Jack Andrews: I'm doing great, Zach. Thanks for having me.
Zachary Klaassen: So this is an important topic. You and I have had these conversations offline for a couple of years now. We've been using ARPIs for over 10 years now in practice. And as we move forward and as the ARPIs continue to move up in the disease space, what's your thoughts on why it's important to have urologists, particularly urologic oncologists who are teaching residents sort of at the forefront of this disease space?
Jack Andrews: Yeah, it's a great question. Prostate cancer is becoming very multidisciplinary. And advanced prostate cancer for a long time has been dominated by radiation oncology and medical oncology. And I think it's important that the urologist still has a seat at the table and is involved in patient care when it comes to advanced prostate cancer. I think we can all work together, and I think that's really what's best for the patient. The urologist, for just about every patient who is diagnosed with prostate cancer, is involved from the beginning.
Zachary Klaassen: Right.
Jack Andrews: Whether they had a biopsy, watching their PSA. And maybe they need localized treatment with surgery, and then they develop advanced disease, or maybe they present with de novo metastatic disease. But the urologist is there oftentimes telling them about their diagnosis or treating the patient. And so, patients have a relationship with their urologist. That kind of goes from the beginning and can spill into long parts of their journey. So I think it's important that the urologist continue to push into that advanced space and take care of their patients. For example, I took a guy's prostate out. He did great for a while, had biochemical recurrence, and then we found low-volume metastasis on PET scans. So now, it's time for him to get some salvage radiation, some systemic therapy. And he asked me, "Are you still going to be involved in my care? Are you kicking me to the curb?" He said that in jest. And I tell him, "We have a discussion here that the radiation oncologist and medical oncologist may eventually take over as your quarterback, but I'm still here and I'm here to take care of you. And should they be your quarterback? My door's still always open for us to have any discussions." It's because there's a connection between the urologist and their patient.
Zachary Klaassen: Sure.
Jack Andrews: You know what? And I also think that the urologist provides unique perspective that radiation oncology and medical oncology don't have. We all have our unique perspectives when it comes to the disease, and I think it's additive when we're all involved in the patient's care. So as the advanced prostate cancer gets more and more advanced, things will continue to shift. And with ARPIs getting easier and easier to use and kind of a shift away in the hormone-sensitive space from doublet therapy with docetaxel and using more ADT and ARPIs together. That maybe is more receptive for the urologist to first get the patient started on systemic therapy and seeing how the patient does.
Zachary Klaassen: Yeah, great answer. I think too, just to highlight as well. I mean, obviously we're taking care of the urology patient's sexual dysfunction that's in our purview, lower urinary tract symptoms. One that sometimes people forget about, managing nephrostomy tubes, managing stents. All these things will come back to us. So I think for the urologist listening out there, even if you're not yet prescribing ARPIs and ADT, this is something you're going to see these patients, and we should be heavily involved. So I thank you for that answer. You know, when we look at the discussions that come around the time at diagnosis and setting that stage for management, there's a lot of things to consider. Obviously, efficacy, safety, quality of life. And this may take place over several discussions in the subsequent weeks. How do you approach hitting all those key points and setting that mindset for the patient?
Jack Andrews: Yeah, I think you have to realize that they're not going to absorb it all right away.
Zachary Klaassen: Yep.
Jack Andrews: And it depends on the patient, right? Somebody who's got biochemical recurrence, and we're walking towards hormone-sensitive disease, you have time to kind of set the table and get things going. For example, if I see that somebody very likely has long-term ADT in their future, I'll get them on a workout regimen. One, if they're obese, I want them to lose weight. If they're not lifting weights, I want them to incorporate some kind of resistance training now, so that they're at a better physiologic state later on. The number one thing I think though, is giving patients hope. Right? So even in advanced prostate cancer, this is not going to kill them tomorrow, okay? And we want to lengthen their life, but not at the expense of quality of life. And so, it's all about personal choice, educating the patient, getting them informed so that they can make the best decision for themselves. And so, you just ease into it. Every patient has a little bit different tolerance for how fast they're willing to move with that discussion.
Zachary Klaassen: Yeah, absolutely. And just to dovetail off an answer you just gave there, that survival discussion. I think when you and I were starting out a decade ago, we had ADT and chemotherapy coming around, and we're trying to get survival over two years, maybe three years. Many of these patients will live a long time. Now, they hear metastatic hormone-sensitive prostate cancer. They may not know that. How do you go sort of from that discussion of, you have aggressive cancer that we need to treat aggressively? But you're not going to die tomorrow, the next day, et cetera, cardiovascular risk factors. Looking at that whole package to sort of give them the mindset that this is going to become a chronic disease that we treat and we need to manage just like we do your hypertension, your diabetes, et cetera. How do you go about that discussion about, let's pump the brakes. We've got options here. We have time.
Jack Andrews: Yeah, so it depends on what the state of their disease is. But in some men who are potentially going to be alive for another decade, and depending on how old they are and their life expectancy, they may be losing sleep about this prostate cancer, but they're not losing sleep about their terrible congestive heart failure.
Zachary Klaassen: Right.
