Speaker 1: Welcome to Symptomatic.
Speaker 2: Today, we are tackling prostate cancer, the most common cancer
Speaker 2: men face, something one in eight men will navigate during
Speaker 2: the course of their lifetime, which also has a ripple
Speaker 2: effect on their friends and family. And we're recording this
Speaker 2: episode from the twenty twenty four Asco American Society of
Speaker 2: Clinical Oncology Annual Meeting. I am joined by a gentleman today,
Speaker 2: ideally suited.
Speaker 1: For this complicated conversation.
Speaker 2: Doctor Mohammad Attique is an assistant professor in the Department
Speaker 2: of Medicine at University of Chicago Medicine, where he specializes
Speaker 2: in hematology and oncology, with a focus on genitorinary cancers.
Speaker 2: His research has appeared in leading publications and has earned
Speaker 2: him recognition as an American College of Physicians Young Achiever
Speaker 2: and a Prostate Cancer Foundation Young Investigator.
Speaker 1: Welcome, Doctor Atique.
Speaker 3: Thank you, thank you. Happy to be here now.
Speaker 1: Right out of the gate, What drew you to this specialty?
Speaker 4: Yeah, so it really kind of started out my father's
Speaker 4: medical oncologist, and so when I was younger, my siblings
Speaker 4: and I would kind of go into the clinic maybe
Speaker 4: help out there, and we grew up in a small
Speaker 4: town in Arkansas. We really got to see the development
Speaker 4: of the relations that he had with his patients, and
Speaker 4: so that development of relations was something that we always
Speaker 4: kind of grew to admire, But for myself it was
Speaker 4: really I began to learn more about molecular biology and
Speaker 4: genetics and getting into that, I became fascinated with the
Speaker 4: science behind cancer, and so as I went through medical school,
Speaker 4: I knew that I wanted to do something with it.
Speaker 3: I just didn't know in what shape, and so.
Speaker 4: I just kind of found myself gravitating more and more
Speaker 4: towards medical oncology as I finished residency and I was
Speaker 4: kind of looking at next steps. I was fortunate enough
Speaker 4: to have great mentors at University of Arkansas who advised
Speaker 4: me on considering joining a lab based in oncology or
Speaker 4: oncologic work that could then help me further delineate my pathway,
Speaker 4: whether that be in terms of a lab based physician, scientist,
Speaker 4: or clinical investigator. And I connected with Philip Kantoff at
Speaker 4: Memorial Sloan Kettering joined his lab and began the work
Speaker 4: in prostate cancer at that bench side, and that kind
Speaker 4: of was basically the start of getting into this area.
Speaker 2: And medicine is a passion shared by your siblings as well.
Speaker 4: Yeah, yeah, So I have a elder brother who is
Speaker 4: a oncology resident at Lo Melinda. I have a younger
Speaker 4: brother who's actually presenting a poster right now. He is
Speaker 4: a medical oncology fellow at the National Cancer Institute, works
Speaker 4: in bladder cancer. And then I have a sister who's
Speaker 4: a first year resident at Cleveland Clinic and interestingly enough,
Speaker 4: has already kind of gravitated towards one of the gu
Speaker 4: oncology attendings there and is looking at doing research with her.
Speaker 1: Wow, that's amazing.
Speaker 2: If I ever get bad news, I'm going to come
Speaker 2: to your next family reunion. Now, in terms of breaking
Speaker 2: down prostate cancer, let's just start at a basic definition,
Speaker 2: because a lot of people don't even understand what a
Speaker 2: prostate is, right.
Speaker 4: So, this is a glendon, and it's anatomical position tends
Speaker 4: to be you could think more kind of behind the
Speaker 4: bladder and sort of encompassing a twobe that leads from
Speaker 4: the bladder that drains out urine. The pro state itself
Speaker 4: produces a protein, and so this kind of is something
Speaker 4: we'll probably talk about a little bit more. But prostate
Speaker 4: specific antigen. This then is a protein that comprises seminal fluid,
Speaker 4: and so it produces that protein that then becomes a
Speaker 4: component of that.
Speaker 1: Do we know why it is such a common cancer, So.
Speaker 4: We don't really have a clear understanding of why we know.
Speaker 4: You know, different risk factors we obviously understand for the
Speaker 4: development of it. So one of the most common things
Speaker 4: is age, So about seventy percent of the cases diagnosed
Speaker 4: in men are in men over age sixty five. We
Speaker 4: know that family history plays a role in this, so
Speaker 4: those with the first degree relative who have prostate cancer
Speaker 4: have a two fold risk of developing disease, whereas those
Speaker 4: with two first three relatives have a.
Speaker 3: Five fold risk of developing disease.
Speaker 4: We know that race also plays a role, so there
Speaker 4: is a much higher incidence of the disease in the
Speaker 4: United States and African American men. There's not clear evidence
Speaker 4: that diet is causal, but we know that there are
Speaker 4: some associations where having a higher red meat consumption the
Speaker 4: diet can be associated with an increased risk, but nothing
Speaker 4: that's clearly causal there.
Speaker 2: It's so interesting to me in how many ways prostate
Speaker 2: cancer for men almost mirror statistically breast cancer for women.
Speaker 4: Yeah, you know, we look at both of these cancers,
Speaker 4: and so even though they are obviously separate cancers, but
Speaker 4: then in terms of a commonality, you kind of describe
Speaker 4: it as an indocrine cancer, right, just something that's kind
Speaker 4: of a gland sort of cancer in that sense, obviously
Speaker 4: being very common in each individual sex, but also sharing
Speaker 4: that kind of general category.
