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Alicia Morgans: Hi, I'm so excited to be here to talk about metastatic hormone-sensitive prostate cancer, these high-volume genomic metastatic patients. That can really be a challenge, especially as we try to work collaboratively across our practices of urology and medical oncology. I have two wonderful team members here today to talk. I'd love for them to introduce themselves. Jonathan, why don't you go first, please?

Jonathan Henderson: Great. Thanks, Alicia. My name's Jonathan Henderson. I'm a urologist practicing Uro-oncology in Little Rock, Arkansas, at Arkansas Urology.

Alicia Morgans: Fantastic. And Sunil.

Sunil Kakadia: Thank you, Alicia. My name is Sunil Kakadia, one of the medical oncologists from Genesis Oncology, and it's a pleasure to be here, part of the GU Oncology.

Alicia Morgans: Wonderful. So you two were really selected as a pair that works collaboratively together. We know we've got a big urology group, and we have a wonderful group of medical oncologists. And finding that interface, finding the way that we can best work together to get the best outcomes for our patients, particularly as they have high-volume metastatic disease and can be quite complicated, is difficult. I think we wanted to really highlight some of that collaboration around a particular case.

And, Jonathan, I think this was a case that presented a gentleman who presented through the emergency room, came into the hospital. It sounds like PSA over 700, really felt quite despairing that he had just not been feeling well, peri-suicidal it sounds like, came into the hospital. When you see a new patient in the hospital consulted, maybe even for obstructive symptoms in that workup, how do you really approach that patient? How do you go through that? Because in the hospital, it can be even more challenging, though we can get our scans more quickly sometimes.

Jonathan Henderson: Yeah, absolutely. Well, normally, the pressing symptomatology is the inability to void. Like this guy was in retention. Oftentimes, they have some aspect of renal failure as well, so you have to manage those symptoms first. It's not usual to get a PSA in that setting when you're in retention because, as you know, they're sort of wacky. But his PSA was like 2,800 or something like that. And in retention with a catheter, either way, it's a little iffy, but we try to get the presenting problem taken care of in the inpatient setting and then do the workup as an outpatient. And there's a lot of reasons for that, but mainly because we have the ability to have everything all in one site at Arkansas Urology with the surgery center to do the biopsy pathology to do the diagnosis. And so we get it all done there. So in this situation, we made sure that he wasn't suicidal and his creatinine stabilized, got a catheter in, so his bladder's draining now, and get him back home, and then worked him up as an outpatient.

Alicia Morgans: That's so important. And I think, especially, getting tissue in the inpatient setting can be really, really challenging. And medical oncologists are usually sticklers, no tissue, no treat. And there are many other phrases that are very similar. So I'm glad that you and your team were able to get those scans, get the biopsy. And, Sunil, how do you connect with Jonathan and his team members in urology? How do you make that pass-off, make that transition when it's clear a patient needs to see the medical oncologist for systemic treatment in this kind of setting?

Sunil Kakadia: So typically, in cases like this one, Dr. Henderson, as already mentioned, would have undergone a short follow-up, discussed the clinical impression. He may have gone for a prostate tissue biopsy. And once it's confirmed, we would have... If it is time-sensitive, which is the case too, I would pretty much get a call from Dr. Henderson or Dr. Henderson's nurse practitioner or nurse to my nurse navigation team. And we would get this patient in as quickly as within a matter of several days. Most of the time, these cases already have the imaging performed. We have the tissue biopsy confirmed, and even somatic mutation testing is also already done by the time the patient reaches my clinic. And they would have already had the discussion regarding the ADT or NHT, and subjective approaches.

Alicia Morgans: Great. So does that happen typically with the urology clinic, then, Jonathan? Do you guys usually start the androgen deprivation therapy and maybe the oral androgen receptor signaling inhibitor? Do you leave that to the medical oncology team? How do you coordinate that aspect of care?

Jonathan Henderson: Yeah, good point. We typically do initiate it if, in some situations, not this particular patient, but say you had a patient who is more of an intermediate-risk strata and there was some wiggle room with ADT on longevity or how long you give it, we might not initiate it until we coordinated with radiation oncology. But a de novo metastatic high-volume HSPC patient like this, they're going to need ADT. And so we're going to go ahead and have that conversation and discuss that with the patient as well as everybody who gets ADT. We're going to do a bone health assessment, a FRAX score, and discuss that as well. We don't want to overlook that. I think that's one aspect that a lot of clinics forget about. If you look at so many of the studies that we've had over the past 10 years, like 10% of the patients have their bone health addressed. And I think that's something that we don't do well.

Alicia Morgans: I agree. And it's important certainly to do all those supportive things. And in our clinics, mainly medical oncologists are doing genetic testing, but it sounds like that's actually often spearheaded by the urology team for you guys. Is that the case usually too, Jonathan?

