Supportive Therapy in Androgen Deprivation (STAND) - Rahul Aggarwal
March 1, 2020
Charles Ryan sits down with Rahul Aggarwal to discuss one of the first of its kind, the UCSF STAND (Supportive Therapy in Androgen Deprivation) Clinic providing comprehensive care to men with prostate cancer who are receiving androgen deprivation therapy (ADT). While ADT is extremely effective, it causes side effects, including fatigue, hot flashes, and sexual changes, such as decreased libido (sex drive) and decreased erectile function. It also can cause weight gain and loss of muscle mass, and increase the risk of diabetes. These side effects are related to decreased levels of testosterone and can greatly impact quality of life. This clinic supports men with prostate cancer and their partners.
Biographies:
Rahul Aggarwal, MD Assistant Professor of Hematology/Oncology, Director of STAND Clinic, UCSF Helen Diller Family Comprehensive Cancer Center
Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.
Biographies:
Rahul Aggarwal, MD Assistant Professor of Hematology/Oncology, Director of STAND Clinic, UCSF Helen Diller Family Comprehensive Cancer Center
Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.
Read the Full Video Transcript
Charles Ryan: Hello, I'm joined to today by Dr. Rahul Aggarwal, associate professor of medicine at the Helen Diller Family Comprehensive Cancer Center. Among many things that Dr. Aggarwal does, he's been involved a very successful program called STAND at UCSF, which is an acronym for Supportive Therapy in Androgen Deprivation. And it's really around survivorship for men who are receiving hormonal therapy, and you just started publishing some data here this year on some outcomes from the STAND program. Tell us about the program and what the goals are?
Rahul Aggarwal: Yeah, this program is really focused in patients with prostate cancer who are in the initial phases of starting hormone therapy. They had to have received or started hormone therapy within six months, and then they're enrolled in this program. It really recognizes the fact that when a man goes on hormone therapy, it's really a sort of profound change in sort of their metabolic profile, their hormonal milieu, and the side effects and effects it has therein. Things like hot flashes and fatigue affecting quality of life, as well as some of the metabolic impacts of hormone therapy, decrease in bone density, increase in cholesterol level, insulin resistance, all the things that factor into patients general overall health.
What we wanted to do with this pilot program is really sort of test the concept of a multidisciplinary clinic that can really try to address these different facets of a patient's healthcare as they're starting hormone therapy to make a man feel like he's supported, can have his symptoms addressed appropriately, but also sort of monitor the metabolic health of the patient.
Patients were enrolled in this clinic and they would come into our center on a monthly basis. And in a rotating basis, would see either a nutritionist who specializes in patients with cancer, would see an exercise trainer, would see what's called a symptom management specialist which is an internal medicine trained doctor who really focuses on patients with various symptoms, including those with hormone therapy.
And then, receive Lupron and get counseling from medical oncologists during the context of this treatment, and we really collected a lot of data, sort of understanding what are the different metabolic features that change in patients. Really the primary endpoint was really to determine that yes, this is feasible, that men are wanting and willing to come in on a monthly basis-
Charles Ryan: I think it was wildly popular, right?
Rahul Aggarwal: Yes, it was very popular even though it asked of patients more frequent visits.
Charles Ryan: Yeah.
Rahul Aggarwal: Think they really felt like they were getting supported, and I think it does translate into better health outcomes.
Charles Ryan: And what did you see?
Rahul Aggarwal: So we found that feasibility was high, so over 90% of our visits patients completed and that's not a trivial matter, especially in San Francisco, just dealing with the logistics of patients coming in. We did see that patients did have very favorable metabolic characteristics coming into this study even, so I think the study really showed that these are men who are already interested in sort of what can they do diet and exercise-wise.
And so, our profile of our patients was actually quite healthy coming into this study. I think during the course of study, we saw actually pretty well-maintained metabolic health, much better than the average expected sort of changes that would be observed with hormone therapy. We didn't see as high of rates of increase in weight gain, insulin resistance, changes in cholesterol level and blood pressure. Whether specifically participating in the STAND program made the difference versus these are just healthier patients, we'll need larger randomized studies to really answer that question. But it was encouraging for a first step.
Charles Ryan: What was the exercise that was prescribed?
Rahul Aggarwal: Yeah, so this was really an individualized, one-on-one session with a counselor. We intentionally did not pre-specify that every patient had to follow a specific exercise regimen, recognizing that sort of patients have different interests as well as abilities in different things that we could do. We did have sort of four pillars that patients would focus on during their visits with exercise trainers, not surprisingly, things like strength, endurance, balance, and flexibility.
And really we had patients ... We have a fitness center that's adjacent to our cancer center clinic. Patients would be taken over there. There's a center where they would get this kind of individualized counseling, then supervised exercise training that they could then take home or take to the gym, and really be able to do these types of activities at home.
Charles Ryan: That's wonderful. I was really proud to be part of the program and-
Rahul Aggarwal: You came up with the acronym.
Charles Ryan: Yeah. Well, I think that's all I can take credit for, that's why I led with it. But it's really a great thing, and I think that there's ... We know that in cancer centers around the country now, there's a huge focus on wellness, and exercise, and nutrition-
Rahul Aggarwal: Absolutely.
Charles Ryan: And I hope that we're able to continue collaborating and doing this kind of work because we really want to put some data around the efficacy-
Rahul Aggarwal: Absolutely.
Charles Ryan: Of exercise and nutrition counseling. It's not that long ago that we were asking the question, could men with metastatic cancer actually exercise, like was it safe?