Speaker 2: What is the typical timeline in terms of symptom onset
Speaker 2: to prostate cancer diagnosis?
Speaker 4: So this is something that you know is actually kind
Speaker 4: of where the screening and prostate cancer also comes into
Speaker 4: play and why there's been a lot of debate and
Speaker 4: discussion there in the percent decade or so as well.
Speaker 4: So in terms of the timeline to diagnosis and symptom onset,
Speaker 4: the way that I kind of look at prostate cancers,
Speaker 4: we have a lot of diagnosis that happens in the
Speaker 4: asymptomatic stage, which is through screen, but in the symptomatic
Speaker 4: stage that can be pretty variable. So symptoms could be
Speaker 4: anything from what are those associated would say, just an
Speaker 4: enlarged prostate BPH and so that can just be issues
Speaker 4: with urinating, There can be some trouble with maybe weak
Speaker 4: streams et cetera.
Speaker 3: But then symptoms.
Speaker 4: Kind of as a sort of spectrum, because it can
Speaker 4: be as mild as that versus a gentlemen presenting to
Speaker 4: an emergency room with.
Speaker 3: Severe back pain or difficulty walking.
Speaker 4: At that point, the prostate cancer is typically very, very advanced.
Speaker 4: So it's a bit variable there in terms of that
Speaker 4: timeline to diagnosis.
Speaker 2: And then what key role does timing play in terms
Speaker 2: of fighting prostate cancer and what are the hurdles many
Speaker 2: patients face in terms of recognizing early symptoms.
Speaker 4: Yeah, so in prostate cancer, early detection is very important,
Speaker 4: so you're able to kind of keep an eye on
Speaker 4: the disease going forward. You want to detect before the
Speaker 4: cancer has spread or is causing severe symptoms. Now I
Speaker 4: say severe because there's different kinds of symptoms you can have.
Speaker 3: When I say.
Speaker 4: Severe, meaning back pain and ability to walk, or pain
Speaker 4: in the bone specifically that the prostate cancer is spread there,
Speaker 4: but also the less severe forms of symptoms, which include
Speaker 4: urinary hesitancy or weaker streams. And so the ideal timing
Speaker 4: is obviously going to be before that you have severe
Speaker 4: pain in the bones. Absolutely, But yes, in that earlier
Speaker 4: part where maybe it's just in difficulty with urinating or
Speaker 4: even before that. But we have to differentiate that early
Speaker 4: detection does not equate early treatment, okay, And the reason
Speaker 4: for this is that prostate cancer is risk stratified based
Speaker 4: on some of its components. And so what we look
Speaker 4: at here are the PSA level, which is a level
Speaker 4: that's detected from the blood. So this is a protein
Speaker 4: made by the prostate. If you have prostate cancer, then
Speaker 4: it tends to be made in higher amounts.
Speaker 3: So that's one.
Speaker 4: Thing that we look at in terms of risk stratifying.
Speaker 4: The other would be how the prostate cancer looks underneath
Speaker 4: the microscope. This comes out to what's called a gleic
Speaker 4: In score. And then we also look at what the
Speaker 4: prostate cancer its extent of involvement is on exam or
Speaker 4: on imaging, so that's called a clinical stage. So these
Speaker 4: things help risk stratify prostate cancer. Now, when we have
Speaker 4: prostate cancer that's detected early.
Speaker 3: And it falls in the low risk.
Speaker 4: Categories, these are the ones that are really managed with
Speaker 4: active surveillance. And what I mean by that is that
Speaker 4: active surveillance doesn't mean you're not doing anything, but it
Speaker 4: means you're not going to surgery or radiation. What you're
Speaker 4: actually doing is having PSA's check, digital rectal exams, repeat
Speaker 4: biopsies on a periodic basis. And the rationale behind this
Speaker 4: is that these low risk cancers, it's estimated about fifty
Speaker 4: to sixty eight percent of the patients who have these
Speaker 4: when it need treatment within ten years of diagnosis. And
Speaker 4: so some will say, Okay, well, if I don't need
Speaker 4: it within ten years, but i'll need it later, why
Speaker 4: don't I just get it now? And that's because there
Speaker 4: are side effects and there are issues when you have
Speaker 4: surgery or radiation, just as within any medical treatment, and
Speaker 4: so delaying the time to which you would need that
Speaker 4: treatment and focusing on quality of life for a patient
Speaker 4: is something that I think is very important. Just because
Speaker 4: we can do something doesn't happen exactly.
Speaker 2: So it's not even just a wait and see, it
Speaker 2: is strategize and observe.
Speaker 4: Oh absolutely absolutely so. Yeah, it's not just you know,
Speaker 4: oh you have prostate cancer. I'll see you when I
Speaker 4: see you, right, it's you have prostate cancer. But we
Speaker 4: have a plan for this, and our plan is to
Speaker 4: monitor this in conjunction with you, and we're going to
Speaker 4: do this together. But like when do you do something right.
Speaker 4: Let's say it's not ten years. I'm one of the guys.
Speaker 4: Within ten years. Well, that's based on say the PSA,
Speaker 4: so if it starts to increase rapidly, if on a
Speaker 4: repeat biopsy so these are done periodically. If on that
Speaker 4: say the gleas and score chains or the prostate cancer upgrades,
Speaker 4: then that would be another trigger to then intervene. So yes,
Speaker 4: it's not sit and wait, but it's actively watch and
Speaker 4: make sure nothing's going on.
