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Alicia Morgans: Hi. I'm so excited to be here today with Dr. Matt Rettig, who is joining me from the Greater Los Angeles VA Medical Center. Thank you so much for being here today with me, Matt.

Matthew Rettig: Well, thanks for having me.

Alicia Morgans: Wonderful. So I am really excited to talk to you about the changing landscape of the metastatic castration-resistant prostate cancer setting and how we, in our veterans populations, are really able to adapt and accommodate making these treatment decisions which are becoming increasingly complex.

So tell me, how do you approach a patient with metastatic CRPC in the VA, and how do you think about all of these new therapies that we're trying to bring into the fold?

Matthew Rettig: Yeah, well, thanks for the question.

I think what we've observed over the last several years is that we're building infrastructure that helps take care of patients with metastatic castration-resistant prostate cancer, mCRPC. So we have the infrastructure to do genetic analyses on the tumor or on their own normal DNA. And along with all of the access to drugs, to imaging, to molecular imaging, we're able to make fully informed decisions.

Now, veterans can be at any VA to access care, and especially in this era of precision oncology, veterans need experts. So we have the ability to provide expertise to veterans who may be at rural VAs and not have access to a medical oncologist or a medical oncologist with a particular expertise, say, in prostate cancer.

So there is a national teleoncology or telehealth program. We have clinical trials that can be run virtually where there's no clinical trials infrastructure required on the ground at any VA in order to enroll that patient in a clinical trial.

So between the standard of care options, the telehealth programs, and our clinical trials programs, and particularly the virtual clinical trials programs, we can get pretty much any veteran, irrespective of their geography, into appropriate therapy, be it standard of care or a clinical trial.

Alicia Morgans: That's amazing. And really, I think even light years ahead of what we're able to do with our many clinics across the country, many of them in communities where patients actually live that are less connected to some of the centers that may have clinical trials and really think about prostate cancer every day. So phenomenal. Congratulations.

Matthew Rettig: Thank you so much.

Alicia Morgans: And I know you're continuing to make advances there.

You mentioned genetic testing, which is something that we, as a field, are trying to integrate more and more. Tell me a little bit about how that impacts your care. Are you able to get things like PARP inhibitors, combinations? These are some recently approved therapies. Can you do that in the VA system and how do you work together to get that done?
Matthew Rettig: Yes, in the VA medical system, we have access to all of the drugs that have received approval for prostate cancer. In fact, in many ways, once a patient is in the VA, it's much easier to access the drugs.

The issues of copayments have really been mitigated by the VA, and the most a veteran can pay for a month's supply of a drug is $11. In fact, I have a practice at our affiliated academic center, UCLA, and I have patients who have trouble paying for the drugs that we prescribe for prostate cancer in my UCLA practice. I'll always ask these patients, "Are you a veteran?" If they are, I bring them over to the VA, they get their care, and they ultimately end up preferring to receive their care at the VA as opposed to our academic affiliate.

So there's absolutely no issue with getting drugs and reaching out for new imaging modalities. It's really all there at the VA, so really no issue for our veterans.

Alicia Morgans: Wonderful.

Matthew Rettig: Yes.

Alicia Morgans: So tell me, how do you, as a multidisciplinary team at the VA, and of course, this is just your VA, but you can comment on others and how that may work there, work to get imaging things like PSMA PETs? If you have a patient who needs something like lutetium PSMA-617, needs these new treatments, how do you work together to make that happen?

Matthew Rettig: Yes, there are over 150 different medical centers in the VA system. There's close to 1,000 outpatient clinics. So not all of the VAs have the same access to some of the state-of-the-art treatments and diagnostics. But if a VA has that, it's just a matter of ordering the test or the drug, just like one would order a chest X-ray to evaluate a cough. The same thing for a PSMA PET scan, we can just order it, and it'll get done.

In fact, we can use PSMA PET scans much more liberally because we don't have to worry about authorizations. So we can use PSMA scans serially to monitor the status of a disease in response to treatment.
Now, other VAs may not have access to some of the state-of-the-art technologies. In that situation, the VA has a system in place where patients can access community care. So a veteran can request community care, or a doctor can request it. Either way, we can get a patient to the community where a particular diagnostic, like a PSMA PET scan, is available. So ultimately, veterans have access to something like a PSMA scan or other imaging modalities.

Alicia Morgans: That's fantastic.

Matthew Rettig: Yes.

Alicia Morgans: And to your point, one of the treatments that we've been using more and more, lutetium PSMA-617, is something that at this point in time, at least in my academic practice, I cannot necessarily routinely follow with follow-up PET scans when I'm using that agent. So tell me a little bit about that. How does that help you as you're trying to treat a patient and really be responsive to the disease?

