Zachary Klaassen: Hi, my name is Zach Klaassen, urologist in Augusta, Georgia. I'm joined by Steve Freedland, urologist at Cedars-Sinai in Los Angeles. We're in Chicago at ASCO 2025. We're going to be discussing some data that Steve presented this weekend, looking at treatment patterns, specifically by race for mCRPC in the United States from 2020 to 2023. Steve, thanks for joining us on UroToday.

Stephen Freedland: Thanks so much for having me, Zach.

Zachary Klaassen: So just at a high level, we have a lot of options for mCRPC and they keep getting added to almost every indication, every few months we're getting something different or a new space. It's a great time. But we don't know a lot, especially contemporarily, if there are different treatment patterns by race. Just tell us a little bit about why this study is important and why you guys took it on.

Stephen Freedland: Yeah, no, it's a great question. So what we do know is that Black men in the United States are about 2/3 more likely to get prostate cancer, and over twice as likely to die from prostate cancer. So the death rate exceeds the incidence in terms of that excess relative to Whites. So something's going on. So one of the questions is, is there innate biology in the tumors? It's either genetic or systemic racism that's created a more aggressive tumor, somehow diet, lifestyle, lots of things you could hypothesize.

Or is it access to care and that they're not being seen by the same physicians, they're not getting the same treatments? And that that's contributing to the worst outcomes. And there's increasing data that suggests probably access is obviously very crucial. Doesn't explain why there are 2/3 more cancers. So I think there is still something, systemic racism, other things going on. But at least there's increasing data that if you can get them in a good health system with equal access, treat them equally, you're going to have similar outcomes. But it's not 100% sure.

So that was the basis and background for why we undertook this study.

Zachary Klaassen: That's great. Just give us a little background, because these are important, to discuss the database you use, and so the study design that you guys undertook.

Stephen Freedland: Yeah, so it's the ConcertAI database. So it's a group of patients who all had insurance and were being seen by physicians, so I think that's important. It wasn't in the safety net, hospitals and different things, the uninsured, county hospitals. So I think we'd see a very different picture there, which is hard to study because they don't necessarily have the EMRs structured the same way. But at least within this data set, so all have insurance, all being seen. And we looked at patients who had metastatic castration-resistant prostate cancer, mCRPC, between 2020 and 2023.

And so you would think that many of these may have come from mHSPC, but their diagnoses of mHSPC would have been 2018, 2017, had been more historical, where we weren't as aggressive with doublet therapy or even triplet therapy. We're still not as aggressive now as we should be, but we've gotten better. So these are patients, and they were mostly White patients. But there were a decent amount of Black patients. And just really looking at what the treatments they got and their survival outcomes.

Zachary Klaassen: And what did you guys find in terms of treatment demographics, outcomes between these two groups?

Stephen Freedland: Yeah, so I think the good news is, again, patients all had insurance, being seen by physicians. And the treatments that they received were by and large the same, a little bit more RPs, a little bit less chemo, but subtle differences. But overall survival was the same.

Zachary Klaassen: That's great.

Stephen Freedland: So I think, again, that's the good news is when we get these patients in and can take care of them with access to care, we can get outcomes similar to what we see in Whites. And there's actually some data suggest outcomes might actually even be better. But getting the access and how we do this for all of our patients in this country is a challenge.

Zachary Klaassen: Yeah. Speaking of challenges, again, in this study, we've seen it in multiple studies, not just in this country but across the globe, still 53% getting ADT alone. And granted this is 2020 to '23. Have we made great improvements in the last two years? Maybe slightly. But just talk a little bit-- I know you and I have done some work looking at some of the qualitative aspects of this. Maybe just talk to why we're still under treatment, intensifying a lot of these patients.

Stephen Freedland: Yeah, it's a great question. And so it's interesting. I recently gave a talk of why aren't we intensifying RP. Let's take the contrarian view. And it was actually interesting to put on that hat. And that there's a number of reasons. I think it's interesting if you look at NCCN guidelines only two years ago, ADT alone was still an option. Even though we had multiple phase 3's with overall survival benefit, it was still in the guidelines.

Zachary Klaassen: Which back ends it at the end of the 2023 for this study.

Stephen Freedland: Correct. And if you read the AUA guidelines, actually statement 14 advanced prostate cancer guidelines-- I was on their website literally a week ago-- actually says ADT should be given and it lists orchiectomy, agonist or antagonist, but should be given for mHSPC. And you have to read the next line that says and it actually has strong evidence level B. You have to read the next statement to actually say it should be given with an RP. You could very easily read that statement and stop and say ADT is a good enough.

Study you and I did, where we asked physicians, when treating a metastatic hormone sensitive, how low do you want that PSA to go? And the average was like a PSA of two, which is ridiculous. If you're not less than 0.2, you really aren't going to get those benefits. So I think we do have a lot of work to do in terms of education. So I'm very appreciative of your efforts, UroToday's, to get this message out that we really do need to go lower, be more aggressive. And so hopefully I think we are moving the needles.

This study looked at mCRPC patients '20 to 2023, which means their mHSPC would have been even earlier. So I think we are moving the needle, but not nearly as fast as we should be.

Zachary Klaassen: It's a good answer to a very impossible question to answer. So great conversation as always, Steve. Any take home messages before we wrap up?

Stephen Freedland: I think the message is we really need to focus on delivering better care, better access to all the patients in this country.

Zachary Klaassen: Absolutely. Thanks so much for joining us, Steve.

Stephen Freedland: Thanks for having me.