Two leading women talk about the future of treatment of advanced prostate cancer

Nearly 30 years ago, when your sitemaster first attended a prostate cancer meeting (in 1989) related to the upcoming approval of a new drug called flutamide, he doesn’t remember there being a single clinician at the meeting who was female — out of the 150 or so urologists and medical oncologists who had been invited. The only women present were two of your sitemaster’s professional colleagues and a few women from Schering Oncology who were involved in the conduct of the clinical trials and the preparation for the launch of flutamide (Eulexin) in the US. And this was long before the existence of the Web or web sites or this web site in particular.

Indeed, at that time, you could could count the number of medical oncologists who were considered to be “opinion leaders” in the treatment of advanced prostate cancer on the fingers of one hand (or maybe two hands, but only just). Things have changed a lot over the past 30 years — and definitely for the better. Quite apart from the advances in new forms of treatment developed and brought to market over those years, the greater involvement of female medical oncologists in the management of advanced forms of prostate cancer has brought a greater level of emotional empathy to how the oncology community thinks about the management of prostate cancer and issues related to quality of life for patients. So, …

There is a very pleasant, 11-minute video on the UroToday web site this week showing Dr. Alicia Morgans (of Northwestern University, Chicago) talking with Prof. Silke Gillessen (of the University of Berne, Switzerland) about key items to be on the agenda at the second Advanced Prostate Cancer Consensus Conference (APCCC), which will be held in Basel, Switzerland, in August 2019. For the clinical research community, this meeting has already become a “must go to” meeting on clinical trends and research into the management of advanced prostate cancer. And Dr. Gillessen is one of the most critical developers of this “new” annual meeting.

Key issues that were clearly on the minds of Dr. Morgans and Dr. Gillessen in the discussion were these:

  • How do we actually apply the new data from the CHAARTED, STAMPEDE, and LATITUDE trials in the management of men with newly metastatic prostate cancer?
  • What research will need to be done to clarify whether some patients might do better on docetaxel chemotherapy first whereas other might do better on abiraterone acetate first?
  • Is there going to be a role for “triple therapy” with ADT + docetaxel + abiraterone (at least in some patients) — and are the potential side effects manageable?
  • How do we define “metastatic” (i.e., M1) as compared to  “micrometastatic” (M0) prostate cancer in light of the newly available imaging techniques that either can already or will soon be widely used to show much smaller amounts of metastatic disease than could ever have been seen on a bone scan?
  • How will those new definitions affect future clinical trials and also our interpretation of how to use the currently available agents in the treatment of MO and M1 disease?

As an example of the last-mentioned issue, it is worth bearing in mind that the trials that led to approval of apalutamide (Erleada) and demonstration of the effectiveness of enzalutamide (Xtandi) in the treatment of castration-resistant M0 prostate cancer (the SPARTAN trial and the PROSPER trial, respectively) defined the eligibility of patients for those trials on the basis of a rising PSA level and no sign of metastasis on a bone scan. Many of those patients would almost certainly have shown the presence of metastasis on the basis of a scan like a lutetium-177-PSMA-linked PET/CT scan, so were they really Mo? It depends how we define it!

And then, of course, there are issues around

  • How soon will all these new imaging techniques become widely available?
  • Is one of these new imaging techniques going to be demonstrably “better” than all the others, such that it becomes the new standard for assessment of the presence of metastatic disease?
  • How do we ensure that the radiology and the nuclear medicine community is fully educated about how to carry out and interpret the results of these new types of scan and communicate those results accurately to the urologic oncology and medical oncology community
  • Is the “average” urologist even properly educated about how to treat a man with advanced prostate cancer today — and does he or she have routine access to the necessary diagnostic and therapeutic techniques (or should all men with indications of potentially systemic prostate cancer be referred to specialized centers that do have access to these capabilities)?

Your sitemaster has been wondering for a while now whether he can scrape up the money to get himself to Basel for the 2019 meeting of the APCCC. We’ll have to see about that.

