Read the Full Video Transcript

Alicia Morgans: Hi. I'm so excited to be here today to talk about patients with metastatic hormone-sensitive prostate cancer and how we collaborate between medical oncology, urology, and of course others across that continuum of care. We have two doctors here with me today. I'd love to have you both introduce yourselves. We'll start with you, Damian.

Damian Sorce: My name's Damian Sorce. I am a urologist in Denver, Colorado, with Colorado Urology, and I lead the Advanced Prostate Program for our group.

Alicia Morgans: Wonderful, thank you. And Manoj.

Manojkumar Bupathi: My name is Manoj Bupathi. I'm a medical oncologist, just primarily a GU medical oncologist in Denver, Colorado, with Rocky Mountain Cancer Centers and Sarah Cannon Research Institute. I lead the GU research team for Sarah Cannon as well in Denver as well as nationally.

Alicia Morgans: Fantastic. So, two highly qualified doctors who work together on a daily basis. Damian, can you share a case that you've worked on recently?

Damian Sorce: Sure. I mean, it's funny. Just happened just a few weeks ago. So again, I do the advanced prostate cancer. So my partners will send me patients who have newly diagnosed or very high-risk localized prostate cancer. And so, a patient who had just had a PSA maybe six months earlier was in the two-ish range. He had a TURP because he was in urinary retention by one of my partners. Pathology came back as a Gleason nine. My partner did the completing metastatic workup showing widely, widely metastatic disease. This was a 66-year-old super healthy guy and sent him to me.

So clearly, when someone's like this, we want to start them on hormone therapy, an oral, and consider triplet therapy. Pick up the phone. I think having a phone number, either way, the medical oncologist needs to talk to the urologist when they need procedures done and when I'm considering chemotherapy or research studies, I will talk to Dr. Bupathi. We have tumor boards. Those take months, weeks to actually present them. The patient in the room wants to know what's going on, pick up the phone, "Dr. Bupathi, I have this patient here. Here's the deal. What do you think?" And I started him on the hormone therapy, so Darolutamide and Orgovyx, and sent him to Dr. Bupathi for the chemotherapy.

Alicia Morgans: Wow. I love that rapid communication because, especially in our practices as they become bigger, they need their own space and even as they are initiating in private practices, they aren't in the same geographic location and email even can take hours to days to hear from somebody, but if you have the cell phone, you can make what's a physically separated practice actually really come together in moments as you just mentioned. So Manoj, tell us, how did that conversation go and how do you manage when you get the call and you think, "Well, now I have to take the next steps for this patient?"

Manojkumar Bupathi: Yeah. So fortunately, we've perfected this over the last few years. It is always a work in progress, but partly because of staffing. So that's where the issue becomes, but I think both of our staffs are very accustomed to this, and so we've kind of streamlined the process. So to kind of lean onto what Damian mentioned, once I get the patient information, I literally have my MA and my scheduler reach out to the patient that same day or the next morning, and I'm usually seeing the patient within 48 hours. And so I am already familiar with the story; I've just heard the story, and so I think patients are really appreciative because it's a very clean transition and handoff in the sense that I know the background. We review the background really quickly and then we really spend our time focusing on data and really understanding why triplet therapy or why doublet therapy, genetic testing, and what kind of genetic testing, "Why are we doing it? How is this going to help us now? How is this going to help us later on?"

So while Dr. Sorce starts the conversation and introduces those topics, we reinforce those topics and emphasize the importance of why we're doing it, how long we're going to do it, side effects, and all those things. And then we start on chemotherapy. This specific patient started on chemotherapy within a week of me getting the information from Dr. Sorce. That's similar to most of our other patients as well. So we'll see the patient and then I'll see the patient usually once every three weeks prior to chemotherapy, and I'll have them see Dr. Sorce once every other cycle or every third cycle to manage the ADT as well as the NHA, and we'll co-manage the side effects relating to both these drugs upfront.

Alicia Morgans: That's fantastic. And I love the way you alluded to Damian starting the conversation around a lot of these topics and you picking up and reinforcing. And I think that kind of messaging where it's coming from both of you must be really powerful for the patient and must be really, I think, reassuring in some way that it's truth and that it's really necessary and that it all is really in the best interest of the patient. What do you think, Damian?

