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Alicia Morgans: Hi. I am so excited to be here today on UroToday talking with our team about how we manage really complex patients who are coming into our clinics with metastatic hormone-sensitive prostate cancer, and how we work as collaborative teams through urology and medical oncology partnerships to really make that care the best that it can be. So I'll leave it to my colleagues here to introduce themselves. We'll start with Dr. Paul Eber.

Paul Eber: Hi, Paul Eber. I'm a general urologist in the Memphis, Tennessee area. My office is in Germantown, but I am and have been, since about 2010, the director of our advanced prostate cancer clinic. Although I'm not a specialty-trained urologic oncologist, I do mostly prostate cancer.

Alicia Morgans: Wonderful, and Dr. Brad Somer.

Brad Somer: Hi, I'm Brad Somer. I'm a medical oncologist at the West Cancer Center in Memphis, Tennessee. I'm a general medical oncologist, but my focus is on GU oncology and GI oncology.

Alicia Morgans: Fantastic. Well, thank you both for being here today, and I think Paul is going to start us off with a case of a patient with metastatic hormone-sensitive prostate cancer who came into your care.

Paul Eber: Yes. In fact, there was a week, probably three months ago, where I had three patients all in the same week, all of whom Brad and I collaborated on, each one of them had PSAs over 1500. We are seeing more and more patients with high-volume metastatic castrate-sensitive prostate cancer that are coming in the door. Our practices here in the Memphis area are unique because we live in an area of very underserved medical care. Eastern Arkansas, Northern Mississippi, are some of the poorest areas in the country and least educated. It is not uncommon for us to have somebody hobbling in here to my office who's being referred for elevated PSA, and that's all I get. I don't even get a number. We check their PSA and they're crippled, and their PSA is 1800. Then we do imaging studies and we find that they have high-volume osteosmetastatic disease.

In that one week, we had three patients that were very similar. I was on the phone with Brad just about every day trying to make arrangements. I think I should go back a little bit and say that when triplet therapy first got approved, I don't know if it was me or Brad, one of us called each other. I think actually Brad called me and said, "Look, I know this has just come out, and we both know that we like using NUBEQA because of the side effect profile, but for these people with high-volume disease who I would oftentimes consider chemotherapy anyway, now we have an opportunity to do this triplet therapy. Because of our long-term relationship, he immediately said, "Look, you send these patients to me, I'll give them chemo, send them right back to you, and then you guys can manage them from there." That's kind of what we've been doing basically ever since triple therapy has come out. I think our relationship is founded on mutual respect, which I think is unique in the relationship between medical oncologists and uro-oncologists.

Alicia Morgans: Thank you for that. What an incredible way to collaborate with each other and to really be on the front end as these therapeutic advances come out. I'm sure that's part of what makes your relationship so successful. When these patients come in, how is it that you know they're going to be a patient that you need to get over to Brad? How do you make that connection happen, Paul, and then we'll hear from Brad. How does he take it from there?

Paul Eber: Obviously, we're seeing lots of people with metastatic hormone-naive prostate cancer these days, and some of them are not these high-volume people. Even though the clinical trial for triplet therapy didn't specifically say high volume, low volume, I think most of us feel comfortable with just double therapy, if you will, for patients who have lower volume metastatic hormone-naive prostate cancer, at least for me personally. It's usually these people that have high-volume disease.

For us in our relationship, I literally will either in the middle of the clinic or immediately after the clinic, just text Brad, "Hey, you got a minute," and he'll immediately call me back. It seems like almost no delay. We'll talk about the patient. I'll send him the information and seamlessly those patients are in to see him within a few days. Me personally, I have no concern about whether I'm going to see that patient again. I don't even set up an appointment for follow-up at that point. I just wait to hear back from Brad saying, "Okay, we finished." Now my ABCC nurses will be seeing those patients because oftentimes we've already started them on NUBEQA. We're giving them either ORGOVYX or LUPRON or some LHRH drug. They're seeing them to maintain their therapy. We initiate that therapy here, send them to Brad, and then we get them back after they complete their chemo.

Alicia Morgans: That's great. Brad, how does that work on your end? You get a text, how do you work together to make sure that's so seamless? How do you know when it's the right time to send that patient back? Not that they're necessarily severing the relationship because they're still getting their ADT and their oral agent, but how do you know when it's the right time to send that patient back to Paul?

Brad Somer: Yeah, sure. When Paul calls, obviously I answer the phone. That's the first step. Once he gives me the information to call them, I'll just get them in, see them as a new consult. Then essentially, as any patient with newly diagnosed hormone-sensitive prostate cancer, you do the checklist of what should be done, what I usually would do, and that might include, are they on a bone resorptive agent? Have they been tested for genetics? Those kinds of additional issues. Is their pain well managed? Are there any social determinants of health, other components that color the conversation? With Paul, I know it's pretty much done because most urologists in a general practice wouldn't necessarily focus on the comprehensive component of a patient with metastatic disease or don't necessarily have the resources to. There are additional dimensions that I might add to that case rather than just chemotherapy.