Speaker 1: Interesting.
Speaker 2: What do you think are the biggest misconceptions that people
Speaker 2: have about prostate cancer in general?
Speaker 4: One of the biggest things is that you hear the
Speaker 4: word cancer and you think I need to treat this now, right,
Speaker 4: And I think that's one of the things that we
Speaker 4: have to really make sure people understand is that you
Speaker 4: may not have to immediately proceed to treatment. I think
Speaker 4: the other thing is that there's a lot of misconceptions
Speaker 4: about what the treatments mean for a person, and I
Speaker 4: think it really requires a discussion with a physician about
Speaker 4: what your treatment options are and where there's ability to
Speaker 4: do something different than say just what one recommendation may be.
Speaker 2: That is interesting because you're right when people hear cancer,
Speaker 2: they want to be as aggressive as possible, and perhaps
Speaker 2: the best strategy is much more nuanced and measured.
Speaker 4: Yeah, yeah, you hear cancer and you think I have
Speaker 4: to fight this. And it's not that you're not fighting this,
Speaker 4: it's that you are fighting it appropriately in a way
Speaker 4: that really helps you enjoy life to the best of
Speaker 4: your ability.
Speaker 2: It can't be easy delivering that news to anybody. As
Speaker 2: a doctor, how do you emotionally prepare for that conversation?
Speaker 4: Right, So, when we've become physicians, we take our hippocratic oath,
Speaker 4: and as physicians we understand that it truly is a
Speaker 4: privilege to be caring for someone. When someone comes to
Speaker 4: you and you're two strangers and you walk in through
Speaker 4: that patient or the clinic door, all of a sudden,
Speaker 4: you're the most important person in that room and the
Speaker 4: connection that you make with that person is very sacred.
Speaker 4: And so you understand that, yes, this is an honor
Speaker 4: to be able to take care of someone a major
Speaker 4: responsibility as well. And so what that means is that
Speaker 4: you have to focus on your training and preparation for
Speaker 4: understanding of how to be able to be pragmatic with
Speaker 4: someone but still balancing that with being too blunt. It's
Speaker 4: kind of a mix of things that you sort of
Speaker 4: have experienced during all your training that allows you to
Speaker 4: be able to walk in that room and be able
Speaker 4: to share with them the news that's going to be important,
Speaker 4: but letting them know that we have an idea, we
Speaker 4: have a plan of what we're going to do.
Speaker 2: For those and I should imagine anybody in that situation
Speaker 2: receiving that news is going to immediately go to a
Speaker 2: place of shock, fear, anxiety. How do you help the
Speaker 2: patient navigate the information overload but also detach themselves emotionally
Speaker 2: enough to be able to wrap their head around treatment.
Speaker 3: That's a great question.
Speaker 4: Some advice that you know, I generally have for patients
Speaker 4: is if you have someone who can come with you
Speaker 4: to an appointment that you you know, involve in these decisions,
Speaker 4: it's great to bring them along because, as you rightly
Speaker 4: mentioned there, you know the moment that someone hears about
Speaker 4: what's going on with them, Sometimes they just shut down
Speaker 4: and you can be talking and you think they're receiving
Speaker 4: what you're saying, and at the end they may have
Speaker 4: no clue. If you ask them to repeat back what
Speaker 4: you talked about or what their understanding is. It may
Speaker 4: just be blank stares. And so it's a matter of
Speaker 4: sort of going through the visit where you've set the
Speaker 4: stage and you're kind of doing it in increments, so
Speaker 4: it's not just an information dump all at once, right,
Speaker 4: you kind.
Speaker 3: Of work through things.
Speaker 4: You're frequently checking in with the patient to see, Okay,
Speaker 4: do you have any questions about that? Are there things
Speaker 4: is that you know you're wondering about there? I think
Speaker 4: it's also important for patients. So what I frequently advise
Speaker 4: is after our initial visit that whenever a random question
Speaker 4: comes into your head about your disease, you're able to
Speaker 4: write it down because that way, when you come to
Speaker 4: see me the next time, we can talk about these
Speaker 4: things and you're not scrambling, Oh what was it I
Speaker 4: wanted to ask? So I think it's a matter of
Speaker 4: just giving information and increments, checking with the patient to
Speaker 4: see how they're understanding that, and also understanding, you know,
Speaker 4: how you build on your visits with a patient. So
Speaker 4: you know, a new patient visit, there's some very important
Speaker 4: things that need to come across and decisions to be made,
Speaker 4: and then there are other things that we add in
Speaker 4: that maybe won't affect the patient's immediate care plan, but
Speaker 4: would have a role as time goes on.
Speaker 2: We talked about, you know, the similarities and the parallels
Speaker 2: between breast cancer for women and crosstate cancer for men.
Speaker 2: But in terms of the emotional impact and the fear
Speaker 2: that men have when they get that diagnosis, how do
Speaker 2: you help them process that in terms of being so
Speaker 2: attached to their masculinity and other fears.
Speaker 4: Right, it's through kind of having a very open and
Speaker 4: honest discussion with them about what it looks like with
Speaker 4: and without treatment, what things may look like for them.
Speaker 4: How making the decision to undergo treatment is something that
Speaker 4: you know, is obviously a very difficult decision, We understand that,
Speaker 4: but at the same time, you know, is something that
Speaker 4: they have to balance what kind of priorities are important
Speaker 4: for them.
