Zachary Klaassen: Hi, my name is Zach Klaassen, urologic oncologist in Augusta, Georgia. Delighted to be joined, as always, on UroToday by Dr. Neal Shore, urologist in Myrtle Beach, South Carolina. Today we're going to be discussing one of Neal's AUA 2025 presentations, looking at real world treatment patterns and outcomes in patients with mCRPC treated in community urology centers in the US. Neal, thanks for your time on UroToday.

Neal Shore: Thank you, Zach. Great to be with you.

Zachary Klaassen: So this has been a really interesting database. We've talked to Dr. Sartor about some studies looking at the PRECISION data platform. So maybe just tell us about this platform and really why multi-d care, particularly for mCRPC, we're seeing it more in urology clinics, why this database fits so well for your guys' study that you looked at AUA.

Neal Shore: Yeah, this was from-- came from the PPS database, which began with an organization called Specialty Networks. And now they're part of the Cardinal. This is retrospective, non-interventional. This was over 12,000 mCRPC patients in a urology database over a five-year period. And looking at patient characteristics, types of treatment, type of treatment, time to treatment initiation, overall survival, all the approved therapies.

And so it's always curious and interesting to see how community urologists do things versus community medical oncologists, academic colleagues as well. And we had even broken down by regions. A lot of the data is broken down by insurance providers, certainly by age, and by race.

I think one of the really compelling things that we saw, and I think you have a slide on it, is really the treatment patterns. And in the US community urology setting, there's a very strong use of both Sipuleucel-T and Radium-223 as really, really the go-tos in first and second line therapy, and then very soon alongside that or sometimes concomitantly is ARPI therapy, all the different ones all get used. And so with not a lot of use of taxane therapy. And so I think that there's an interesting aspect to that, as many of these community urology practices are comfortable with infusions for both radiopharmaceuticals and immunotherapy, but not necessarily the taxane therapies.

Interestingly, we have additional and a lot of data that we're combing through, about 50% of these patients had bone protective agents. But one of the things that was kind of fascinating about it is that the median overall survival for these patients was about 30.5 months. So historically speaking, that's actually pretty good, isn't it, for an mCRPC group in the community.

The most common sequence was a first line ARPI followed by Sip-T, or first line Sip-T followed by a second line ARPI. And it's really very intriguing to me, at least in the arc of my career, looking at a lot of this data, seeing how much more aggressive uro oncologists are starting to become.

Zachary Klaassen: Yeah.

Neal Shore: I think there's room for improvement. I think we still need to embrace more of the multidisciplinary team. But this is a real treasure trove of data, and we have a lot more analyses that we're doing.

Zachary Klaassen: Yeah, great summary. I think when I look at this data, there's so much we could pull out of it. One of it was that, as we just showed on the slide, ARPIs were the first, second, and third line most common. Is it ease of use? What sort of your thoughts behind maybe why we're seeing such high ARPIs use not even just in the first and second, but even the third line?

Neal Shore: Yeah, I think that's probably it. These are orals, right? They've been approved now, gosh, enzalutamide has been approved for over 10 years, apalutamide has been on the market a fairly long time, darolutamide and assuredly abiraterone. So I think that the monitoring, understanding the AE profiles, the differences, many of these groups have the accessibility of an in-office dispensary. So I think that speaks to a lot of it.

One of the things that I'm really intrigued by is it takes some time-- Oftentimes, the developers of these drugs, whether they're oral or systemic, they say, well, wait a minute, I just gave you this phase III trial. Why aren't we seeing the next quarter adoption? And it does take-- There's education that has to happen. There's been a lot of education on these oral ARPIs. I think what we're seeing a lot more education coming forward on radiopharmaceuticals. We're seeing more education coming forward on PARP inhibitors. More will come forward on antibody drug conjugates over time. And I think there tends to be a lag.

So I think that probably explains hey, one ARPI to another to another. I don't typically personally recommend that. But at least it's better than people not getting much therapy at all. We presented a few years ago data that 77% of patients in Canada and the US met a prostate cancer specific mortality and only had one life prolonging therapy. So I think this data is compelling to me. We're doing better.

About 50% of the patients were on a bone protective agent, which I think is really actually pretty good.

Zachary Klaassen: Yeah.

Neal Shore: It probably should be closer to 95%. But we're making good progress. And I think this data set will have a lot more interesting presentations in future congresses.

Zachary Klaassen: Yeah, and I think, too, as this PRECISION database continues to get patients, we move forward with time, it'll be almost interesting to see what this looks like in a year or two with what's the uptake of PARP inhibitors, what's the uptake of lutetium. Because these big practices are equipped to do all this now, correct?

Neal Shore: Absolutely. I think that lutetium in particular will be extremely well embraced, as has Radium-223 been embraced in the US uro oncology community. They work well with radiation oncologists as they're authorized users. They can work with a nuc med authorized user as well. And as you have to have the right licensure to handle it.

But lutetium, like many of these other therapies, whether it's Sip-T or radium, and frankly, the orals ARPIs, and I feel the oral PARP inhibitors, these drugs are very manageable. And as we see these community centers of excellence really striving towards true expertise and subspecialization, I think we're going to start to see some interesting changes in these graphs that we presented at AUA.

Zachary Klaassen: Yeah, absolutely. I think we know 80% of the community treats prostate cancer. We're seeing-- I was very encouraged by this data. I think, as you mentioned, we're doing really well. Obviously room for improvements, but great data, lots of food for thought. Any final remarks, Neal, before we wrap up our conversation?

Neal Shore: No, I just really appreciate the fact that the folks from Novartis and our steering committee, as you mentioned, Oliver Sartor, Mike Morris, Xiao Wei, Karim Fizazi, there's a whole bunch of other really great people on this. And we're continuing to-- Dan George is on it-- to cull the data and try to really get a better understanding of how we can interpret it better.

Zachary Klaassen: Yeah, well said, Neal. Thanks so much for joining us, as always, Neal.

Neal Shore: Pleasure.