Damian Sorce: You picked up on it perfectly. I think patients will remember 10% of what I tell them. It's the first time they're hearing it. It is overwhelming. I try to write things down, but I know when I'm on the patient side, everything makes sense when you're in the office, and you leave and things become jumbled. And so it's really nice to hear a consistent message and the information over again and after they've had time to sort of calm down and come to terms with what's going on, and I think that's why we work as a really good team. It's very concerning for patients when they show up and they hear something different. And so Dr. Bupathi and I are on this. We've already discussed the case, or we're already on the same page, so they're hearing a consistent message.

Alicia Morgans: That definitely makes sense. And it's nice that you work so closely together. You share so many patients that you know what that message is going to be. How do you make sure you're on the same page? When triplet therapy first became an option, when we first heard data, whether it's PEACE-1 or ARASENS, that this might be an approach to use, how did you guys come to the conclusion or come together around potentially using this approach to treatment, Manoj? What do you think?

Manojkumar Bupathi: So it's actually an ongoing discussion. So Damian will call me. He'll see a patient in his office and he'll be like, "Hey. I have this patient. X years. Seems like a fit guy to me. I think he needs triplet therapy. Let me know what you think, evaluate, and then we'll figure it out." Okay. So then I'll have the patient come in and while Damian's very good at what he does, I think chemo eligibility is always a little bit challenging for those that don't do it all the time. And like I said, Damian's amazing at figuring out who can get chemo and who cannot, but it's not an easy thing. And so I'll see them and it'll be, "Well, I agree with you," or, "I think I'm worried about A, B, and C," in which case then I would say, "I wouldn't do chemo. I think you should just do the doublet therapy."

"Let me know if they progress and we'll go from there." And that's kind of how we would leave it. And I will let the patient know saying, "Hey, you're in great hands because Dr. Sorce knows what he's doing and if he has any issues or concerns, he'll always reach out to me. And if I think there's a new trial or something else, we always talk at tumor board or he'll hear about it in one of our various forms of communication. And if you're a good fit for it, he'll have you come see me again for evaluation for that specific option."

So that's usually how we do it, and for this patient that Damian was giving you the example for, it was very clear that this patient needed triplet therapy just given the high-volume disease, high-grade disease, extensive disease, younger age. So there was just no question. But unfortunately with prostate cancer, that's not always the case, and we'll see patients that are in their 80s and they may not be suitable for chemotherapy, and that becomes more of a conversation that we both have. And I'll see the patient, I'll call Damian back, and be like, "Hey. This is what I think and this is what we need to do."

Alicia Morgans: That's great. I love that you guys have the system where, even while patients are getting chemo, they're still going back to the urology team and they're going back and forth and really engaging over time with both teams. How did you decide that that's what you want to do? Did you just fall into that? Do you kind of talk over time about that, or how did that come to be, Damian? What do you think?

Damian Sorce: I hope I'm not going to step on what Manoj just said, but I think it just sort of fell into place. We have been working together. Both of us have been in the same practice area for years and years and years. And as prostate cancer treatment develops more and more, it just sort of meshed, and that's just the way I think it has become. I think a lot of it was that we were, at first, I practiced a lot just across the street from him, and so we had seen each other a lot at the hospital, become friendly, get cell phones. I think if you don't have that sort of friendly relationship before, it can be a little harder, but I highly recommend anyone just picking up the phone, calling through the office, that's the hard part, and then getting the cell phone. Getting through the staff is the hard part usually to try to get to another provider. So cell phones to me are key.

Alicia Morgans: Yeah. I could not agree more with that. And I wonder, Manoj, from your perspective, how this dance that you do and the way that you support these patients collaboratively, how would you suggest that younger practices or practices that don't have those relationships try to build up that rapport and that level of collaboration?

Manojkumar Bupathi: And Damian, please don't get me wrong when I say this, but I think it's more of the medical oncologists that I'm speaking to, not the urologists. And what I would say is that I think we have to understand from a medical oncology perspective, there was nothing in GU cancers for a long period of time. Urologists have been taking care of these patients for an extremely long period of time, and they know what they're doing. And I think there's a lot of apprehension from medical oncology thinking that they may not know, and that's not the case. And I think we have to give our urology colleagues a lot of credit. They know what they're doing when they're managing a lot of these advanced prostate cancer patients, and they know what they're doing when they're managing the side effects of these prostate cancer patients as well. So I think having that level of trust is super, super important.