Speaker 2: There are there common misconceptions that patients have about the
Speaker 2: likely outcome.
Speaker 4: So I think one of the common misconceptions is that
Speaker 4: when they are diagnosed with this, that instantly they're like,
Speaker 4: spend has now just become within a matter of months.
Speaker 4: And I think that's something that's not necessarily unique to that.
Speaker 4: I would say in general, patients when they hear the
Speaker 4: word cancer. There's a lot of images and thoughts that
Speaker 4: are evoked from just maybe things they've seen in movies
Speaker 4: or TV shows, et cetera. You know, when patients come
Speaker 4: to see me, sometimes they say, so it's just a
Speaker 4: couple of months, like, you know, this is it right?
Speaker 4: And you know you have to kind of temper that
Speaker 4: and really let them know that not all cancers are
Speaker 4: the same things behave differently and kind of let them
Speaker 4: know where their cases are in terms of the spectrum disease.
Speaker 2: And so that is probably how you have to individually
Speaker 2: tailor treatment to each specific patient.
Speaker 1: Can you just walk me through the stages of doing that.
Speaker 4: Yeah, So we're talking a little bit about risk stratification,
Speaker 4: and what I'm referring to here is the National Comprehensive
Speaker 4: Cancer Network Risk Sertification so NCCN guidelines.
Speaker 3: So that's something we commonly use.
Speaker 4: And so that risk traffication goes from very low risk
Speaker 4: to very high risk, and it depends on PSA Gleason
Speaker 4: score and then kind of the clinical staging meaning what
Speaker 4: the prostate cancers and atomic involvement is based on digital
Speaker 4: rectal examine imaging and so basically when a patient is
Speaker 4: first diagnosed with prostate cancer. So this, you know, is
Speaker 4: confirmed on a biopsy, so then that gives us a
Speaker 4: Gleason score to start, we have a PSA value that
Speaker 4: we'll get with that. Sometimes there's some imaging indicated there
Speaker 4: as well, or maybe it's just a digital rectal exam,
Speaker 4: but that will kind of put the patient in one
Speaker 4: of these categories. Now, the risk categories are the risk
Speaker 4: of the patient's cancer progressing or spreading. Essentially, it is
Speaker 4: kind of what those fall into, and so based on
Speaker 4: those risk categories, then we kind of look at life
Speaker 4: expectancy as well. Sometimes you can have men who are
Speaker 4: diagnosed with a prostate cancer, but they are much later
Speaker 4: in life, and so at that point whether or not
Speaker 4: to even pursue the surveillance can be a question simply
Speaker 4: because there may be other things, natural causes that may
Speaker 4: shorten one's life versus the prostate cancer itself. So after
Speaker 4: you do kind of risk traification, life expectancy is a
Speaker 4: big important part of that. Some patients may have severe
Speaker 4: other medical issues that are affecting their life expectancy, so
Speaker 4: those are kind of the initial sort of factors we
Speaker 4: weigh when trying to decide which sort of treatment route
Speaker 4: we're going to go with a patient after kind of
Speaker 4: determining that. So let's say, you know, we have a
Speaker 4: patient life expectancy, age, etc. Everything is within the range
Speaker 4: that makes sense to pursue treatment. Then the discussion on
Speaker 4: what treatment is more appropriate kind of comes down to
Speaker 4: what the patient's tolerance for particular side effects may be.
Speaker 4: Sometimes there are medical comorbilities that know they don't necessarily
Speaker 4: limit someone's life significantly to where treating the prostate cancer
Speaker 4: is inappropriate, but they still may mean that, say, radiation
Speaker 4: may be more appropriate than surgery or something along those lines.
Speaker 2: Assessing a variety of risk factors is just the starting
Speaker 2: point for creating a personalized treatment plan.
Speaker 1: Balancing each person's.
Speaker 2: Unique symptoms and treatment tolerance paves the road to recovery.
Speaker 2: After the break, we'll continue our conversation with doctor Atique,
Speaker 2: delving into the advancements made in prostate cancer therapies over
Speaker 2: the past few decades and how they are reshaping patient outcomes.
Speaker 2: Now back to my conversation with doctor Atique. Let's talk
Speaker 2: about advancements and treatment, because obviously there's no good time
Speaker 2: to receive a diagnosis of cancer, but there's probably been
Speaker 2: no better time. Right now, tell me about the weapons
Speaker 2: you would have had in your arsenal thirty years ago
Speaker 2: as opposed to what you have now.
Speaker 4: So thirty years ago, we didn't have the radio ligands
Speaker 4: that we have today. There's a lot of immune therapies
Speaker 4: that although prostate cancer itself, you know, the disclaimer there
Speaker 4: is it hasn't been traditionally one where immune therapy has
Speaker 4: been as successful as compared to say, other gu cancers
Speaker 4: like renal cancer for example, But we.
Speaker 3: Didn't have that.
Speaker 4: Even chemotherapy had really just come about into usage in
Speaker 4: prostate cancer more in the late nineties. If we go
Speaker 4: back thirty years, we're talking right about the time that
Speaker 4: that came in there. Really what we had was hormone injections,
Speaker 4: androgen approvation therapy and basically steroids, and then there was
Speaker 4: also an agent called mitoxantrone, but that was really meant
Speaker 4: to be one that was shown to help with palliation
Speaker 4: for symptoms, so not really treating the disease. So you know,
Speaker 4: you're talking about basically a handful of things that really
Speaker 4: one was using at the time.