Jonathan Henderson: Yeah, so we have an arrangement with our pathologist where there's a standing order. Anybody who's in the high-risk group, their tissue automatically goes for somatic testing from the biopsy itself. And that way, we don't have any delay in getting that testing. So usually, by the time a patient is seen back to discuss the biopsy results a week later, we have not only the histology report, but we also have the somatic test as well.

Alicia Morgans: Wonderful. So, Sunil, is germline genetic testing something that you and your team work on then? Or how do you share that with the urology team?

Sunil Kakadia: Typically, that has already been discussed, and if indicated, that has already been ordered; it may not be resulted just yet because of how quickly we get these patients in. And we'll just end up discussing that at a subsequent point.

Alicia Morgans: And when you're thinking about chemotherapy, so this patient has high-volume disease, is it quite reasonable to use triplet therapy in this setting? Do you find that you're the one who is really kind of broaching that subject with the patients? Or do you feel like the urology teams that you work with so closely are often kind of giving some warning shots or sharing with the patient before he even gets to you that they may need to potentially also add chemotherapy? Who introduces that, and who really kind of finalizes that consideration?

Sunil Kakadia: So that's a good question. In our monthly tumor board, we do discuss these cases, which is a multidisciplinary; we have radiation oncology, medical oncology, along with the expert urology team. So, in that tumor board meeting, we come up with a consensus or indication on the triplet therapy. A lot of times, if the tumor board is far away, let's say three or four weeks out, we just finished one. And if I have a case that is already referred to me, a lot of times the urologists would have already at least had some preliminary discussion that this is volume burden, this is where you are in your spectrum of disease at the time of diagnosis, and maybe this is what you need to discuss with the medical oncologist and [inaudible 00:08:18]. And then I take it over from there, further discussion.

Alicia Morgans: Yeah. And Jonathan, do you feel... It sounds like the urology team is kind of setting the patient up to understand what to expect, which probably makes it easier when those conversations are broached by other providers down the line. Is that something that you and your team do consciously? Is that something you do to try to facilitate that continuity of care even though you are in different buildings and in separate practices?

Jonathan Henderson: Yeah, that's a great point. I think we learned historically that these patients are scared and confused, and we need to do everything we can to smooth their path for them. And when they're not getting consistent messaging from provider to provider, that makes things even worse. And so our job is at the front end to sort of set expectations and gently lay the foundation there of what possibilities there are. And then that way, when Dr. Kakadia comes in, it's not a shock because so often some of my colleagues call it the Charlie Brown Teacher Effect, right? The patients hear you've got cancer, and after that, all they hear is "want want want." And so we don't want that underwater sound to go on. We want to prepare them and try to make it not going to be a pleasurable experience, but it has to seem coordinated and cohesive.

Alicia Morgans: Yeah, I think that's so important. I'm sure that's appreciated when the patient gets to you that they've kind of heard these words before. Now, Sunil, I wonder how did this patient fare and what other issues may remain for this patient, and how do you address those?

Sunil Kakadia: That's a very good question. So this particular case, he has a history of hypertrophic cardiomyopathy. He has renal disease, chronic renal disease. He has psychiatric comorbidity. And so it requires delicacy and more attention than usual cases. And he's just 52 years old. So when I talk about systemic therapy with him and the long-term side effects, including the pulmonary artery disease or anything related to his heart health, that is a very sensitive topic from his perspective. So you have to be very careful. You have to lay out the data, you have to make sure his cardiac health is optimized. You talk to the cardiology, which I did for his cardiac team to make sure that they understand what he's on so that they are on top of the periodic assessments for his... Even if he needs a cardiac stress test, make sure that he has a psychiatrist that he follows or psychology counseling that he follows.

Somebody in the family is aware of what he's going through, what treatments he's on, and what other side effects they should be watching for him. Because ADT and NHTs, they will have some effect on psychological health as well. So this is an important aspect of his life to monitor along with like Dr. Henderson mentioned about the bone health and so forth.

Alicia Morgans: Great. So it sounds like for this patient, he had ADT, and I believe you said darolutamide and six cycles of docetaxel. Sounds like he had a pretty nice response but continues to have some concern around urinary obstruction. And that is absolutely, at least in my view, always a wonderful thing for the urologist to take care of. And it's great that you have such nice collaborative care, and you've got a urologist on board who can help to deal with that. And now I wonder, Jonathan, as you think about these things, how do you approach this after a patient's been on therapy? Obviously, we all hope that they can pass a voiding trial that the prostate's shrunken down if they've been through all this systemic therapy, but it doesn't always happen. What do you do as a urologist to try to close the loop on that and try to avoid having patients with indwelling catheters in perpetuity?

