Phillip Koo: Hi. This is Phillip Koo from UroToday. We're here at the PCF retreat, and today we hosted a panel session titled Luminaries in Prostate Cancer: How the Past Helps Inform the Future. We had panels that included Dr. Maha Hussain, Dr. Cora Sternberg, Dr. Oliver Sartor, Dr. Emmanuel Antonarakis, Dr. Jim Hu, Dr. Michael Hofman, and Dr. Neha Vapiwala. And the whole purpose of this was to help us understand how far we've advanced with regards to prostate cancer diagnostics and therapeutics and what direction we head from there. And to help summarize the findings from this robust panel discussion, we have Dr. Maha Hussain joining us. So thank you very much for joining us, Maha.

Maha Hussain: Thank you very much. Thanks, Phil.

Phillip Koo: So before we begin, I want to congratulate you on the Lifetime Achievement Award. It was so wonderful to see you recognized for the amazing work you've done from the beginning to your career, and you're still right in the middle of it.

Maha Hussain: Thank you so much. I'm truly humbled and I'm really, really delighted. It was really an absolute pleasure.

Phillip Koo: I think it's really nice to be able to take time to recognize those people who've really changed the lives for patients, but also have really changed the trajectory for so many physicians and scientists in the community as well. So we really, really sincerely appreciate that.

Maha Hussain: Thank you.

Phillip Koo: So let's boil down some of the findings and the discussion points. I think clearly you mentioned, you talked about in your lecture about all the progress we've made, but there are clearly some unmet needs left. So what are some of those unmet needs?

Maha Hussain: Well, I think one thing we know about the human body is that it has the ability to adapt and cancer cells come from the human body, and this is how we survive millions of years in reality. The difficulty, of course, is this, the minute you have cancer and you go into treatment, it doesn't mean whatever we're giving right now, even though it's much better than what it used to be before, irrespective of the state of disease, whether it's hormone-sensitive or castration-resistant, it doesn't mean every cell will die. So I do think we need to have a better understanding of the biology and how to detect the micrometastatic disease, and then better understanding of mechanisms of resistance. Because when all is said and done, the reality of it is this, we're not curing these patients. We have come a long way.

There's no question about it. I think better imaging is an important thing, but as I tell my patients, this big, one cubic centimeter has a billion cancer cells and not every cell is going to be the same as the one next to it. So this is where I do think partnering with the scientists and the clinical researchers and the clinical providers to try to delve deeper into all of this. I also think a very critical part is early access to care. And so there are times, and again, this is I see it in my practice where patients might have had a PSA, let's say, and it was elevated and slightly, but then nobody followed up because they told them, "Oh, it's okay. They did a rectal exam, everything was fine." A year later, metastatic disease. There is a lot of issues with needing to make sure that one is following up with their doctors, that they're getting evaluated regularly. And of course, we talked a little bit, I mentioned it, my concern obviously with the issues of insurance and everything else, not everybody is able to get equity in terms of access to care.

Phillip Koo: I think those are really great points, access to the care and getting that implemented in the community, which we all know is very complicated. A lot of discussions about precision medicine, there's so many different advancements, which in and of itself are very complicated. And just to think about how that actually gets disseminated in the community is going to be a challenge.

Maha Hussain: Yes, absolutely. And I think one of those things, now that we have media and different societies that have information for the lay people, non-physician type audience, I do think it would be very critical for when a patient is diagnosed with cancer, them or their loved ones, family members or whatever, to basically get into this kind of patient oriented type information as much as possible. And then definitely hook up with their doctors to kind of delve deeper into some of these things.

Phillip Koo: So Jim brought the urology perspective, Neha brought the radiation oncology perspective, Mike Hofman discussed the nuclear medicine perspective, and we had Emmanuel with med-onc. What are some of your key takeaways from those various multidisciplinary discussions?

