Charles Ryan: One of the most important advances in the care of men with prostate cancer is treating the patient alongside treating the cancer. Helping patients live better, helping patients be supported in other organs of their body, through other treatment types. And we call this cancer survivorship. And prostate cancer is really a case study in survivorship because many patients live a very long time after the diagnosis while receiving treatment.

So, the Prostate Cancer Foundation has been involved in prostate cancer survivorship for quite some time, and I'm delighted today to be joined by two pioneers in the area of prostate cancer survivorship. Dr. Matthew Smith, who's a Professor of Medicine at Harvard Medical School and a Medical Oncologist at Massachusetts General Hospital. And Alicia Morgans, who is a Genitourinary Medical Oncologist at the Dana-Farber Cancer Institute. So congratulations both of you on establishing the paradigm of survivorship in prostate cancer. And I want to start with you Matthew, you were really one of the early pioneers in establishing this concept and focusing, I think at first on bone health. Tell us a little bit about how that story developed and what strides we've made in the context of treating bone health in men with prostate cancer?

Matthew Smith: Happy to do so. So men are living longer with prostate cancer and they're living longer, but with a greater burden of the consequences of treatment. And in 1997, we had an idea when I joined the faculty to look at the issue of the effects of androgen deprivation therapy, the most commonly administered systemic treatment for prostate cancer on the long-term health, short- and long-term health of men with this disease. And the idea was there, but we had a really difficult time getting support for it until we partnered with the Prostate Cancer Foundation and they funded one of our first trials. And that was designed to look at the effect of androgen deprivation therapy on bone loss and also to look at an intervention to prevent bone loss at the same time. And that initial investment in that work has led to this tremendous body of literature and of understanding that we now call prostate cancer survivorship.

Charles Ryan: I will say that that's been a tremendous alleviation of the burden of fractures, of even pain, and other arenas. Give us a sense of the scope of the benefit that men now receive from bisphosphonates and RANK-ligand therapy, and I would say even just a greater awareness of bone health.

Matthew Smith: Yeah, at the time we began that work, there was a lot of misunderstanding. There was this general view that osteoporosis and fractures do not occur in men. This is of course untrue. And androgen deprivation therapy and other forms of prostate cancer treatment, while they've dramatically improved cancer outcomes also have potential negative effects on the health of our patients with prostate cancer. So we've now demonstrated through that and subsequent work, that we can prevent bone loss and fractures during androgen deprivation therapy for prostate cancer. There's been subsequent recognition that the other therapies that we administer following androgen deprivation therapy also increased risk of falls and fractures, highlighting the importance of this field. And one of the unintended benefits of this early PCF support is, in studying bone loss we also studied other impacts of androgen deprivation therapy in that same initial study and found that men lose muscle, gain fat and have negative effects on predictors of cardiovascular disease risk. So that, again, initial work looking at bone loss led to this much broader body of understanding of the impacts of androgen deprivation therapy.

Charles Ryan: So that's the origin story of the conversation that I have with patients all the time now when I'm putting them on androgen deprivation, bone health, cardiovascular health, et cetera. So, Alicia, you're now leading a survivorship clinic, a survivorship program at the Dana-Farber, and this is focusing on men with prostate cancer. How are you working that language into your care of men who are receiving androgen deprivation therapy in today's world?

Alicia Morgans: Sure. So the program actually takes care of all cancer patients in the center. We have specific emphasis, of course, in GU for patients with prostate cancer, and we try to work it in by talking about some of those key factors that you've already mentioned. So really an emphasis on bone health and an emphasis on cardiovascular health. And the changes in reversible cardiovascular risk factors that happen in the setting of androgen deprivation therapy.

One thing that's still in process in our clinic, and I think that is also still in process across clinics around the world probably, is ensuring that this is a standardized and structured conversation. Because without that standardization, it's really easy to forget one or two components or perhaps all of it in a busy clinic visit. So ensuring that there's maybe even a checklist or specific visits to focus on these complications of androgen deprivation therapy, I think is really important. And touching on all of those things that we need to do in terms of risk assessment, addressing reversible risk factors for cardiovascular disease, and addressing bone and cardiovascular health.

Charles Ryan: Matthew, as we look to the future, what are the current unanswered questions about bone-targeted therapy, bone health in men with prostate cancer? What more do we have to do for them?

Matthew Smith: Well, I think a lot of it has to do with education and implementation. So we have the evidence, we know that this is a problem in men with prostate cancer. It's worsened by androgen deprivation therapy. And then as I alluded to earlier, subsequent therapies, AR pathway inhibitors, many of them further increase the risk for falls and fractures. And yet this is not widely implemented therapy. And most studies, even at academic medical centers, in prospective clinical trials, relatively few patients are being advised about this or offered these interventions. So despite recognition, general recognition is a problem, the actual implementation of preventative therapies for fracture risk reduction have yet to occur. As we look to the future, we need to focus on two things. One is implementing what we already understand, and that is to apply the therapies and interventions that we know can prevent complications of prostate cancer treatment. We also have a more comprehensive understanding of other adverse effects of therapy for our prostate cancer survivors.

Alicia Morgans: We look forward to partnering with the Prostate Cancer Foundation on the issue of survivorship to help implement a standardized approach to prostate cancer survivorship that can be disseminated across all clinics. An approach to cardiovascular health and understanding reversible risk factors and an understanding of bone health and ways that we can intervene on that to ensure that patients can not only identify complications of survivorship, but prevent them in the future.

Matthew Smith: I look forward to partnering with the PCF on continued work in prostate cancer survivorship. The PCF was instrumental in establishing this field of innovation and research, and really improving the lives of our patients with prostate cancer. The focus on survivorship with PCF really makes a prostate cancer diagnosis a teachable moment. This is not only about a patient's prostate cancer diagnosis, but a general recognition of their overall health and the impact of treatment on those other health issues, including bone loss and fractures, cardiovascular disease risk, and risk for diabetes and other conditions.

Alicia Morgans: What this means for patients is that we not only focus on your prostate cancer and ensuring we have good disease control, but we focus on all of you. Keeping your heart healthy, your bones healthy, and keeping you mentally able to deal with the challenges ahead.

Charles Ryan: Well, thank you both to Dr. Matthew Smith and Dr. Alicia Morgans, who have established the paradigm of survivorship in prostate cancer. Have established the need to address the physical and mental and emotional needs of the whole patient who's undergoing therapy. And we look forward to your continued work with the Prostate Cancer Foundation in this really important topic.