A brief discussion on the role of PSMA-targeted therapy’s role in managing patients with nonmetastatic castration-resistant prostate cancer.
Robert Dreicer, MD, MS, MACP, FASCO: Let’s take this time before we segue into our next case to just remind our audience of one of the unique aspects of taking care of patients with prostate cancer in that there are unique subsets of clinicians who manage these patients. We have our community medical oncologists who are in a sense, generalists who take care of everything. There are urologic oncologists who are either in large community centers or in academic practices that really focus in GU [genitourinary] cancer. We have urologic oncologists. These are urologists who work in large urology group practices where there are advanced prostate cancer clinics. There are many urologists who don’t manage advanced prostate cancer frequently. Then, our colleagues in radiation oncology. Depending on where you practice, the nature of the interdisciplinary play and who’s managing patients, it’s intriguing because the care when you see patients, when we see patients, is different. I work at an interdisciplinary academic program, so we see people coming for second opinions for their local disease management all the way through the spectrum. If you’re a community medical oncologist and you practice near a large urology group practice, you may not see patients until very advanced disease. We all know this, and we have to, in a sense, again, we work in programs that allow us to see patients across the entire disease spectrum, but we’re talking to some of our colleagues in the real world who may not see patients frequently in a number of different disease sets. One of the things we have to remember is that our experience may not necessarily translate because you can’t do something if you don’t see the patient. With that background, let’s briefly touchback on the case. This is a guy, again, probably has lymph nodal mets [metastasis] on conventional imaging. He doesn’t get a PSMA [prostate-specific membrane antigen] PET [positron emission tomography]. What I’ve heard is both of you are going to treat this gentleman. You both are going to use an oral agent. You might use enzalutamide [Xtandi] or darolutamide [Nubeqa]. Dr Scholz, you might consider some local treatment to the 2. Would you prefer before you do that to have better imaging because you don’t want to go after? You practice in a place where you can always get it, but if somebody calls you from a place where they can’t get it paid for and the out-of-pocket expense is $28,000 for the patient, they can’t go there. Are you advocating this patient get stereotactic [body radiotherapy] to those 2 nodes? Are you going to say no? Why don’t you just start the ARI [androgen receptor inhibitor]? We know that that can impact on survival. I’m worried there might be more disease. What’s your approach there?
Mark Scholz, MD: The latter. His doubling time is not egregious 9 months. His PSA [prostate-specific antigen] is not terribly high but he is 62 years old diagnosed with glycine only 2 years ago in manifesting with early androgen independence. The median time to androgen independence is about 10 years in your average PSA relapsed patient. This patient frightens me that he has more life-threatening disease than the average patient that you see with prostate cancer by far. It is a fuzzy area in terms of radiating lymph nodes, but there’s early signals in certain trials that these patients are doing better. I have my own homegrown experience with patients like this that we’ve treated with radiation, which could be done very non-toxically now with the modern radiation techniques and seen durable remissions where men have been able to go off hormone therapy. I’m not saying that happens with greater regularity but without much downside of this approach, of this multimodality approach, and radiating the metastatic sites, which I think is going to be greatly enhanced when we use PSMA. There are certain people that win big and there isn’t much downside with that type of therapy.
Transcript edited for clarity.