Interview recorded on April 2, 2020.
So first, I wanted to talk about the group of patients who I think are the most anxious, and they’re the patients with localized prostate cancer. In other words, they had a plan to cure them or rid them of the prostate cancer, and all of a sudden, they’re either put on pause or basically told, we don’t know when we’re going to get to you. ORs may be canceled. ORs may be delayed. Things that we had told them that they had to do in order to get a good quality of life is all of a sudden changing. So, what is your experience with this current group of patients? We’ll start with you, Dr. Sartor.
Dr. Sartor: Well, it’s just been very frustrating, you know. As you well know, the operating rooms are basically shutting down, and the options for radiation are still open and hormonal therapies are still open. So, I must admit that we’re maybe slanting a little bit more toward the hormonal/radiation front right now, but we don’t really know when the surgery front is going to open, and that’s a primary option for many, many patients. It’s quite frustrating.
Dr. Harris, what are you seeing on your end? What’s the situation currently in Tulane?
Dr. Harris: Yeah. So, New Orleans is in the acceleration phase of the COVID epidemic, and I would say that our parish, in particular, has been hit hard. And so, we have made a lot of changes to radiotherapy treatment in order to try to increase the safety for patients that need to come in, and this has included things like, you know, not using the general waiting room, having temperature checks before entry to the building, everyone gets masked. We’ve actually also moved all radiotherapy treatments out of clinic hours.
One of my main concerns is that this might go on for a very protracted amount of time. And so, in general, we have been taking a very patient-specific approach for those radiation treatments which can be managed in some other way, maybe for patients who need palliative radiotherapy, but they’re not convinced that their discomfort is sufficient to warrant the trips in. I have a couple of patients, for example, pursuing palliation for follicular lymphoma, which we would otherwise intervene now, but we’re waiting.
But for anybody who’s on a potentially curative pathway, I have been asking first, is there another reasonable temporizing treatment, and if there is, fantastic, and then we use that temporizing treatment to hold the patient. If there really isn’t another temporizing treatment, then we have been proceeding with all radiotherapy treatments. I think, you know, I’d love to hear Dr. Silberstein’s thoughts on this. I’m not sure…you know, I think there’s this grey zone for prostate cancer patients who need definitive management, men in their maybe mid-60s and older, where often we would do…consider surgery. Maybe that’s a place where there might be a lean in the sort of older decades. I’m not sure that I would do primary radiotherapy on a very young man. I think that you have to take an individualized approach because ultimately, coronavirus will end, and so we don’t want to make changes that we think are really...dramatically differ with our underlying typical standard of care, if there are reasonable ways to avoid it.
Dr. Moon: Yes. Dr. Silberstein, what are your thoughts about this?
Dr. Silberstein: So, for patients with localized prostate cancer, we need to take a wide view of this and understand essentially that the benefits of any localized treatment for prostate cancer are modest, at best, and understand that with anything we say going forward about treatment within the coronavirus era.
Second thing we need to understand is why surgery might be mitigated, which is understanding that we need to protect our patients from coming to hospitals, which are laden with the virus. We need to protect our staff from essentially being exposed to a patient who is going to carry the virus without symptoms. We need to make sure that we’re you know, utilizing our resources the best way possible by making sure that we reserve PPE and operating rooms and personnel for the really dire situations. So, with all that in mind, I would say that surgery for prostate cancer in my institution is not going on and should not be for the foreseeable future.
With that being said, we need to now risk stratify the individual patients and understand that those with very low-risk prostate cancer probably need no treatment at all, and no imaging, bringing them to hospital centers, having them leave their houses. Televisits are a good way to mitigate a lot of these risks. For patients with favorable intermediate-risk prostate cancer, there’s excellent data from Canada from the Capture Group that delays by up to 6 months for localized treatment of their prostate cancer can be applied with no significant detriment to their prostate cancer outcomes. For unfavorable intermediate-risk prostate cancer, there’s some data from Johns Hopkins which suggest delays by up to 6 months can result in minimal impact on their oncologic outcomes.
So, really, we’re limiting our conversation primarily to those with high-risk, localized prostate cancer. For these patients, I think it’s important that we understand that surgery is off the table for the time being. Certainly, androgen deprivation therapy is an option to delay any localized treatment for many months, 4 to 6 months. It’s important that if we are giving androgen deprivation therapy that we are giving longer Depo shots and not monthly based shots, and that essentially these patients should probably have limited imaging modalities performed on them, as well, again to limit exposure, to limit resource use, and so we really have to be cognizant about all of this, as well.
The one group of patients that I’d want to address are those with very elevated PSAs who have not yet undergone a prostate biopsy. We’ve had some challenges regarding this group of patients, as well, you know. The exact cutoff is unclear, but hopefully, you have some sort of doubling time history that gives you some sense of what’s going on with their prostate potentially. For those with PSAs less than 10, we are not doing any imaging or prostate biopsies, while those with PSAs above 20 and rapid doubling times, we need to get a diagnosis in order to begin to get them on treatment or they’re off to more advanced disease, and under this very limited circumstance, potentially a prostate biopsy is a reasonable option. Of course, every prostate biopsy has about a 1% to 2% chance of significant urinary tract infections or sepsis, resulting in hospitalization and so exposure to the patient. So, again, very, very limited utility for this, as well.
Dr. Sartor: There’s actually good data with the 50 mg of bicalutamide being able to control the disease for some period of time. I actually discourage the use of the 150 mg, which is the higher-dose bicalutamide, that had an excess risk of cardiovascular toxicity in studies and which is not in use in my clinic.
Going back to Jon’s point a little bit earlier about the duration of the LHRH analogs, we typically think about 6 months and longer durations, and so, more frequently we use 6-month analogs even for the intermediate risk, where 4 to 6 months of hormones is typical. And then we have the abiraterone–prednisone combination. The 5 mg of prednisone, I don’t really think gives a lot of risk, and I’m not so concerned about 5 mg. I’m really more concerned about disease control for those people who have advanced cancer, and of course, we have enzalutamide and apalutamide and darolutamide that are already FDA approved.
So, our modus operandi is now to diminish the use of chemotherapy to the extent feasible, use hormones to the extent feasible. Monotherapy with bicalutamide, we are certainly using in our practice. When doing so, I typically limit to the 50-mg/day dose.