6 Responses

  1. I agree with your point that “non-metastatic” CRPC probably exists only because of the limited ability of bone scans to detect smaller metastases. (BTW: I think you meant to write “a scan like Ga-68-PSMA-linked PET/CT.” Lu-177-PSMA, while theranostic, isn’t all that good at detecting metastasis; they usually give Ga-68-PSMA-11 along with it for that purpose.)

    I have noticed several great female medical oncologists in the US, including Maha Hussain, Celestia Higana, and Elizabeth Plimack. Here in Los Angeles, I’ve met and been impressed by Tanya Dorff, now at City of Hope. There are a couple of top female radiation oncologists (both SBRT practitioners) that come to mind — Debra Freeman and Arica Hirsch, but it is still largely a boy’s club. I can’t think of any top female urologists that work on prostate cancer off the top of my head. With more women than men entering medical school now, I hope there will be more balance in the future.

    I do remember one patient remarking that he felt uncomfortable with his female urologist, and he wouldn’t want a gay urologist either. It is tragic that such redneck attitudes are enabled in our current political climate.

  2. My husband has been going to a female medical oncologist for over 5 years now. Her speciality is advanced prostate cancer and she is in her early 70s. She was a true pioneer in the field of advanced prostate cancer. We travel 90 miles each way to see her.

    My husband had been seen by four male doctors (three urologists and one medical oncologist). His present doctor is the only one that believed had a fighting chance to slow the progression of disease. We think she is the most knowledgeable, and so far so good, he remains in remission.

  3. Alan and Sitemaster:

    Is 68Ga-PSMA offered anywhere but UCSF and is it covered by Medicare? At what level of PSA is it effective? Is it clearly superior to Axumin? Which type of scan if any is best for bone and visceral mets? Where are these women MOs located?

  4. I’d be willing to kick in some money so that you could go. I bet others who frequent this site would as well. I gain a lot of benefit from you being on top of all things prostate cancer.

    Set up a kickstarter or some other donation site: let’s get you there.

  5. Dear Steve:

    Thanks for the offer. We do already have a donation site to fund all things PCaI does. See the top of the right-hand column. :O)

  6. (1) There are several different centers in the US where trials are ongoing into the use of 68Ga-PSMA PET/CT scans for identification of biochemically recurrent and high-risk forms of prostate cancer. Click here.

    (2) 68Ga-PSMA is not yet approved as a diagnostic imaging agent in the US, so no, costs related to the use of this agent are not covered by Medicare or any other insurance company as far as I am aware, and it should only be available in the US in an approved clinical trial.

    (3) In most trials related to biochemically recurrent prostate cancer, patients must meet standard criteria for biochemical recurrence. This means a PSA level > 0.2 ng/ml at more than 6 weeks after radical prostatectomy and a confirmatory persistent PSA level >n 0.2 ng/ml in a repeat test or a PSA level that is greater than or equal to one’s nadir PSA level + 2 ng/ml after radiation therapy.

    (4) We do not know whether 68Ga-PSMA is or will be shown to be any more or less accurate that Axumin (yet). That would require very specific types of trial of each test in the same patients so that each patient acted as his own control … and I’d be surprised if either manufacturer wanted to carry out such a trial.

    (5) For most of the past 50 years, a standard bone scan has been considered the most appropriate type of scan for identification of bone metastases and a CT scan has been considered the most appropriate form of scan for visceral metastases. However, the new types of scan that are coming available — either as approved scans (e.g., Axumin PET scans and choline-11 PET/CT scans) or as investigational types of scan (e.g., 68Ga-PSMA scans) — have rarely been tested against each other under appropriately controlled circumstances. It is consequently impossible to tell you what might prove to be “the best” type of scan for a specific individual. Ask me again in 2 years and I might be able to give you a better answer. Cost is also going to be a critical factor for a lot of people.

    (6) The two female medical oncologists are located in Chicago, IL, and in Switzerland. You can find them easily using Google or similar.

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