And then that leads to communication. So they both kind of go hand in hand. So I think a lot of us worry that, "If I am not involved all the time, what's going to happen? Who's going to be responsible? The patient's going to crash," things like that. And to be honest with you, that's not the case. We haven't shared a single patient that "crashed and burned" and where we were like, "Should somebody have done something different?" We've never had that experience, and that's partly because we have that open relationship. We know our limitations. We know that if there's something going on, then we can rely on each other. So for me, I know that the patient's going to be fine if I send them back to Damian, and I don't need to worry about it. And I think that's a key thing. It's not only managing the patient, but it's also trusting your urology colleagues to know that they know what they're doing, and that is okay. That is perfectly fine. At the end of the result, we want the patients to have a good outcome.

Damian Sorce: I was going to say, I think part of our relationship is that we have a larger urology group. We have me who specializes in probably half my patients are advanced prostate cancer patients. And we have Manoj who's the head of GU nationally for standard-of-care research. So he specialized. Both of us specialize in this since we both know what we're doing. That's not, I hate to say it, not always the case throughout the country. Everyone on the call probably knows that, unfortunately. And so every individual situation is going to be different, but the key is going to be communication.

And so even if you're not specializing in this, you're dabbling and the other side's dabbling, you guys can come up with a very good game plan if those are the only options in your geographic area, but as long as you're communicating, I think it's okay. The problem becomes when there's a lack of trust on the other side. From a urology standpoint, "Well, I'm sending it to an oncologist, but he deals with four prostate cancer patients a year. He may not have any idea what they're doing or she has no idea what they're doing." So communication is, I can't stress that enough, is the key.

Manojkumar Bupathi: Also, from a medical oncology standpoint, I think in community practice it really needs to get divided just very much like academics, where it shouldn't really be a general oncologist. I think the concept is changing and, from a community standpoint, that's going to be important going forward, is that there are certain focuses and that will actually help build the relationships and ultimately lead to better patient care.

Damian Sorce: And this is also a big difference from any academic practice. So in academia, for the most part, my understanding at least in this community, as soon as they're on ADT, they're gone from the urology standpoint. It's very strange. In community practices, especially large community practices, it's the exact opposite. And so I think both urologists and oncologists in the community are trying to figure out how this new world is developing very rapidly and how we're going to share patients.

Alicia Morgans: Well, I think the keywords there are share and, to your point, communication and trust. And I love that you're really acknowledging that not everybody is a specialist on the medical oncology side or the urology side. There are people who do not see a large number of these patients, and that can be okay as long as there is communication to say, "This is happening. Help me with that," or, "Help this patient." And there's trust that the person is going to be there to help ensure that the knowledge is gained and that the patient is on the right track. And I think as we work together, whether we're in academics or whether we're in community practices, if we keep those things in mind, I really think that, to your point, we can get the best for these patients. So as we wrap up, what would your message be as you're thinking about your collaborative care in metastatic hormone-sensitive disease? What is your message to the listeners, Manoj?

Manojkumar Bupathi: So I think it's kind of what we've been talking about, what you just said. It's really, you have to communicate, you have to be somewhat flexible, right? That's important. The other thing is keeping each other up to date. There's a lot of things that are happening locally for local regional prostate cancer that I'm not aware of that Damian is amazing at. I don't know what to do for a patient that has local recurrence within the prostate that already had radiation and had surgery. He's my source.

And similarly, what's happening in advanced castration-resistant prostate cancer with all the new drugs? I'm his source. So I think we both have respective areas within the prostate cancer field that we contribute a lot to, and that's important to acknowledge and important to keep building on to advance this care overall. But communication, trust, and again, those two are probably the most important thing, and then tumor boards and such, just keeping apprised of each other of what's going on.

Alicia Morgans: Great. And Damian, what would your message be?

Damian Sorce: I don't know if I can add anything. That was really good. I just have to second everything that was just said. So I think part of it also is leaving your ego aside and knowing that you don't know everything. And I think that's one of the faults of a lot of doctors is they don't want to tell patients they don't know. I think that's actually a good thing. I think patients are very appreciative if you say, "This is outside of what I do. I am not really sure. I'm going to send you to an expert in this." So I guess that would be the only thing I could add.

Alicia Morgans: Well, that's fantastic. I so appreciate the two of you taking the time to talk through the way that you work together to take care of these patients and ensure that collaboration includes good communication and egos aside. So thank you so much for your time and your expertise.

Damian Sorce: Thank you.

Manojkumar Bupathi: Thank you.