Speaker 2: And why are technological advancements so important in terms of
Speaker 2: treating cross a cancer.
Speaker 4: Yeah, So in general, when you look at the population
Speaker 4: we have, people are living longer, so there are more
Speaker 4: people who are being diagnosed with prostate cancer. And so
Speaker 4: while a large number of those people have localized cancers,
Speaker 4: even out of the localized cancer, so this is about
Speaker 4: a little bit over our quarter million men are diagnosed
Speaker 4: every year, and out of that, around thirty to forty
Speaker 4: percent who have treatment will have recurrence of disease and
Speaker 4: then that eventually can progress to metastatic disease. And so
Speaker 4: this is metastatic disease currently is an incurable state of disease.
Speaker 4: But incurable doesn't mean that we can't control or manage it,
Speaker 4: and that's where having these treatment options is vitally important.
Speaker 4: And so what we've seen is that while we've been
Speaker 4: able to add newer treatments in the past decade or
Speaker 4: so to improve on the survival of men in these states,
Speaker 4: cancer has been able to develop mutations or mechanisms of
Speaker 4: resistance to get around those treatments. And that's where subsequent
Speaker 4: treatments are important to be able to have in our
Speaker 4: arsenal Wow.
Speaker 2: So for patients, it's important to find a doctor who
Speaker 2: is evolving their arsenal as these new advancements come out.
Speaker 4: Right, there's a lot of advancements and options that are
Speaker 4: available widely available, whether that's a physician in the community
Speaker 4: or at a tertiary academic center. But then there are
Speaker 4: options that you know, include clinical trials, and those tend
Speaker 4: to be more isolated to kind of the larger groups
Speaker 4: or larger centers, and so those are important things that
Speaker 4: you know, we have to have available for patients as options.
Speaker 2: It's very interesting in terms of cancer trying to outsmart
Speaker 2: the treatments.
Speaker 1: Yeah, what are radiopharmaceuticals?
Speaker 4: So basically you're thinking about a therapy that uses a
Speaker 4: radioactive particle for treatment. So that's kind of the short
Speaker 4: way of thinking about that. We've had that in prostate
Speaker 4: cancer some time. But we've also had kind of a
Speaker 4: newer particle added within the last couple of years getting
Speaker 4: FDA approval in the form of lutetium. So this is
Speaker 4: a beta emitter.
Speaker 2: We touched upon it a little bit, but why should
Speaker 2: healthcare providers discuss innovative treatments early with metastatic castration resistant
Speaker 2: prostate cancer patients?
Speaker 4: So in terms of discussing these early, so patients should
Speaker 4: be able to know what their options are. I think,
Speaker 4: you know, when patient's here they have metastatic cancer, their
Speaker 4: mind just goes to how much time do I have?
Speaker 4: And you have to also let them know that just
Speaker 4: because you've heard this diagnosis doesn't mean there's nothing we
Speaker 4: can do.
Speaker 3: So letting a patient.
Speaker 4: Know about their options upfront, I think kind of frames
Speaker 4: things for them and gives them a sense that while
Speaker 4: this is not what we wanted to hear, and this
Speaker 4: is not what we would have desired, we are here together,
Speaker 4: we're going to do this together, and we have a
Speaker 4: plan for you.
Speaker 2: Are there certain patients that are better candidates for innovative treatments?
Speaker 3: Yeah?
Speaker 4: Absolutely so having a number of treatments and metastatic castration
Speaker 4: resistant proces state cancer is great or in metastatic prostate
Speaker 4: cancer in general. But what we're having to learn and
Speaker 4: discover in the current field is the sequencing of these treatments.
Speaker 4: So which one should go first?
Speaker 3: Right?
Speaker 4: We know based on some data, you know, okay, well yeah,
Speaker 4: and we might start with X treatment and go.
Speaker 3: To the next one.
Speaker 4: But then there's just kind of a mix of options
Speaker 4: which can all be appropriate, and so which one going
Speaker 4: next and which one is the best to continue and
Speaker 4: linked in to survival is kind of a big poin.
Speaker 2: Discussion do you have a favorite success story that illustrates that.
Speaker 4: So we had, you know, a great success story, and
Speaker 4: this was at my prior program when I was in
Speaker 4: training and I was working under the guidance of doctor
Speaker 4: Robbie Maddens, one of my mentors and friends. We had
Speaker 4: a patient and this was on a clinical trial that
Speaker 4: we had there using aminocytokine when that was in combination
Speaker 4: with androgen deprivation therapy, so the subcutaneous injections and then
Speaker 4: dose tax which is chemotherapy. And I really like this
Speaker 4: example because this was a much elderly gentleman. He had
Speaker 4: just gone into his early eighties. And you know, when
Speaker 4: you get here and you have a multitude of options,
Speaker 4: choosing one most appropriate for you is always a big question.