Jonathan Henderson: Yeah, yeah. So not just indwelling catheters, but indwelling ureteral stents too, right?

Alicia Morgans: Yes.

Jonathan Henderson: This guy had some reflux nephropathy from his retention, and fortunately, that resolved and it became just a voiding issue. But either stents or catheters, we want to get rid of everything if possible, right? Because the guy obviously has some limitation on his life expectancy. We want to give him quality of life as well. I'm not hesitant. Once we've given the patient a fair trial at voiding, after his ADT, after his chemo, and downsizing the tumor burden, if he's going to fail, we're going to take him back for a TURP.

Alicia Morgans: Great. I think having that communication, saying, "Okay, you know what? He's finished with systemic therapy, at least from the intensive chemotherapy piece. We're still on ADT and a novel hormone therapy ongoing until progression. But it's a good time now that we really need to kind of make a decision." I think that's great. And in my clinic, this patient was clearly in a crisis situation when he came in, but when possible, I try to get that catheter out before I even use the chemotherapy because I always worry about urinary tract infections that night and the potential for things to go wrong. So as you guys think about this, I'd love to hear closing thoughts. How do you communicate between tumor boards? I'm sure you have to talk more than once a month. So how does that happen when you're in different buildings?

Jonathan Henderson: Yeah, so text, generally, I will text Sunil or vice versa. The patient. For example, this patient may be in his office, and he'll text, "Is it time for voiding trial?" Mr. So-and-So has finished his chemo; he's as good as he's going to get. So text or phone. And if we're not immediately available, we can get each other's staff. It is funny, the whole question of communication has historically vexed our collaborative efforts, and still, it's a holdover even in the day of cell phones. It is completely just patterns of behavior. There's no rational reason for why we don't communicate readily. Our children do; they communicate instantly. And so I think, to me, this is the real topic that we need to explore further: why is this even a question? It should be automated. Every practitioner should communicate immediately with each other, but we don't. Fortunately, I think our relationship is such that we're getting better at that.

Alicia Morgans: Absolutely. And Sunil, would you agree? I hope you're not sending Instagram or Snapchat back and forth to each other. My kids seem to do endlessly, but absolutely, we should be able to get each other very clearly and easily. There shouldn't be these barriers with using our cell phones. We used to page each other. That was a pain in the butt, but now we can just send a little text, get each other on the phone in between when we're both free. Sunil, how does that work for you? How do you feel that communication goes?

Sunil Kakadia: So first of all, communication is part of that collaborative approach. So if there's no communication, patients will sense it. They know how much you communicate between the providers. I typically make a point where I would have Dr. Henderson's nurses' direct access or excessive phone extension number or some way of communicating where I can take care of some care coordination. And that is true for different urologists, nurse practitioners, PAs, the nursing or lead nurses, nurse navigation, all these numbers. So at least you have a message delivered with a potential action plan. And most of the times, there will be an agreement between the two teams, and you take care of things in real time rather than just playing phone tag.

Alicia Morgans: Yeah, I have to say, I think that some of the most rewarding parts of medicine are actually those collaborative communications where you feel so good that you just helped that patient in real-time, and you feel so good that the loop has been closed, that there's not some ongoing crisis for the patient. So, final words, what would you both say? We'll start with Jonathan. What's your recommendation to practices that are trying to emulate and do this collaborative care just like you and Sunil? Jonathan, what's your message?

Jonathan Henderson: Well, thanks for the platform for allowing us to discuss this. I think it's something that's getting better organically in our practices. It is very rewarding. I think the patients are really surprised when they find out that things can come together that cohesively because they expect less. And I'm sorry that's the case. But today, it's easy. I mean, there's no reason other than stubborn adherence to the past that anybody in any situation in our country can't have a real-time collaborative effort like we do. That's my belief.

Alicia Morgans: That's raising the bar, and it is doing so in a very appropriate way. So thank you for that. And, Sunil, what would your message be?

Sunil Kakadia: Communication and knowing each other's team members. That's probably the best way to set this up. Once you have achieved that, I believe we can minimize the urgent care visits, ER visits, and stress that the patient has with some time-sensitive issues and complications, which is actually a very powerful factor. Like, who would want their patients to go to the ER and urgent care for trivial complications? So if we can minimize that, the journey for the patient becomes much more manageable. They feel comfortable and confident and have their faith in their doctors. So it's very important.

Alicia Morgans: And their doctors feel like they're doing something right too. I think you get a good sense when you're doing the right thing for people. So, thank you so much for taking the time today. I so appreciate you sharing your expertise, and we look forward to talking again. Thank you so much. Bye-bye.

Jonathan Henderson: Thank you.

Sunil Kakadia: Thank you.