Maha Hussain: I think the critical part is this is we're not going to cure cancer as one person. We're going to have to work together and that's going to involve everything. Ideally, you want to pick it up early and you want to pick up if it's spread early so that you can actually attack it harder to cure it. So to me, cancer care has to be multidisciplinary and definitely I would say consulting with the right group of people who work together. And definitely what I always explain also to my patients and my mentees is that when you read a report, just don't go by the report. If you have a question or if you think something is not making sense or you're not sure about it, reach out to the radiologist and talk to them about it. And a lot of times things can be adjusted based on that. The other thing I would say, definitely discussion of cases in tumor boards whenever that's feasible as it relates to the different practices so that everybody is on the board together, delving deep into the images and the history and the pathology. And come up with a shared decision as to what would be the best approach.

Phillip Koo: I think that's a great piece of advice. I'm a radiologist and it's interesting, before COVID, we had more physicians would come into the reading room and we would welcome it. It'd be great discussions and we would be able to tell them something different than what we put in a report. And it's really sad, post-COVID I think we've noticed a significant drop in those types of visits.

Maha Hussain: Well, I think for us, I mean, we have the ability to have the tumor board, so these discussions, but I will tell you, I'm constantly bugging my radiology colleagues through either my Epic messaging or email messaging to try to discuss with them or call them. And because I think putting the two brains together makes a huge difference on what a radiologist is thinking and what is an oncologist is looking at and try to make more sense out of it.

Phillip Koo: So another big exciting topic was combination therapies that are synergistic, maybe not just additive or maybe both. But what are your thoughts on some opportunities for these types of synergistic combinations?

Maha Hussain: Well, I think the critical part, like anything else, the basic principles in oncology, we usually start with one drug, and then as we come up with something else and there is potential preclinical and biological data to explain that there is at least more than an additive effect or even at a minimum an additive effect, then get it tested and then move into doing it. And clearly we need the science for that. We need the biology for that. And I have to say, it was forever that we were not doing multi-targeted treatments in prostate cancer, but nowadays we have entered that phase. And so certainly hormone treatment plus chemotherapy, hormone treatment, both suppressing testosterone production plus AR inhibitors, plus chemotherapy, now plus the radioligand treatments with the lutetium PSMA and the radium actually with enzalutamide.

I mean, so there's all these things are coming in and there's actually some work looking even at using PARP with radioligand type treatments as a way of sensitizing, you're sensitizing the... What you're doing is basically trying to damage the cancer cells and then prevent the repair with the PARP inhibitors and things like that. So I do think there's a lot of stuff going in that regard. The hard part is going to be is accruing the right number of patients for these trials. And in countries like the U.S., we have pretty much for most patients, we have all these agents available. So the difficulty is going to be when there is a level one data available, "Am I going to put the patient on a trial that's looking very experimental?" Versus giving them the option for level one. That's the challenge. I do think where there is potential opportunities also to test these things is through international collaborations.

Phillip Koo: Great. So it sounds like the future is bright, but we need to really embrace that multidisciplinary approach.

Maha Hussain: Absolutely. And I honestly think that early detection is very critical and I would say that getting the best possible treatment upfront is the best treatment. And then continuing to understand the science. And I would say ultimately we would love to get a situation like test this cancer, metastatic, BEP, three cycles, four cycles, you're cured, you're done. I'm hoping that we can get to that level, but one thing I would say, prostate cancer is a very sneaky cancer. And the reason I say that is because when you get a patient who got prostatectomy or radiation 10 years ago and 10 years later comes up with metastatic disease, where was that cell sitting all this time and what did it do? Was sleeping and why did it wake up now?

So there's a lot of stuff that we need to do, but I do think we have come a very long way. Actually, Phil, when I entered the field, the median survival for castration-resistant disease, metastatic disease was nine months, and nowadays we're hit almost three years. And then for the hormone-sensitive disease was two and a half years to possibly three, now we hit five plus years. So I do think we're, and now that we have better imaging, potentially detecting micromets early, we're trying to then need to have the right trials to try to see if we can intensify therapy early with the hope of stopping treatment after a period of time and not continuing forever kind of thing and hopefully cure the cancer. So I do think there's a lot of hope.

Phillip Koo: That's wonderful to see how much we've been able to impact the disease. So we're so grateful for all the efforts across the globe that helped make all this happen.

Maha Hussain: Yes.

Phillip Koo: Thank you very much.

Maha Hussain: My pleasure. Thank you.