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Zach Klaassen: Hi, my name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia, and I'm joined for this UroToday discussion with Dr. Vahan Kassabian, who is at Advanced Urology in Atlanta, Georgia, and Dr. Sreekanth Reddy, who is at the Cancer and Blood Specialists of Georgia in Atlanta, Georgia. Today we're going to be discussing the continuum of care for prostate cancer patients, specifically those with metastatic hormone-sensitive prostate cancer. Gentlemen, thank you so much for your time and joining us today.

Sreekanth Reddy: Thanks for having us.

Vahan Kassabian: Thank you.

Zach Klaassen: We all know the ARASENS data, and we all know that treatment intensification, even with doublet therapy, has been sort of lacking in uptake, so today we're going to focus on basically a patient or patients that you guys share between yourselves and focusing on the collaboration with triplet therapy based on the ARASENS data. The first question I'll ask you is, for our listeners, how did you guys find each other, how do you collaborate, and what was that relationship development?

Vahan Kassabian: Yeah, I guess I'll start. I've known Sreekanth for many, many years through working on mutual patients in urological oncology. I've been in Atlanta for about 30 years, close to 30 years, and he's been here quite a while as well. So we've had mutual patients throughout the years, and there aren't many medical oncologists who have an interest in urological oncology, as you know, and in a city like Atlanta of 6 or 7 million, there's probably less than a handful who have a really keen interest. That's where their relationship developed. And of course, now for the subject of our talk, which is triplet therapy, that sort of relationship was easy to continue for these patients who are newly diagnosed with metastatic hormone-sensitive prostate cancer or good candidates for triplet therapy. So, it's been in the community for a long time, having relationships with different medical oncologists, led to this collaboration.

Sreekanth Reddy: I would kind of echo that, that we started out having a few patients in common and we started talking about new data that comes out, particularly with Dr. Kassabian, he has been so involved in research and trying to explore new avenues for patients. It's just really been fun to work with him. And so, over time, we both realized that we were interested in doing new things and offering new treatments for our patients and trying to get them better.

Zach Klaassen: Yeah, that's great. I think when you think about a patient or say a subset of patients that you're targeting for triplet therapy, how do you guys communicate, how do you collaborate with those specific patients, and what sort of are the logistics that goes on behind the scenes? Obviously, the patients need to be told it's not chemotherapy forever, it's six cycles, and so how do you guys manage that between yourselves?

Vahan Kassabian: Usually, the referrals come from the urologists in our community, because we end up doing the biopsy, diagnosing the disease, and the stage, and we have that initial conversation with the patient. And if we think they're good candidates for triplet therapy, what I do typically is start the approval process for the darolutamide, for NUBEQA, and then refer them to Dr. Reddy. The best way for me to communicate is I have his cell phone number. We call each other for any concerns or questions. "Hey," give him a heads-up, "Mr. Smith or Mr. Jones is coming to see you. This is the disease state. I think he's a great candidate for triplet," and that's how the communication is.

It's unlike an academic center. I'm sure you, Dr. Klaassen, also have cell phones of medical oncology that you can call, but it's different because you're in the same, perhaps, building, maybe even on the same floor, you may have a collaborative tumor board where you're all together discussing patients. Because we're in the community, we're in separate private practice groups, we don't have that luxury. But we have the luxury of immediate response via a cell phone, so that's one of the benefits that we have.

Zach Klaassen: Maybe I'll ask Dr. Reddy this, because I think you're absolutely right. I think that the concern is always, if the urologist has the patient, is the medical oncologist going to share them or are they going to take over? Is it going to be back and forth? In my practice, like you mentioned, it's very collaborative and it sounds like it is for your guys. So it sounds like, Dr. Kassabian, you see the patient, you send them to Dr. Reddy, they get the docetaxel. So do you guys then both follow the patients long-term, or how does that work?