Rahul Aggarwal: Right.
Charles Ryan: It seems such a quaint question now because now we know it's not only safe, but it's probably quite beneficial.
Rahul Aggarwal: Absolutely. I think looking at these patient's outcomes, both from a cancer perspective as well as just quality of life, and how they're doing in terms of the impact of hormone therapy are really important questions.
Charles Ryan: Yeah. Well, thank you. Congratulations and we'll look forward to hearing more great data from this program.
Rahul Aggarwal: Great. Thank you, Chuck.
Charles Ryan: Hello, I'm joined to today by Dr. Rahul Aggarwal, associate professor of medicine at the Helen Diller Family Comprehensive Cancer Center. Among many things that Dr. Aggarwal does, he's been involved a very successful program called STAND at UCSF, which is an acronym for Supportive Therapy in Androgen Deprivation. And it's really around survivorship for men who are receiving hormonal therapy, and you just started publishing some data here this year on some outcomes from the STAND program. Tell us about the program and what the goals are?
Rahul Aggarwal: Yeah, this program is really focused in patients with prostate cancer who are in the initial phases of starting hormone therapy. They had to have received or started hormone therapy within six months, and then they're enrolled in this program. It really recognizes the fact that when a man goes on hormone therapy, it's really a sort of profound change in sort of their metabolic profile, their hormonal milieu, and the side effects and effects it has therein. Things like hot flashes and fatigue affecting quality of life, as well as some of the metabolic impacts of hormone therapy, decrease in bone density, increase in cholesterol level, insulin resistance, all the things that factor into patients general overall health.
What we wanted to do with this pilot program is really sort of test the concept of a multidisciplinary clinic that can really try to address these different facets of a patient's healthcare as they're starting hormone therapy to make a man feel like he's supported, can have his symptoms addressed appropriately, but also sort of monitor the metabolic health of the patient.
Patients were enrolled in this clinic and they would come into our center on a monthly basis. And in a rotating basis, would see either a nutritionist who specializes in patients with cancer, would see an exercise trainer, would see what's called a symptom management specialist which is an internal medicine trained doctor who really focuses on patients with various symptoms, including those with hormone therapy.
And then, receive Lupron and get counseling from medical oncologists during the context of this treatment, and we really collected a lot of data, sort of understanding what are the different metabolic features that change in patients. Really the primary endpoint was really to determine that yes, this is feasible, that men are wanting and willing to come in on a monthly basis-
Charles Ryan: I think it was wildly popular, right?
Rahul Aggarwal: Yes, it was very popular even though it asked of patients more frequent visits.
Charles Ryan: Yeah.
Rahul Aggarwal: Think they really felt like they were getting supported, and I think it does translate into better health outcomes.
Charles Ryan: And what did you see?
Rahul Aggarwal: So we found that feasibility was high, so over 90% of our visits patients completed and that's not a trivial matter, especially in San Francisco, just dealing with the logistics of patients coming in. We did see that patients did have very favorable metabolic characteristics coming into this study even, so I think the study really showed that these are men who are already interested in sort of what can they do diet and exercise-wise.
And so, our profile of our patients was actually quite healthy coming into this study. I think during the course of study, we saw actually pretty well-maintained metabolic health, much better than the average expected sort of changes that would be observed with hormone therapy. We didn't see as high of rates of increase in weight gain, insulin resistance, changes in cholesterol level and blood pressure. Whether specifically participating in the STAND program made the difference versus these are just healthier patients, we'll need larger randomized studies to really answer that question. But it was encouraging for a first step.
Charles Ryan: What was the exercise that was prescribed?
Rahul Aggarwal: Yeah, so this was really an individualized, one-on-one session with a counselor. We intentionally did not pre-specify that every patient had to follow a specific exercise regimen, recognizing that sort of patients have different interests as well as abilities in different things that we could do. We did have sort of four pillars that patients would focus on during their visits with exercise trainers, not surprisingly, things like strength, endurance, balance, and flexibility.
And really we had patients ... We have a fitness center that's adjacent to our cancer center clinic. Patients would be taken over there. There's a center where they would get this kind of individualized counseling, then supervised exercise training that they could then take home or take to the gym, and really be able to do these types of activities at home.
Charles Ryan: That's wonderful. I was really proud to be part of the program and-
Rahul Aggarwal: You came up with the acronym.
Charles Ryan: Yeah. Well, I think that's all I can take credit for, that's why I led with it. But it's really a great thing, and I think that there's ... We know that in cancer centers around the country now, there's a huge focus on wellness, and exercise, and nutrition-
Rahul Aggarwal: Absolutely.
Charles Ryan: And I hope that we're able to continue collaborating and doing this kind of work because we really want to put some data around the efficacy-
Rahul Aggarwal: Absolutely.
Charles Ryan: Of exercise and nutrition counseling. It's not that long ago that we were asking the question, could men with metastatic cancer actually exercise, like was it safe?
Rahul Aggarwal: Right.
Charles Ryan: It seems such a quaint question now because now we know it's not only safe, but it's probably quite beneficial.
Rahul Aggarwal: Absolutely. I think looking at these patient's outcomes, both from a cancer perspective as well as just quality of life, and how they're doing in terms of the impact of hormone therapy are really important questions.
Charles Ryan: Yeah. Well, thank you. Congratulations and we'll look forward to hearing more great data from this program.
Rahul Aggarwal: Great. Thank you, Chuck.