Speaker 4: And so there weren't particular mutations or things that would
Speaker 4: have said he should have one treatment versus another. So
Speaker 4: he was a great candidate for this study, and on
Speaker 4: the study he was able to have over year and
Speaker 4: a half two years on the same treatment in metastatic
Speaker 4: castration resistant prostate cancer, which the overall survival for this
Speaker 4: tends to be around years, but he was still on
Speaker 4: one treatment in that area. And the reason that that
Speaker 4: story really stood out to me was, you know, he
Speaker 4: was a big hockey fan. The patient was able to
Speaker 4: go to games frequently, he was able to attend his
Speaker 4: daughter's wedding cross country. He had a very meaningful quality
Speaker 4: of life without having to undergo different or other treatments,
Speaker 4: whereas sometimes certain treatments may be particularly tough for a
Speaker 4: patient tolerate. It may really limit what they're able to
Speaker 4: do on a day to day basis.
Speaker 2: What are you most excited about in terms of the
Speaker 2: advancements in terms of treating pasta cancer.
Speaker 4: There's a couple of different advancements coming into play, some
Speaker 4: with phase one and phase two study data, so meaning
Speaker 4: that you know, they're being shown to have safety and
Speaker 4: or some efficacy in the disease state in the last
Speaker 4: just couple of years here. So we kind of talked
Speaker 4: about radio pharmaceuticals and I use the example of a
Speaker 4: lutetium based radio pharmaceutical you know, and mentioned as that
Speaker 4: was a beta emitterr there, but we also have alpha
Speaker 4: emitters coming into the play, and so a different kind
Speaker 4: of form of a radioactive particle, so phase one study
Speaker 4: ongoing with that. So actinium is one that kind of
Speaker 4: comes to mind currently, another kind of radio pharmaceutical coming
Speaker 4: into play. The other things that you know are pretty
Speaker 4: exciting to me include antibody drug conjugates and so what
Speaker 4: these are are basically molecules here treatments that use a
Speaker 4: targeting moniiclonal antibody. So it's kind of a portion of
Speaker 4: this treatment is designed to target say a protein that's
Speaker 4: expressed on protestate cancer cells. And then the other part
Speaker 4: of the treatment is what's considered to be a payload
Speaker 4: of a cytotoxic particle, and so these have approval and
Speaker 4: other cancers, and so bringing it to prostate cancer is
Speaker 4: something that's pretty exciting. And then another thing that actually
Speaker 4: comes to mind as well. So those are the antibody
Speaker 4: drug conjugates. But then we also have a form of
Speaker 4: immune therapy called bispecific T cell engagers, and so basically
Speaker 4: again has one part of it that targets a certain
Speaker 4: protein and another part of it that brings in a
Speaker 4: T cell. So basically brings a part of your immune
Speaker 4: system to a cancer cell and kind of has it
Speaker 4: recognize it to get a therapeutic event. So basically overall
Speaker 4: kind of summarizing it is all comes back to targeted therapies, right,
Speaker 4: So whether that's in the form of an antibody drug conjugate,
Speaker 4: a BUI specific T cell engager, or in a radio
Speaker 4: pharmaceutical that's you know, targeting psma.
Speaker 2: As somebody who is so on the cusp of advancements
Speaker 2: as they're happening, do you find a hesitancy with more
Speaker 2: traditional or old school providers and patients even to embrace
Speaker 2: these advancements.
Speaker 4: So I think that you know, my interactions with fellow
Speaker 4: physicians and you know call leagues around the country has
Speaker 4: been pretty open to clinical trials because part of your
Speaker 4: training is exposing you to understanding clinical research and trials
Speaker 4: and the importance of these and developing the treatments that
Speaker 4: we currently have. So, especially being at University of Chicago,
Speaker 4: we do get a large number of referrals from physicians
Speaker 4: in the community who have been practicing for a number
Speaker 4: of years because you know, they kind of recognize when
Speaker 4: the standard options may not be appropriate for patients. There
Speaker 4: can be obviously some skepticism and this isn't I don't
Speaker 4: think unique necessarily to physicians in the field for longer
Speaker 4: durations versus you know, some who are just out of
Speaker 4: kind of training. But you know, there can be some
Speaker 4: skepticism about a trial, but that tends to be more
Speaker 4: on scientific merit, So there can be debates about these things, right,
Speaker 4: That's why we're doing trials. We don't know that X
Speaker 4: treatment is really going to change the world. That's why
Speaker 4: we're obviously trying to learn about it. I think for
Speaker 4: patients there can be some hesitancy as well. You know,
Speaker 4: when you use the word clinical trial, sometimes you know
Speaker 4: just kind of flat out responses. You know, Doc, I
Speaker 4: don't want to be a guinea pig.
Speaker 1: I was going to say guinea pig is right.
Speaker 4: And obviously, you know, in past years, with recent climate
Speaker 4: in questions about some treatments that were around during the
Speaker 4: pandemic and all, you know, from patients side, and a
Speaker 4: lot of misinformation that have kind of bempeld around, there's
Speaker 4: a higher sense of sort of maybe a garden nature
Speaker 4: at times from patients that you may meet. But it's
Speaker 4: really on physicians to explain kind of what we're doing
Speaker 4: and why we're doing it. And you know, I think
Speaker 4: through that when you're able to kind of let the
Speaker 4: patient know first you are there to establish a relation
Speaker 4: with the patient. When you are there and they know
Speaker 4: that you're there to care for them and you're on
Speaker 4: the same team with them, then I think that makes
Speaker 4: it easier to bring up these subjects of you know,
Speaker 4: some unknown therapy and when it may or may not
Speaker 4: be appropriate for them.
Speaker 1: You just answered it.
Speaker 2: But I was going to touch upon the challenges that
Speaker 2: healthcare providers in terms of new treatment plans.