Jack Andrews: You know? And that's more likely to kill them. So I think putting some perspective there helps the patient kind of digest what's going on. You know what? And you brought up another point about what things were like 10 years ago, 20 years ago, 25 years ago. The reality is, in the early 2000s, especially in the '90s, the treatments were essentially toxic placebos by today's standards. And I like to give the patient hope that the best day to get diagnosed with advanced prostate cancer in the history of the world is today.
Zachary Klaassen: Yeah.
Jack Andrews: And it was better than it was five years ago, and you're going to be around in a year, in two years, and we're going to do everything that we can to maximize your life expectancy, because we don't even know what's going to be around in five years and where the treatment paradigm will shift.
Zachary Klaassen: Right.
Jack Andrews: And so, I think that gives them hope too. And I think that also gives them the runway of what you're thinking. These patients are all dealing with different chronic diseases, so they're used to managing hypertension, and they don't think that they're going to be cured of hypertension or whatever it may be. And I think it's just putting it in perspective of, this is another thing that you're going to deal with and we're going to be there every step of the way with you.
Zachary Klaassen: Yeah. No. Great answer. You kicked off the discussion, mentoring, multidisciplinary collaboration, and certainly that's the goal of this discussion we're having is, the urologists need to sit at the table. We're often involved early, we're often involved all the way through, and that's important. But just go through some of the key players in this discussion, in this journey, and maybe if there's a unique way you do it at the Mayo Clinic.
Jack Andrews: Yeah, and I recognize that my practice is a little bit different being exclusively prostate cancer here at Mayo Clinic and having a heavy lean towards advanced prostate cancer. But I think that the multidisciplinary approach is really, really important. And there's multidisciplinary even within urology. So with urology, we have our experts in BPH. I can't do a HoLEP, but there's a lot of patients with advanced disease that might need a HoLEP.
Zachary Klaassen: Sure.
Jack Andrews: Or a HoLEP prior to radiation. We have men's health experts that can help with the sexual dysfunction. We have a focal therapy expert. And all of us as urology provide that urology component for the management of prostate cancer. And then, we work very closely with radiation oncology, and we have experts in radiation oncology, and we have our experts in medical oncology. And the key here is that we just pick up the phone when we want to talk about a patient or we share a patient. Now, we do have a dedicated multidisciplinary tumor board every week where we go through our GU malignancies. And you see different people's perspectives. And I think we all know a little bit about everybody's field, but I don't know the upcoming radiation oncology trials as well as our radiation oncology colleagues will. And I don't know the medical oncology trials as well as our medical oncologists will. And they won't know the urology perspective as well as we will. So that together is extremely important. And then what's often forgotten is the role of imaging and pathology. So once every three to four weeks, we have a prostate-specific tumor board where all of our residents are here, but we also have a representative from nuclear medicine, radiology, pathology.
And we pull the slides up, we pull the imaging up, and we correlate. This is usually done after treatment. But we correlate the path findings on biopsy and prostatectomy, and then we look at the imaging, and we talk about what we could've done differently. And really what we're trying to do is inform our biases going forward. And I think that's really helpful. You know, there's so many pieces of this puzzle, and it's going to keep growing. We've already seen nuclear medicine now has a huge stake in advanced prostate cancer, and bridging those gaps. And I think in today's day and age, we see a lot of this with doctors as yet, either we don't want to say anything negative, we don't want any confrontation, or somebody's always looking for confrontation. And I think the ideal spot is somewhere in the middle where you're willing to advocate for your patients. You can have a differing perspective from somebody else in a different specialty, and that's fine. For example, I had a patient, he asked what I would recommend, and I said, "I think both options are good. This is what I would suggest." And he said, "Well, I want you to talk to the radiation oncologist, and I want you to tell me what to do." And I said, "Well, they may have a different opinion, and it doesn't mean they're right or I'm right. I think really our job is to talk and to inform you, give you different perspectives, so that you can make the best decision for yourself."
Zachary Klaassen: Yeah, absolutely. And I think if we look at the... Going back to our title, Long-term Management and Setting That Stage. That's exactly what it is. It's called multidisciplinary collaboration. I love the fact we do prostate tumor boards as well. Patients like the fact that we discussed their cases at tumor boards. I think that's important as well. And I think that's something that gives them peace of mind that maybe we, "Hey, we're going to talk about it in a group, make sure we're giving you the right options. Then, we'll come back and we'll discuss it, so." Jack, always great chatting with you. Anything we didn't hit on, anything burning that you wanted to leave us with? Maybe a couple concluding statements before we wrap up.
Jack Andrews: No, I would just encourage any of the urologists out there to continue to see if you're comfortable with advanced prostate cancer, anybody in academics to continue to feel like you can be a urologist that can contribute to the advanced prostate cancer space. I think we provide a unique perspective. And some of the best friendships I have in the advanced prostate cancer specialty are with other people in other fields. You know?
Zachary Klaassen: Yeah.
Jack Andrews: It really is, I think, a benefit for our patients.
Zachary Klaassen: Yeah. Well said, Jack. Great way to conclude it. Thanks for joining us.
Jack Andrews: Thanks, Zach.