Pedro Barata: Hi there. Welcome to another awesome conversation this time around AUA. Today, I have the pleasure to have with me Dr. Klaassen-- Zachary Klaassen, famous urologic oncologist out of Georgia Cancer Center. It's a pleasure to have you here.

Zachary Klaassen: Pedro, thanks for the kind introduction. Always good chatting with you.

Pedro Barata: Absolutely. So I'm Pedro Barata, a medical oncologist out of Cleveland, Ohio. Today we're going to be talking a little bit about metastatic hormone-sensitive prostate cancer. A lot has happened in the last few years. Almost a decade actually looking at bringing combination strategies on top of ADT alone, which is something that for-- it's almost what's happening in the trial data.

What we've seen, Zach, in regards to the addition of ARPIs, abiraterone or antiandrogens like enzalutamide and apalutamide or even both chemotherapy with ARPI, with triple therapy, with darolutamide and docetaxel. The reality is, it appears that a significant number of people are still not being offered anything beyond ADT or ADT in first generation antiandrogen.

Let me just start first by asking you, what's the reality in Georgia? You are taking care of a very special population. You have a significant number of diverse patients, including African-Americans. So I'm interested to understand your academic center-- how are you working with the community, with your colleagues, and also with the medical oncologists there?

Zachary Klaassen: Yeah, great question. I think I'll just take it back to treatment intensification real quick. I mean, we know even five years ago, 50% in this country, were not getting treatment intensification. And we think maybe it's other countries throughout the world, but it's in the United States as well.

And there's a lot of nuances and we've looked at possible ways-- is it patient related? Is it physician related? It's probably a combination of both. But the point is that we know treatment intensification works. And pick whatever doublet, whatever triplet, we know it's better than ADT alone. And there may be instances where you have an older, frailer patient where maybe ADT alone is OK, but the majority of patients showing up with either de novo or recurrent metastatic hormone sensitive prostate cancer will benefit from an intensification regimen.

So getting back to my practice, you're right. I see I have a huge practice catchment area in Georgia, in Augusta, which is about two hours East of Atlanta. And so Georgia is very interesting. It's 11 million people, six million live in Atlanta, the other five million live in a very vast area of Georgia, majority of which is underserved, not just from urology standpoint, but also from an oncology standpoint.

So we have a huge catchment area all over Georgia into South Carolina, even parts of North Florida. And so when we look at that patient population, this is much different than Los Angeles or Miami or Chicago or New York. These are people that-- salt of the Earth people. It's a very minority-driven population. I'd say about 50% to 60% of my population is African-American.

Pedro Barata: Wow.

Zachary Klaassen: And so we have a lot of high risk patients that get referred to us. And so it's not uncommon even in 2025 to have a 47-year-old African-American gentleman working healthy, showing up with a PSA of 300, probably a couple times a month. And so that presents challenges that we just don't think about when we're thinking about all these beautiful trials and PSA screening. There's still a lot of groundwork.

And this is not probably specific to Georgia. It's probably happening all across many states in the country. So we partner with a lot of our small urology practices and certainly oncology practices as well. And the nice thing about our cancer center, we're a small cancer center, collaboration is fantastic. My medical oncology team and myself and my partners, we have a lot of back and forth. And so there's a lot of sharing of patients.

Oftentimes they present to the urologist because that patient had mentioned PSA 300, maybe a little bit of urinary retention. So they see us, we do the workup. And then you start to get the ball rolling and really meet these people where they need to be met. And this is much different than maybe some clinics in bigger cities.

Pedro Barata: That's fantastic overview. And since we're here in a way, most of these patients, as you said, will have neurologic involvement from the get go.

Zachary Klaassen: Sure.

Pedro Barata: That's really-- and there are folks who can help those patients to begin with. Sometimes you do involve medical oncology, sometimes you don't. I think it depends on the setup. At my center in Cleveland, in university hospitals, for example, we have a very, very close relationship. Medical oncologists tend to help out with systemic therapies.

But in many places, it's not like that. If we think here in AUA, I was talking to both of our colleagues, telling me that where they are, either they don't have a medical oncology. Or sometimes, when they try to involve some medical oncologists who are not as well versed, specifically on the changes-- their recent changes. And they feel there's a barrier there.

Other times, they are asking their advice. And for whatever reason, patients end up transferring their care somewhere else. So there's always been this-- how do you balance things between different specialties who touch the patient where he is and meet the patient's needs, if you will?

What else do we need to do to try to optimize that relationship between medical oncology and neurology? Because both specialties could or may be capable of helping the patient. But how do you handle that? Do you think there are regional differences? Do you think there's a national problem if there is such a problem? But what do you suggest we can do more to make sure there's really a close relationship?

That sounds to me the one you have going on in Georgia, for example, where we have in Cleveland.

Zachary Klaassen: It's a great question. I think there's multiple ways to answer it. But you're right. I think there's regional differences even across the country, but even in different states. And I think at the very high level, if you think about prostate cancer multidisciplinary as it gets, we talked about medical oncology and urology, radiation oncology, nuke med, geneticists, social workers, pathology.

