Jacqueline Brown: Thanks for having me, Zach. Happy to be here.
Zachary Klaassen: Just at a high level, what is multi-D care? Who's involved in a metastatic hormone-sensitive prostate cancer patient? There are a lot of them, so take your time and lay it out.
Jacqueline Brown: Let's talk about the players because it's more than, I think, patients might think, even we think sometimes. There are concentric circles of care. If we're talking about the physician layer, I'm thinking the urologic oncologist, the medical oncologist, and the radiation oncologist, but it is so much more than them. Beyond that, and this has become a broader team as we have new approvals, we're on the cusp of new approvals, and we're just using more drugs in this space. I'm thinking about everyone with very high-risk localized and high-risk localized to metastatic disease needs germline testing, so we have a geneticist who's on our tumor boards and we refer to easily from clinic. I'm thinking about nuclear medicine. I know that at some institutions, it's radiation oncology that gives lutetium radioligand therapy. Our nuclear medicine docs do that. They're helping us read and understand PSMA PETs, so they're part of that team as well. Certainly, our interventional radiologists who are getting us biopsies, our diagnostic radiologists who are helping us with our scans. Then on a day-to-day clinic level, it's our dietitian, it's our social worker, it's our pharmacist who's helping to protect patients because we're making these quick decisions, and always checking the fine print of drug interactions and all those things. I'd say that's the team in general.
Zachary Klaassen: That's the team. It's literally patient, and then a bunch of spokes around it.
Jacqueline Brown: Yes, exactly.
Zachary Klaassen: Ultimately, the goal is to provide better care. I think the more that we get this into patients' minds earlier, the better. My next question is kind of along those lines. When you meet the patient, they develop a rapport with you, and you say, "I need you to go see the urologist or radiation oncologist," they may want to stay with you. How do you discuss multi-D care with them?
Jacqueline Brown: I'll reframe that question in that I'm often inheriting patients who are already receiving good care, and so I might be a later doctor in their care. Hormone-sensitive prostate cancer is a spectrum of disease with biochemical recurrence, particularly now that we detect metastatic lesions sooner. These are patients who often have a urologist who they've trusted and followed with for a long time, maybe had prior radiation. If they're seeing their urologist, they are often inheriting people who have started on ADT, have started on an ARPI, maybe darolutamide, something like that. They're already coming to me on best standard of care doublet therapy. The questions for me, and the role for me as a medical oncologist in their care is, is there a role for chemotherapy in this setting? As we talk about new approvals, maybe a different triplet in the future. That's my role for them. I have to work very closely with those urologists. Honestly, they're doing the work of helping this patient trust me. "Why am I seeing this person?"
From my end, if I'm talking to a patient, maybe I'm their first point of contact in the system. I'm starting the right regimen of drugs for them. I want them to see radiation oncology for consideration of palliative radiation or something like that. I think the role here is I don't know everything. I can't do everything. We don't work in silos. I work closer with my urologists than anyone in medical oncology. Those are my colleagues. Those are the people I trust with my patients. I think I'm saying, "This is a team approach, this is what I do, and there are some overlapping circles of this Venn diagram, but we need him. You'll love him. I'm right here once you get that consultation to catch you with what he says after."
Zachary Klaassen: Yeah, well said. We all have our favorite referring docs. I have my favorite med oncs, my favorite rad oncs, you have your favorite urologists and rad oncs. What makes a good multi-D team player as a clinician?
Jacqueline Brown: Yeah. I think turf wars are the worst, the absolute worst.
Zachary Klaassen: They're the worst.
Jacqueline Brown: We all want the same thing. We all want good care for patients.
Zachary Klaassen: We're all busy.
Jacqueline Brown: We're all busy, and so if that good care for a patient starts with you, as a surgeon, or starts with me, as a medical oncologist, tomato/tomato. The patient got best standard of care, which is a doublet, not ADT monotherapy. I think it is being humble enough to know you don't know it all. I think it is having good relationships and communication with not only people at your center, but in the community, right? I work at an academic center, 20-ish percent of patients are treated and interface with an academic center at some point. That means 80% do not. If I say this is the only sort of outreach I do is to my own people, I'm not going to have very big influence and I'm not going to help the most patients that I can. I think it's building relationships with your community docs who are out there doing a great job, and treating a much bigger proportion of the population with HSPC than I am. And then I think what I said in the beginning is being humble enough to know that we're all providing good care. We just have different job descriptions.
Zachary Klaassen: That's right. At Winship at Emory, how does multi-D work, tumor boards, what's the workflow, just to give our listeners an idea?
Jacqueline Brown: Yeah, we have two ways that multi-D kicks off the ground. It is possible that you just come into a system, you see the urologist, and then they might refer, or you see the med-onc and then we refer. But we try to streamline this in two ways, one of which is we have two multidisciplinary clinics focused on prostate cancer. One is at a hospital we have in our Northern arc, one is at Emory University Midtown Hospital. This is the patient comes to the clinic, they see the radiation oncologist, the medical oncologist, and the urologic oncologist all in the same visit, and they leave with a plan of how we're going to treat that. I think that's typically for more localized disease, but there's a spectrum with low-volume metastatic disease, and so those patients still have a role for coming to that clinic as well. Then we have weekly tumor board in which we're discussing the best way to manage our patients. I think that patient with low-volume disease, should we do SBRT to that lesion? If we're thinking about a clinical trial, is there a role for surgery? Those are the cases that we're discussing there. Those are the two main ways that, on a weekly basis, I am interfacing with every physician member of the care team on these patients.
Zachary Klaassen: Awesome. I think it's a great example, and I think the take-home is it's maybe different at every institution. I think the key is setting up these tumor boards, these discussions.
Jacqueline Brown: I think it's just having a collegial group. I think if someone says, "The surgeons do this poorly and we do it the best," or vice versa, I think an acrimonious relationship between any subspecialty to another hurts the patient at the end of the day. I think it's building those good relationships with the patients so they trust the team, and it's also building good relationships between docs so that we trust each other.
Zachary Klaassen: That's right. Always a fun high-level discussion with you, Jackie. Anything we haven't hit on? Anything you want to leave our listeners with?
Jacqueline Brown: No. I mean, we had a pretty whirlwind conversation. I think my greatest ask is that we, as docs, just do a great job to be transparent with patients, to help them understand this structure at the first visit. I want them to know who the team is, I want them to know the matrix that we work within, and I want them to leave my institution saying, "They've really got it together. She isn't sending a random referral and hoping somebody picks it up. She's actually talking to the surgeon about me who will call me next week." Just a plug for good communication. That's mine.
Zachary Klaassen: Yeah, that's well said. Great take-home point. Thank you so much, Jackie.
Jacqueline Brown: You're very welcome. Thanks, Zach.