this can be given with or without androgen deprivation therapy and is given with the intent of curing the patient for a second time. If the patient has evidence of metastatic spread, this would be defined then as whether it's oligometastatic, a very small volume of disease, or polymetastatic, more than five areas of spread usually. And so the multi-D team, urologists, radiation oncologists, medical oncologists, are really critical here in that conversation about the pros and cons of each treatment approach, what the effects might be on quality of life and what we can expect, either cure or long-term disease control with each of the treatment options. When we think about a patient who's been treated with radiation, things are a little bit different.
In this setting, the patient may have PSA recurrence or perhaps a positive DRE, and again, if they have a limited life expectancy, we might observe. But if they have a life expectancy of at least five years, again, usually we would use a PSMA-PET or some imaging for soft tissue and bone and try to understand if that patient has a pelvic recurrence or M1 metastatic disease. And this is where the multi-D team of urology, radiation oncology, medical oncology, and nuclear medicine oftentimes, because we're often getting PET scans, we all talk together and try to figure out the best way forward for the patient. I think both of these settings lead to what we have now called in the NCCN guidelines, at least a second biochemical recurrence. So if we have primary definitive treatment, the cancer comes back, we apply a second round of treatment, perhaps with a second opportunity for cure and use curative intent there, and the cancer does come back. Again, this is what we would refer to as a second biochemical recurrence. It's important in this setting to think about risk stratification. Is this a low risk biochemical recurrence, which is also often going to be characterized by a long PSA doubling time? Or is it a high risk biochemical recurrence where the PSA doubling time is somewhere around nine to ten months and the patient has a much higher chance of developing metastatic disease and dying from their prostate cancer?
When the patient has a low risk biochemical recurrence, often we favor monitoring, observing, but when a patient has higher risk biochemical recurrence, we can monitor. In most cases, we do try to implement a systemic therapy, and there now is a systemic therapy approved to both prolong the time to metastasis as well as maintain quality of life here. And that's enzalutamide with or without a GnRH agonist or antagonist, ADT. And we would think about potentially also considering if a patient has oligometastatic disease on imaging in this setting, considering metastasis directed radiation as well. But that is something that would be decided in a shared decision, certainly in conversations with the radiation oncologist, if that is in the best interest of the patient and per the patient's preference in a shared decision. If a patient develops metastatic hormone-sensitive prostate cancer, which can also happen in this recurrent setting, it is critical to understand if that is high volume with four or more bone metastases with at least one outside of the axial skeleton or visceral involvement or low volume, which would be anything less than that. For either of these settings, we would typically use ADT plus an AR pathway inhibitor. That's gonna be enzalutamide, darolutamide apalutamide, or abiraterone. And for patients with high volume disease, or for those who have de novo metastatic disease, we often would consider adding docetaxel as a triplet therapy there to try to have more intense therapy for a more aggressive disease phenotype. For patients with low volume disease, we often include our radiation oncologist in the treatment algorithm.
If the patient has not had any pelvic radiation, we might also radiate the prostate. This would be in a de novo metastatic setting. If it's recurrent, this probably has already been done, so would be less necessary. But we often don't use chemotherapy in that setting just because this is maybe a less aggressive phenotype, if it's recurrent or low volume in terms of the metastatic burden. So this, again, shared decisions including urologists, radiation oncologists, nuclear medicine doctors, nursing, patient's family, patient and medical oncology to arrive on the right decision for that patient. Thank you so much for your time.
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MA-MM-19262, February 2026.