Speaker 4: Absolutely, I mean again it comes back to while looking
Speaker 4: up and trying to understand as much about your disease
Speaker 4: as possible is great, there can be a lot of
Speaker 4: less reliable sources out there that you know, make it
Speaker 4: difficult for people to understand their care to the level
Speaker 4: that's needed to make a well informed decision. So that,
Speaker 4: you know, is kind of I think one of the
Speaker 4: bigger challenges.
Speaker 2: In terms of well informed decision how do you navigate
Speaker 2: the topic of risk in terms of treatment with your patients.
Speaker 4: In terms of that, we have adverse effects of treatments
Speaker 4: which are important for patients to understand. So what those
Speaker 4: possibly are now, as you can imagine that list of
Speaker 4: adverse effects and be pretty long anything from things that yes, okay,
Speaker 4: we're more likely to see this too, this was reported
Speaker 4: and I don't know that in treating you know, three
Speaker 4: hundred and four hundred patients, I've ever seen this happen,
Speaker 4: and so I think you know, you obviously relay the risk,
Speaker 4: you provide information in written form as you can, and
Speaker 4: then obviously letting them know of any sort of important
Speaker 4: additional potential adverse risk. So there's some very uncommon things
Speaker 4: but can be particularly severe that you make sure patients
Speaker 4: are aware of.
Speaker 2: So you're constantly monitoring and adjusting.
Speaker 4: Oh, absolutely, absolutely, So if you initiate a patient on treatment,
Speaker 4: then ultimately you are the one who's making sure that
Speaker 4: if there's any issues or problems that come up, that
Speaker 4: those are being managed and as best as you can,
Speaker 4: being cut off before they become major issues.
Speaker 2: How much is avoiding recycling existing therapies a factor when
Speaker 2: you are creating a treatment plan.
Speaker 4: Yeah, so that's something we definitely look at in terms
Speaker 4: of especially in the metastatic prostate cancer. So you're essentially
Speaker 4: trying to get as much mileage as you can out
Speaker 4: of every treatment option, right, and you want to be
Speaker 4: able to go through and use it until the point
Speaker 4: which maybe the cancer develops a sort of resist mechanism
Speaker 4: to that. There are scenarios in which reusing therapies that
Speaker 4: have been used before are reasonable. But the way that
Speaker 4: I kind of look at it is more if a
Speaker 4: patient has progressed on so and what I'm thinking about
Speaker 4: here is one of the chemotherapy options in mind, but
Speaker 4: also one of the oral second generation androgen receptor pathway inhibitors.
Speaker 4: So these are two common drugs used in messin prostate cancer,
Speaker 4: and so there is some sense of, well, if someone
Speaker 4: progresses on say one of the ARPIS for short or
Speaker 4: one form of the chemotherapy, then maybe you could come
Speaker 4: back to that same chemotherapy or the ARPI. Now that
Speaker 4: concept is there, but in the field we understand that,
Speaker 4: especially in particular when it comes to arpis, if one
Speaker 4: has progressed on them, coming back to a different form
Speaker 4: of it is unlikely to produce a meaningful benefit. And
Speaker 4: so that's where having all these other treatment options, including
Speaker 4: the radio pharmaceuticals and clinical trials come into play.
Speaker 2: We've talked a lot about treatment options and also the
Speaker 2: importance of having a support person for someone who receives
Speaker 2: a diagnosis in terms of processing the information and helping
Speaker 2: navigate treatment. But on your end, I know with breast
Speaker 2: cancer there is very much a team approach. Is there
Speaker 2: a medical team approach to prostate cancer?
Speaker 1: And ideally who would be on your team?
Speaker 3: Yeah?
Speaker 4: Absolutely, So there are some patient interfacing team members and
Speaker 4: there are some who work more directly with the physicians
Speaker 4: involved in this case and the other clinical staff involved
Speaker 4: in this case. So in terms of patient facing members,
Speaker 4: so there can be a urologist, a radiation oncologist, a
Speaker 4: medical oncologist. Obviously our nurses who are a major backbone
Speaker 4: and really do a lot of interactions and care with
Speaker 4: our patients, so they're a big part of the patient
Speaker 4: facing team approach. We also have members of the team
Speaker 4: who don't necessarily have patient facing roles, but have critical
Speaker 4: roles in the treatment of this patient. So that includes
Speaker 4: pathologists and then radiologists as well. There's also nuclear medicine
Speaker 4: physicians that can be involved depending on the treatment, so
Speaker 4: it can be a pretty broad group of people working
Speaker 4: together to take care of you.
Speaker 2: Is there also an emotional psychological component that you find
Speaker 2: certain patients need.
Speaker 4: Yes, absolutely, I mean we do have psychological support and
Speaker 4: all through our center, and there's other resources available for
Speaker 4: patients for that, because it is critically important for patients.
Speaker 4: It's sometimes hard to wrap your head around the diagnosis,
Speaker 4: you know, it's hard to just get that first step in.
Speaker 4: But also even with the treatment options or understanding what
Speaker 4: that looks like, having the support of people who have
Speaker 4: gone through the same situation or from a psychologist or
Speaker 4: in some cases psychiatrists of their issues with emotional adjustment
Speaker 4: to this can be very helpful.
Speaker 1: Yeah, because I should think that you know.
Speaker 2: For men it's as equally loaded and complicated and emotional
Speaker 2: journey to process.
Speaker 5: Yeah.