I'm probably missing two or three, but there's this big spoke and wheel-- aspect of how this works. And so ultimately we want what's best for the patient. If we think about, if somebody comes to see me, let's go back to our example of this 47-year-old with a PSA 300. My job is to give him the best recommendation. To me, that patient is a perfect candidate for triple therapy.

And so as a urologist and academics, I don't give docetaxel. So I give ADT plus all the other ARPIs. And so we start them on ADT and darolutamide. But I tell that patient, you're going to go see my medical oncologist, you're going to see both of us. I'm going to make an appointment in four months. You have seen them, you're probably getting close to being done with your docetaxel.

You're going to have two sets of eyes looking at this. This is a partnership between you and me and the medical oncologist and you. And so when I talk to communities that are worried about this relationship, it's about being a personable physician that they want to come back to. So if they like you and you start them on their ADT and ARPI and you say, I'm going to be the quarterback, but we're going to throw the ball downfield.

Medical oncology is very crucial. Not just for that docetaxel frame, but if you progress after this, your next options are going to be with them, clinical trials. And so it's really setting the framework that if you tell them, there's multiple people involved in your team, you're not going to lose that patient. They're going to look at you as the person that's really driving the boat.

And as the urologist, as you mentioned earlier, there's going to be issues with either urinary retention or maybe they need nephrostomy tubes at some point. We're going to handle all of that. But the message to the folks that are worried about losing patients or this turf war, it's you got to take a step back and really look at it as, this is about optimizing patient care.

That patient's a phenomenal patient for triple therapy. But plugging in people to get that done initially but also downstream if they progress to mCRPC.

Pedro Barata: That's really, really well said. I can come up with multiple examples where that's actually happening. They're getting part of their medical treatment really done locally with urology. And then they come to me, for example, for additional therapies, whether it's docetaxel or as you said, clinical trial, et cetera. But I always try to keep them.

Don't break that relationship. Don't break the relationship. So that's something-- we can also work on at our-- wherever we are to make sure that relationship does exist. So one last question before I let you go. And so this area, again, has changed dramatically. And quite frankly, it is more complicated to treat this disease now than it was 10 years ago.

10 years ago, you were to do ADT and that's it. And you wait until it progressed, median time to progression, could be somewhere around a year and a half or so. These days, you have to talk about volume. You have to talk about timing of metastases. You have to have conversations around prognosis. You have to have conversations around combination strategies, genetics, germline, somatic.

Maybe you have to engage a genetic counselor at some point. Maybe you have to talk about family cascade testing. Maybe you have to talk about sequencing. I mean, it's layer after layers. And that brings complexity to the management. For the folks who might be listening to this, what is your-- it might not be easy to do when you're seeing 30 other patients in your day.

How do you organize your thoughts in a process that works, being comprehensive, but at the same time, make sure you keep moving? Because you cannot spend realistically three hours or two hours with one patient. So how do you strategize your approach to men with metastatic hormone, sensitive to make sure we address all points, but at the same time it's feasible?

Zachary Klaassen: So it's a very good question. If I had the answer for this, I think I'd probably sell it for a lot of money because I don't think there's an easy answer for this. Because you're absolutely right, there's so many people involved. But that's also, I think, the solution. If we get the people involved that are going to take this step of the care, and then this person can take this step, this step, this step.

So do I spend 30 minutes talking to them about genetic testing? No. But I say, because you have this, we're going to get you involved with the genetic counselor. They're going to talk to you about all these things, and we're going to come back and have a discussion after we get the results. So it's having all of these things lined up in that visit.

We're going to go visit medical oncology to talk about docetaxel. What are the side effects? There are side effects. They're great at talking about side effects. And so it's really honing in on what you need to talk about and getting the appropriate people involved to use their clinic visit to talk about the other stuff.

So I think probably that's part of why we still have poor uptake to a certain degree of genetic testing. But we both work in cancer centers that have this, and I think we have the resources to do it. It's maybe harder in the community where it's not quite as easy to do that. But we know-- and the take home message from this little part of our conversation is that anybody by NCCN guidelines unfavorable intermediate risk or higher should be getting tested, which is a lot of our patients.

Pedro Barata: So now you're right. The other thing that works for us is, it doesn't need to happen on day one.

Zachary Klaassen: That's right.

Pedro Barata: All of this. You can break it down into three visits at times within the first three months, if you will, and because it can be very overwhelming. Just a conversation around castration is very difficult to have. And we've been using castration for decades now. So that part has not changed. But all the other layers, a lot of them are new. But like--

Zachary Klaassen: You get the people involved to talk about it.

Pedro Barata: Correct. You get the people, as you said, bring everyone you need to be involved. And it's OK if you didn't talk about chemo on the first day or even the ARPI. You can save it for the next appointment. And so that sometimes helps as well.

Zachary Klaassen: Yeah, absolutely.

Pedro Barata: Zach, it's been fantastic as always.

Zachary Klaassen: Always fun chatting with you.

Pedro Barata: Thank you for joining us. It's a great setup. I really enjoy the relationship with urology. You do represent the best of the urology community. I think it's really important for us to get together and see how we can approach it. Same problem, same patients--

Zachary Klaassen: Work together.

Pedro Barata: --and working together to improve their outcomes. So fantastic. Thanks for being here.

Zachary Klaassen: Thanks for having me, Pedro. Great to chat with you.

Pedro Barata: Thank you.