Matthew Rettig: Yes. So first of all, let me say that PSMA scanning has not yet reached the standard of care where we're using it to monitor patients. I think it's moving in that direction, but I think it's better than standard or conventional imaging, especially for prostate cancer because prostate cancer likes to spread to the bones, and the bones are classically very challenging to monitor.

In fact, with standard imaging of the bones, we really have only two ways of assessing response: it's either the cancer is stable or it's worse. We really can't say it's better with conventional imaging. And with PSMA imaging, we can see specific metastases in the bones get better or get worse. So it's very helpful and it can give us a sense of how individual sites of disease may be getting better or worse. And it's not always going in the same direction for all of the tumors for any individual patient. So it's really very helpful, in my view, and I believe it's going to become over time the standard to monitor patients with prostate cancer.

Alicia Morgans: Fantastic. So I think the only other thing, just to kind of comment on, is that lutetium PSMA-617 has been for some patients in certain geographies more difficult to access. It sounds like veterans in those areas are not just limited to getting their scans but potentially could get treatment at a center, whether it's lutetium or whether it is some other treatment that's not available. They could do that at a community center?

Matthew Rettig: Exactly. Yes. Thanks for pointing that out. So it's not only the diagnostics but also the therapeutic treatments, including radionuclide therapies like PSMA lutetium, that can be accessed through the community. So if a particular VA doesn't have that therapy, the lutetium PSMA, they can get it in the community.

Alicia Morgans: That's fantastic because that's been a challenge for many patients across the country, and I'm really glad that the VA is thinking about this and making sure that there's access for veterans.

Now, let's just switch gears a little bit. The veterans' population is a large one, and the electronic medical record is one that really synchronizes across all of those VA centers that you mentioned. I think the power of that, particularly in a community of patients that can include a lot of diversity, is so important. And I know that the Veterans Administration is very committed to research. Can you tell me a little bit about how that happens and where things focus in the mCRPC population?

Matthew Rettig: Yes, we actually have a database on all veterans who have ever had prostate cancer or are in principle at risk for prostate cancer, which basically, if you're a man, you're at risk for prostate cancer. So there are millions of patients in our database, and we can use this database to do research to ask certain questions about real-world data, whether a particular therapy, for example, has more efficacy in an African American patient as opposed to a Caucasian patient. This database also includes all of the radiologic images that have ever been taken on a veteran, whether it's a chest X-ray for a cold. It is all there and can be integrated into the clinical pathologic database that we have to use images as well as pathology to make observations that help us understand the biology of prostate cancer and ultimately pick the right treatment for the right patient at the right time.

Alicia Morgans: That's incredible. And I think what's so powerful in the VA system is that, as you said, you not only have the pathology data, but you've also got the imaging data, and it's not just at baseline. You actually have the follow-up data so you can understand what complications may have developed from treatment, what the patient may experience in terms of comorbid disease. You also have that structured data on imaging and other outcomes, including even mortality events, because these veterans appreciate their care and they stay in the system for a large part. So that is an incredibly powerful database.

Are there genetics integrated in there, as well?

Matthew Rettig: Yes, we really can integrate databases of all kinds. So we have our clinical pathologic database, we have the scans, slides from prostate needle biopsies, we have all of the imaging, and we have the genetics database. Now, the genetics database that we have access to, that we integrate with all these other databases, is the genetics on the tumor. There is genetics on the normal DNA, so-called germ line DNA, but that's a little bit more challenging to access because of medical, legal issues, and privacy issues. But it is out there. And if you have a study that's approved, in principle, you can access those data.

Alicia Morgans: Well, it's great that those resources are available. And of course, it's also great that we're maintaining protections on people's personal health information. So all of that's fantastic.

So, as you think about delivering care for patients with mCRPC and certainly helping to support the advances in research that will help us deliver the care for tomorrow, what would your message be to folks who are thinking about mCRPC and how we understand it in the VA?

Matthew Rettig: What I would want to tell any veteran with mCRPC is that you can get the best care at the VA. You have access to the best imaging, the best drugs, and you have access to clinical trials. So, if you have any concern about your treatment, ask your doctor and get the answers you need to optimize your care.

Alicia Morgans: Fantastic. Well, I thank you so much for your time today and for all of the work that you and your team in Los Angeles, as well as around the country, are doing to support the care of our veterans and make sure that they get the very best. I really appreciate your time.

Matthew Rettig: Thank you for having me.