Sreekanth Reddy: We typically do continue to follow the patient together. Maybe from my standpoint, I don't want the patient coming in too frequently, so I'd like to alternate with Dr. Kassabian. He's been great as far as exchanging lab information, following PSAs, imaging, if need be. And so we'll alternate, make sure that the patient is doing well, follow various parameters every time. And then, if we see progression or see changes, then we just discuss what the next steps are together.

Zach Klaassen: Yeah, absolutely. Dr. Kassabian, do you notice, when you talk about chemo to the patients and discussing that cycle hard stop. How do you manage that?

Vahan Kassabian: Yeah, that's a great question. It depends on the patient and the family, how well it's perceived, right? A lot of patients have this big red box or star over chemo. "I don't want chemo." First, we explained what ADT is and what dose intensification is and what those side effects are. But I think the key here is that we explained that the chemo is six cycles and then you're done, and you're going to continue the ADT and the darolutamide. And I think that's key.

Does Dr. Reddy need to close the deal? Sometimes, yes, he does. If the patient's on the fence or not sure, and I encourage that, at least go talk to the medical oncologist, and hopefully, he can close the deal. But it really is very patient dependent, whether they're open or not. There is some convincing on our part to do because it is chemotherapy, so to speak. But at the end of the day, it's not that hard a topic, especially because it's a single agent, it's typically well tolerated, it's not MVAC, for Pete's sake, and it's usually well tolerated. But usually, it's the medical oncologist, Dr. Reddy, who closes the deal.

Sreekanth Reddy: And it's time-limited, which is really nice for the patients as well.

Zach Klaassen: So, how do you guys incorporate the APPs and the PAs into the treatment algorithm? Because obviously, we're going 19 directions and we're seeing all sorts of patients every day and in the OR, whatnot. Do you guys use them in terms of discussions and counseling? Is it follow-up lab work? Is it phone calls? How do you both, let me start with Dr. Reddy, how do you incorporate those folks into your practice specifically for these triple therapy patients?

Sreekanth Reddy: What I typically do on an initial consultation is have the PA or nurse practitioner that I'm working with in the room so that the patient can become familiar with that person, and also so that the provider hears the same story that I'm hearing. The main utility that we have is that when patients are on therapy, they have, really, a very direct connection with these mid-levels to answer questions, help take care of potential side effects that occur, and then also navigate the complex process of making sure they're getting their NUBEQA on time, making sure that all the appointments are scheduled, and just kind of smoothing that process out so that the patient has a good experience.

Zach Klaassen: How about your practice, Dr. Kassabian?

Vahan Kassabian: We do have mid-levels. I personally have a nurse practitioner that works with me and sees the patients with me. For the advanced prostate cancer patients, most of the time, I'll be seeing them, but I know practices around the country where it's the APP that sees these patients, and then the physician champion in the group, in the large group, sort of oversees this. But she also does see the patients on their own, especially if they're stable, their PSAs are doing well, and clinically they're doing well. We also, in the background, have an entire advanced prostate cancer or advanced cancer team. We have a nurse navigator, we use PPS analytics to look at patients' data to make sure that they're coming in for their appointments, their ADT, make sure that they've been scanned appropriately on a timely basis. So there's a whole group of people behind the scenes. It's not just me and the APP who are on the front lines.

Zach Klaassen: Yeah, that's great. And it takes a lot to keep these patients on schedule and follow-up and imaging, and you get a few in the practice and sharing collaboratively. Speaking a little more to that collaboration, obviously, I'm preaching to the choir, I work well with my medical oncologist, you guys work great together, as we move with triplet therapy and even into radioligand therapy in the next several years where there's going to be several groups of physician teams involved, what sort of barriers do you see out there potentially with collaboration? And what would the message be to folks that are maybe listening to this that say, "I'd like to keep these patients myself. I'll do everything." I'll maybe start with you, Dr. Kassabian. What's that message to the people that are maybe a little skeptical with that collaboration? Typically, not in academics, but in private practice?

