Catherine Marshall: Thanks so much for having me today.
Zachary Klaassen: We have a plethora of options, doublet therapies, triplet therapies. How do we take all that and talk about efficacy, but then still consider patient function, fatigue, all these things that mean a lot to them?
Catherine Marshall: So when I'm talking to patients and getting started on treatment, you have to start with disease prognosis and treatment. And then when I talk to them about side effects, the big thing that I try and convey is that the side effects are not always super obvious. So sometimes after chemotherapy, there can be vomiting, hair loss. And those are things that you can see, other people can see. Some of the side effects and symptoms can be much more subtle with some of our therapies, but still pretty profound and impact patients. And that's what I try and convey to them, that letting me know about these things is also really important.
Fatigue is a big one. And I usually do try and explain to patients what I mean, in that you're so tired that you're not doing things anymore. You sleeping when you weren't. You used to work a full day, you can't anymore. You used to play a full round of golf, you can't play anymore.
So those are the things that I talk to patients, and I do find that it's helpful to explain other people's experiences, so that patients have a sense of what I even mean by fatigue because sometimes it's even a hard thing to explain.
Zachary Klaassen: Right, it is. And treatment burden can be taken a couple different ways. It could be we're in the first-line setting, we're thinking doublet or triplet. We may be thinking this is the first of maybe two, three, or four treatments that you may be getting. Is that something you address early on or does this come into conversations as the patient walks through that journey?
Catherine Marshall: So I address it early on and think about the burden of side effects and even choosing what therapies we're going to do and when we're going to do them. The other thing that I try and let people know, especially with the oral medications, is that we can adjust the doses, and sometimes we need to adjust the doses. Also, I think the big thing for our patients, a lot of times people will ask, "Well, what is it that I can do?" And I think the big thing for patients, especially with fatigue, is making sure that people stay as active as possible. And it's really hard to do when people are on androgen deprivation therapy and these ARPIs, but exercise and activity is really the best counterbalance that we have for fatigue in particular. So I do counsel my patients to try and continue to stay active.
Zachary Klaassen: I think that's really well said. It's something I always say in the clinic. If you're not working out, start working out. And if you are, you got to push through all this to keep that going, because people want to control something. They can control that. I think it's hard to measure fatigue and function. Is there any tools you use, or is it just clinical gestalt of when you walk in the room?
Catherine Marshall: I try and get a sense of people's daily activities. So when I first meet people, I ask, "What is a typical day like for you?" And then I try and go back to that at the subsequent visits. So when I first met you, this is what you told me. These are the things that you told me that you do. How are you doing now compared to that? And that helps me to get a sense of how normal activities are changing. Some of my patients are doing regular exercises and they'll say, "I'm doing a hundred pushups a day, and it used to take me this amount of time." And that's something that I actually can follow for that patient, for how things are going. So there are some tools that you can use around frailty in particular. I tend to use more a quick ... Tell me what activities you're doing, how a day goes for you, and then how that's changing over time on therapy.
Zachary Klaassen: That's really helpful. That's really helpful because I think it's hard to add more time to a visit, but if you have this part of your conversation, it's built in already. It's interesting because oftentimes the people that come with the patient will tell you more than what the patient does. That may be the granddaughter, that may be the neighbor, that may be the spouse. How do you incorporate getting that information back from whoever else is in the room with the patient?
Catherine Marshall: So that, I think, is a really important point. I tell people on the first visit that they may not notice all of the side effects, but the people around them may notice the side effects. So I also counsel the caregivers that, "I want you to be on the lookout for side effects too." And I'm going to ask the patient about what they think is going on and how they think that they're doing, but I'm also going to ask the caregiver, "What have you noticed?" Because sometimes somebody might not notice that they're walking slower, it's taking them longer. They used to be able to keep up with someone, but now they can't, but caregivers can provide really useful information and feedback too on how people are doing.
Zachary Klaassen: Yeah, really important. Anything we haven't hit on? I've really enjoyed our discussion. Is there any take-home messages or things you want to mention still?
Catherine Marshall: I think the biggest thing to think about is that these medications can be dose-reduced. You can hold them to see if you're not sure about side effects, if the medication is causing them. And I use all of these things in clinical practice to try and judge, one, what is the contribution of the medication to whatever side effects we're discussing, but then also see how we can get patients to have fewer side effects and better tolerate the medications.
Zachary Klaassen: Well said. Cathy, thanks so much for joining us on UroToday.
Catherine Marshall: Thank you so much for having me.