Speaker 4: Absolutely, just cancer in general carries that right. And then
Speaker 4: also because you know, there is a lot of thought
Speaker 4: about the treatment we're using, does lower the men's testosterone
Speaker 4: can affect things on a very emotional and personal level
Speaker 4: for them, And so these are things that do require,
Speaker 4: you know, more support than just from the medical side
Speaker 4: of things.
Speaker 2: How has your specialty changed you personally in terms of
Speaker 2: your relationships with patients and just looking back, how has
Speaker 2: it shaped you as a doctor.
Speaker 4: So I think going into being a physician and kind
Speaker 4: of gravitating more into medical oncology, I think personally You've
Speaker 4: really had to exercise a much greater degree of empathy
Speaker 4: than I probably possessed before. To be very frank, I
Speaker 4: treat stay cancer all the time. I may be able to,
Speaker 4: you know, sit there and I'm not worried at all
Speaker 4: about something, but that's because of what I see and
Speaker 4: what I do every day. And so I think personally,
Speaker 4: you know, it's kind of made it to where you
Speaker 4: really have to sit there and really put yourself in
Speaker 4: the other person's shoes a lot more so and really
Speaker 4: kind of think, Okay, if this is someone coming in
Speaker 4: who has little to no understanding or doesn't have this training,
Speaker 4: doesn't see this all the time, then how are they
Speaker 4: going to feel about this?
Speaker 3: What could be going through their head?
Speaker 4: And I think that's probably one of the biggest things
Speaker 4: that you know, I always try to keep in mind
Speaker 4: with my patience.
Speaker 1: I love that.
Speaker 2: I love that your empathy has evolved, you know, and progressed,
Speaker 2: as have the treatments.
Speaker 4: You know.
Speaker 1: What would you like listeners to take away?
Speaker 4: So a couple of key things. One is that when
Speaker 4: you have prostate cancer, not treating it in some cases
Speaker 4: is a reasonable option, and that comes down to how
Speaker 4: it may affect your life and how the disease evolves.
Speaker 4: There's you know, hundreds of men who you know, would
Speaker 4: undergo procedures and things when they could very well have
Speaker 4: just been monitoring and watched for several years. So I
Speaker 4: think that's one key thing. The other is that there
Speaker 4: are a lot of new technologies coming into play in
Speaker 4: prostate cancer, and we're learning the best ways to utilize those.
Speaker 4: But I think it's important to understand that while these
Speaker 4: are there, some of these are not appropriate for every scenario,
Speaker 4: and so it's good for patients to read and do
Speaker 4: their own research and learn about what's out there, but
Speaker 4: also to understand that having every test done, or every
Speaker 4: procedure or every treatment is not necessarily the ideal way
Speaker 4: to go about treating something. To managing a disease, you know,
Speaker 4: you can lead to a lot of overdiagnosis, overtreatment and
Speaker 4: issues there. I think the other thing is is that
Speaker 4: just because you have prostate cancer doesn't mean you don't
Speaker 4: have options, and so I think that's you know, kind
Speaker 4: of a key thing.
Speaker 3: I think all the people mind.
Speaker 4: I obviously encourage patients to do their own research, but
Speaker 4: in doing so, you know, talk to your physician, see
Speaker 4: what they might recommend as an appropriate resource and you know, go.
Speaker 2: From there, and then on the flip side of that coin,
Speaker 2: what do you want healthcare providers to take away?
Speaker 4: So I think that it actually kind of comes down
Speaker 4: to almost similar advice. So in terms of when we're
Speaker 4: advising patients, we need to make sure that we're doing
Speaker 4: a good job of informing them about the risk of
Speaker 4: the disease that they have, about the risk of the
Speaker 4: treatments associated with it. But we also, you know, have
Speaker 4: to be keeping up with kind of the latest advancements
Speaker 4: in our area so that we understand when it's appropriate
Speaker 4: to use something or not. There can be over diagnosis
Speaker 4: or over treatment, you know, with all the new technologies
Speaker 4: and things are available, and so it's on us to
Speaker 4: kind of be understanding when it's appropriate to use something
Speaker 4: or not.
Speaker 1: Is there anything else you'd like to add?
Speaker 4: No, I'm just really thankful for the opportunity to be
Speaker 4: on today and to talk with you all, and obviously
Speaker 4: for any patients out there who are being faced with
Speaker 4: this diagnosis. There's teams of people across the country working
Speaker 4: on this, trying to come up with advancements and there
Speaker 4: to support you.
Speaker 1: Excellent answer thank you doctor for speaking with us.
Speaker 3: No, thank you very much for having me. I really
Speaker 3: appreciate it.
Speaker 2: Thanks for listening to this special episode of Symptomatic. Be
Speaker 2: on the lookout for all new episodes of Symptomatic in
Speaker 2: the coming months, and if you haven't already, be sure
Speaker 2: to go back and check out our two part episode
Speaker 2: on doctor David Fagenbaum. Seemingly in the prime of his life.
Speaker 2: David went from determined medical student to dying in the
Speaker 2: ICU in a matter of days.
Speaker 5: I'll never forget my doctor walking into the room and saying, David,
Speaker 5: your liver, your kidneys, your bone marrow, your heart, and
Speaker 5: your lungs are shutting down.
Speaker 3: I was just treating Pa down the hall.
Speaker 2: Follow David's race against the clock for a diagnosis as
Speaker 2: his efforts towards finding life saving treatment for himself quickly
Speaker 2: become the first piece of an even larger puzzle. As always,
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