Vahan Kassabian: Yeah, great question. When I started advanced prostate cancer in 2010, we had the first therapy, other than ADT, come into the urology sphere with immune therapy and then we had the orals. That's when all this started. That's when large groups started to adopt, "Hey, we have these patients, we can take care of them. Yes, we're surgeons. We were trained as surgeons." Even in the residency programs, typically, urologists were not being trained on advanced therapeutics.

So this was obviously a passion of mine, a personal passion. I was fellowship training in urological oncology, doing all these big cases. This was a natural transition, especially having had done research in CRPC, and it's going to continue to evolve to the point where it's going to get even more complicated. I mean, there's new data coming out on a regular basis. Hats off to medical oncologists like Dr. Reddy, who can keep up with all these therapies, not just in GU, but in every other cancer. I don't know how they do it. It's going to be in the hands of fewer and fewer people, even not just in urology groups, but in medical oncology. So the urologists like me are going to have to have, A, a passion, and B, want to take care of these patients, but it's going to continue to be even more of a collaborative effort because of all the new therapies that are coming on the horizon.

Zach Klaassen: Absolutely. Dr. Reddy, how about yourself? In terms of the folks that may be a little hesitant to share patients and collaboration, what's your message to those folks out there?

Sreekanth Reddy: I would say the biggest barrier is really knowledge. I think that as people learn about these new therapies and understand the options, my biggest fear is that people are not fully aware of the latest data that is available. I think timing of the usage of these treatments is critical. If you look at intervals and follow-up in urology clinics, really knowing what's available, what our options are, is really the biggest barrier. Beyond that, I think that the urologists, at least in the areas that we practice, are very open to collaborating and working together. I don't know that it matters where a patient receives therapy, as long as the team is aware of what the therapies are available and is able to know when to implement those therapies effectively.

Zach Klaassen: Is there anything, when you guys are discussing patients about triplet therapy from the ARASENS data, so let's just flip a little bit to ARASENS. Maybe I'll start with Dr. Kassabian. What are you sort of hammering home on the important points based on the data we know?

Vahan Kassabian: The important point I share is that adding darolutamide to six cycles of Taxotere was better than the standard of care at the time, which was ADT alone plus chemo. So that, I think, is the big point. Now, obviously, the flip side is that, unfortunately, there was no single-arm of darolutamide alone, which would've been, as a purist, as a researcher, nice to see, but at least it was compared to the standard of care and it was definitely better. It's six cycles and you're done, so you're still continuing an ARI along with ADT.  I don't get too much into the weeds of the subgroups or sub-analysis with the patients, unless they're my bucket patients who come in with a stack full of notes and questions. That's a different clientele. But for the most part, it's a relatively easy conversation to have.

Zach Klaassen: Yeah. How about you, Dr. Reddy? What key features from the trial are you using to discuss with your patients?

Sreekanth Reddy: I really focus on the efficacy of the treatment and the toxicities and the tolerance of the treatment.

Zach Klaassen: That's great. I think the way I look at it too is that this is the purest control arm that we've had in one of these advanced trials yet, and I think that's one thing I mentioned to folks, is that the center standard of care is not chemo plus ADT anymore. If you're a chemo candidate, you're getting darolutamide as well.

As we wrap things up, I want to give you guys each a platform just to sort of close it out. A couple of take-home messages from your practice specific to patients with triplet therapy. Dr. Reddy, any take-home messages for our listeners?

Sreekanth Reddy: I think just collaboration and early collaboration in this patient population really is helpful in the long run for everybody.

Zach Klaassen: Yeah, absolutely. Dr. Kassabian?

Vahan Kassabian: Yeah. Find a good medical oncologist in your community that is up on the data, good to their patients, and a good doctor, and has a good collaborative approach. I think that's key to success for the patients.

Zach Klaassen: Absolutely. Gentlemen, thank you so much for your time. We really appreciate it.

Vahan Kassabian: Thank you.

Sreekanth Reddy: Thanks, Dr. Klaassen.