Shared Care in Prostate Cancer

Transcript:E. David Crawford, MD: This whole episode is on shared care, shared decision making, and things like that with the word “shared.” It’s a team approach. We just got done with the World Series. It wasn’t one person that won the World Series, it was the team. I think that’s certainly the case with prostate cancer. But let me just turn to my right and talk to Dan a minute, because part of the issue that’s happening right now has do to with we’re finding more advanced disease.

Daniel P. Petrylak, MD: Absolutely.

E. David Crawford, MD: We conquered it for a long time, and now we’re starting to see a rise. Do you think that’s the case? What are your thoughts, from a medical oncology standpoint, in dealing with this?

Daniel P. Petrylak, MD: My impression is I’m seeing more patients coming in with metastatic disease frontline than we’ve seen in the past, and actually more primary diagnosis with metastatic disease. In other words, not somebody who’s had a prostatectomy, rising PSA, and then goes on to develop metastases, but somebody who starts off de novo with metastatic disease. In fact, we’re seeing a lot of high-volume disease, as well, and very high PSAs. This is just my impression, of course. I don’t have data to support that. But, in general, I think that we’re seeing more of it.

E. David Crawford, MD: I’ve seen a couple articles that I’ve reviewed for journals that say that same thing. We had seen the rate of metastatic disease fall. There was a nice New England Journal of Medicine article on that and looked at breast cancer, which sort of flat lined, and prostate, where it went down and now it’s going back up. So, that means we’re going to be using more advanced treatments, and that’s androgen deprivation therapy, chemotherapy, some of the new drugs like Zytiga, and radium, and all the other drugs that are out there. We have great drugs, if we just move into that area of shared care. Urologists like to think of themselves as captain of the ship, and I think that’s good because they’re the ones that have been taking care of these patients their whole life. We share stuff with the medical oncologists and with the family practice guys. What are your thoughts about how we deal with a team approach going forward? We use a team approach right now. We have nurse practitioners, we have radiologists, and yet, we’re just in this little friction about what’s the best thing for patients. How do you care for them?

Daniel P. Petrylak, MD: I think the key is communication between the primary care doctor, the urologist, and the medical oncologist. Certainly, we have new findings about moving some of these treatments up earlier in metastatic disease. You have to ask the internist or the primary care doctor, is the patient fit enough to undergo chemotherapy frontline for their metastatic prostate cancer if they’re high risk? Do they have urological complications that the urologist needs to take care of? Does their prostate need to be frozen when they’re diagnosed with metastatic disease? Even now, we’re seeing that there are studies looking at the use of radical prostatectomy, along with hormone therapy, for metastatic disease. This requires an integration of all different subspecialties and communication. I’m fortunate. Where I am at Yale, I’m in the Urology Department. So, we actually have a de facto multidisciplinary clinic where John Colberg or Peter Schulam can walk across the hall and ask me a question, and conversely, I can do the same. I think that this team approach is crucial to the management and the overall well-being of our patients.

E. David Crawford, MD: Let’s just back up. A lot of patients undergo androgen deprivation therapy for a whole bunch of reasons. It used to be advanced disease, biochemical failure. We’re seeing it swing back to advanced disease. When I grew up with ADT, androgen deprivation therapy, hot flashes were the side effects. Now we have hot flashes, cardiovascular, weight gain, mental changes, Alzheimer’s, osteoporosis, and it goes on and on and on. To me, that means we need to work with our family practice doctors, and I think that’s part of the team. I think that’s been left out for two reasons. One is we need to deal with the side effects, and two, sometimes we’re afraid to use drugs that we should use because we’re worried about, do we have to monitor things like potassium and blood pressure. Let me turn it over to Matt. Matt, how do we get this team together, and what are your thoughts about it and dealing with me, dealing with Dan in taking care of patients?

Matthew T. Rosenberg, MD: I think that’s a great question. Dan, you made a great point about communication. My phone is always attached to me. If I’m getting a patient treated with something and you’re worried about follow-up as a specialist, just call me. We used to do that, and now, for some reason, we don’t. We always used to be in the hospital and see each other, and some of us are there.

E. David Crawford, MD: We have Epic and all these [electronic] medical records.

Matthew T. Rosenberg, MD: Yes, we cringe a little bit with that. But the reality of it is, if we communicate, we’re better. If the treating doctor, the oncologist, or the urologist, calls me and says, “Matt, we’re treating this patient. We want to give him a steroid for whatever reason,” [I will say], “That’s fine. I’ll take care of it. Just send him to me, and I’ll follow up because I do those things.” That’s easy. The problem that I get into is when I don’t see the patient and then they come back 6 months later with a list of medications. I’m like, where did these come from? And I need to be watching for this, this, this, and this and the patient says, “Dr. Rosenberg, I don’t want to do these things without your approval.” We have to understand and actually embrace the relationship that we, as primary care, have with patients. The commodity that I have as a primary care doctor is that the patients trust me. They’re going to trust me with their health, so they’re going to see you for surgery or you for radiation. They’re actually going to call me and say, “Is that okay? Can I do that?” And I want them to do that. And I say, “Look, I spoke with Dan, I spoke with Dave. This is what we’re going to do, and I’m going to make sure that I’m communicating with them, and I’m going to make sure that you’re okay.”

Transcript Edited for Clarity