With Paul, he is obviously thinking about the entirety of the patient. Essentially, that's already been in progress. Also, trying to get the oral medications is sometimes a big hurdle. That's also something that is well down the path or already done. For the most part, it's all about getting the patient tucked in, cared for, another set of eyes, which I always think, again, I think that prostate cancer, in general, is a team sport. When you have eyes coming from different dimensions, sometimes there are additional components that might take a look, maybe there's a neuroendocrine component, or something that is an additional set of eyes that can add to it.

Usually, for the most part, for the conventional patient, it's pretty straightforward because I can just get them plugged in, give them their chemotherapy, and get them through that. Obviously, a lot of these patients just do fine by the end of their treatment. Through the whole time, I'm telling the patient we're working with Dr. Eber and his team, and at the end, we basically will say, "Dr. Eber and his team have got this, we will get you plugged back in." Then I wouldn't necessarily say goodbye, but I might de-intensify the frequency of the visits to just check in from time to time, just to add an additional set of eyes down the road and stay in communication with Paul or Amy from his team on the patient down the road, which is usually quite straightforward.

For the most part, it is exactly as Paul said. It's just a matter of recognizing the fact that Paul has focused on this area. He's created amazing expertise in this area. For me, it's just about making sure that the patient gets the best possible care that they can get and has every component of care. I think we all are comfortable with that and respect each other for that. That's kind of how the patient walks through my clinic, I think. Did I get that right, Paul?

Paul Eber: Yes. Well, and I was going to say, Alicia, one of the other things I think that's important for us is that I spend a great deal of time initially educating the patient on why I'm referring them for chemotherapy. I failed to mention that earlier. I think that's probably the most important thing that we as urologists can do. We go through extensively and spend, certainly, a patient like this needs time, regardless of their educational level, they need to understand what's going on. We explain to them what each of these drugs does. I even go into, to some degree, the fact that we have this clinical trial that showed that this is the most effective way to manage these patients. I'm not doing this for willy-nilly reasons. I'm doing it for very specific reasons, and that they are a unique patient in their high-volume disease.

I think education on the front end makes it a whole lot easier for Brad when Brad sees those patients so that they can understand why it is that they're going to see him. Oftentimes, it's because they have high-volume disease, but also we want to be able to take advantage of this oral therapy that has such a good side effect profile. The education piece, I think, is the most important thing for me, and we spend a good deal of time on that.

Alicia Morgans: I love that. I want to just make a quick callout to that. When the urologist explains why the patient is going to the medical oncologist and also can say, "You're still following with me for X, Y, and Z reasons, and you'll be back," it makes a huge difference to the patient. I'm sure Brad and I have both seen patients who come through the door and say, "The urologist just said, it's time for me to see you now, and he didn't make a follow-up appointment." That is really stressful for a patient. Whether that happens on purpose or whether that is the patient maybe didn't hear or whatever it is, if it doesn't happen with that education piece, it can be really stressful. I love that you call that out and that you make sure that we're all aware that you do that.

Now, one of the things that I just want to ask Brad about, because I love this piece of what you said too, is that there is a lot of stuff that we need to do in advanced prostate cancer care beyond just ensuring that that patient gets ADT, chemotherapy, and the AR signaling inhibitor here, that triplet therapy. There's bone health, there's genetics, germline and somatic, there's ensuring that the patient doesn't need palliative radiation or doesn't need maybe a catheter for urinary obstruction or maybe a percutaneous nephrostomy tube for some obstruction of the kidneys. There's a lot of additional care that we need to consider.

I wonder, Brad, and then I'll ask Paul, have you had specific conversations around, "You do this, I do this," or does that organically happen? Do you just see what Paul does and kind of make up the difference? How do you as a team suggest that other pairs work on this in their own practices? This is one of the other important things that we do together, we have to share all of those pieces. Brad, what do you think?

Brad Somer: I don't think we've ever necessarily had a formal conversation about who does this, who does that, but there have been conversations on, "If it's done, then this," or I might ask, "Are they on a bone-targeting agent already?" Usually, it's been started, or at least the insurance has been looked into about which one might be given or whatever it is. The genetics is usually cooking and we have a molecular relationship with one company, and Paul might use a different company or whatever it is, but these things sometimes come back and sometimes there's an interpretation that's required or additional interrogation needed. We have a molecular tumor board that meets weekly, and essentially if there are any questions, we can go to that. We have a genetic counselor on staff. If there's any additional dimensions that might be required to be looked into, there's that additional component.

For the most part, the vast majority is pretty straightforward, right? There's not been a real conversation on who does what, but I know that most of the things have already been taken care of, or at least initiated when they come and see us. I'm just kind of filling in and checking the boxes to just make sure that together we aren't missing anything. It's just an additional check. Sometimes I'll circle back to Amy, who coordinates the care for these patients for Paul, and ask them, "Was this done or was that done?" For the most part, it is a joint effort.

Alicia Morgans: I love that. Paul, for those urologists who are trying to forge these relationships with their medical oncologist, do you recommend an official conversation or is it you do what you're comfortable with, the other person does what they're comfortable with, or a strategy like you and Brad have, which is actually similar to what my urologists and I have, which is, or my urologists, there are many that we all work together, but we just double-check everything and we fill in the blanks where those things are necessary. What are your recommendations?

Paul Eber: Yeah, medical oncologists have been doing genetic testing, molecular testing, germline testing for their whole careers, and it's something relatively new for urologists. Of course, with PARP inhibitors, we need that information. We routinely are getting somatic testing immediately on the tissue specimens as soon as we get a positive biopsy. It used to be that I would get somatic testing, and if there was an HRR mutation, then we would send germline, especially if it was BRCA. Now, we're just getting germline testing on all grade group fours and fives or high-risk threes, which is what the guidelines are telling us to do. At least we try to remember to do it all the time. It's not something that's been ingrained in our brains like our medical oncology colleagues. We try to get that on everybody because we're already sort of setting up what options, how many arrows do we have in our quiver to treat these patients?

We have a whole folder full of people who have HRR mutations who are still on their first line therapy, whether they're on triplet or finished their chemo and now just on an oral and an LHRH, or they're somebody that's just been on double therapy all along. We know that we've got a PARP inhibitor in our back pocket when we need it because we already know that they have their mutation.

I think one of the other things that after I educate my patients and tell them I'm going to send them to the medical oncologist, I let them know that we kind of do have a team, and that although the patient will finish his chemotherapy there, come back to me, those patients are all going back to Brad, sadly, at some point. If they come in like that, there's a high chance that they're not going to be real long-term responders to therapies, and they may need something else that Brad has that I can't offer. I have almost an equally good relationship with one of his radiation oncologists. If I have somebody that walks through the door, for instance, with severe bone pain that we can't manage with fentanyl patches and Percocet, we'll send them for radiation, spot radiation, get them started on therapy, send them to Brad, and all three of us will be working together to manage that patient.

Alicia Morgans: Well, I just love your collaborative and comprehensive approach to these patients. I think you've given the listeners so much to think about and to strive for as they're trying to elevate these practices in their own clinics. Final word from each of you: recommendations to the listeners on how they can be most successful. Brad, we'll start with you.

Brad Somer: Yeah, I would add one other dimension to it as well, is an offering that I think is probably the most important thing for the patients: advancing their care because we obviously don't have everything for them. There's clearly, I think, a respect from the urologists for advancement in clinical trials is important. Whenever a new therapy is initiated, we always have clinical trials that are open and close and open and close and all that. To stay in communication about, do we have a clinical trial together or should we refer the patient to somewhere else for a clinical trial, I think this is an important way because the only way that we're going to continue to make these great advances for our patients. I think that together, if we focus on that, I think that that's something that is important.

I think Paul, the additional thing that I respect, is that whenever he has that kind of patient that he clearly could go and give another AR signaling agent or some other therapy, he's thinking about that. I think it's to think just beyond yourself. I have this that I can do, but someone else might have these other things. As Paul said, how many quivers do we have to give the patient down the road if we think about it, how many quivers do we both have or do we all have, or are there out there? Then we can make additional advances for the patient.

Alicia Morgans: Thank you. Thinking beyond yourself and putting the patient first for all opportunities is a wonderful message, including, of course, clinical trials. Paul?

Paul Eber: Yeah, I go to a lot of meetings, as you guys do, to advisory boards and things like that. I do seem sometimes to be the odd man out in having this kind of relationship. I don't know that this is, it may just honestly be Brad's and my personalities just work together. Neither of us feels like we're the man, and we need to take this patient. I think sometimes my urologic colleagues feel like medical oncologists in their community perhaps don't respect what they do as advanced prostate cancer clinic managers.

I don't know what the secret sauce is. This is not something that Brad and I had a huddle about 14 years ago and decided we were going to do this. It's just something that kind of worked. I think that it's just because we both respect what each other does, and maybe that's the most important thing is for people on both sides of this to make sure that they're keeping what's most important, and that is patient care first, and whoever can do it and do it via guidelines-based medicine and help our patients to live longer and have a good quality of life, that's the most important thing.

Alicia Morgans: Well, that's a wonderful message to end on. That mutual respect to collaborate with the patient first is a wonderful way for us to move forward. Thank you so much for your time.

Paul Eber: Thank you.

Brad Somer: Thanks.