Core Concepts for Prostate Cancer Care from Melbourne to Sheffield - Carmel Pezaro

Carmel Pezaro discusses her recent move from Australia to Sheffield, England with Alicia Morgans in which they discuss the similarities in the needs of men with prostate cancer in the two countries where men need treatments, support from their families, and their providers.  There are differences where in Australia they embrace new technologies such as PSMA PET which is not available in the UK.  The need remains for the development and use of these diagnostic and treatment modalities to improve patient treatments and outcomes.  They discuss opportunities to bridge international collaborations around de-identified data sets in prostate cancer towards understanding real-world patients.  Real-world evidence in patient-related outcomes (PROs) of metastatic castrate-resistant prostate cancer (mCRPC) patients can assist in helping to treat patients in new ways, recognizing all patients with prostate cancer are not the same and that personalized treatments are possible through the collaborations of data registries.  

Biographies:

Carmel Pezaro, BHB MBChB, FRACP, DMedSc, MHPE.  Yorkshire Cancer Research (YCR) Senior Clinical Research Fellow.  Dr. Pezaro is a medical oncologist and researcher, with an interest in prostate cancer. Following oncology training and a doctoral degree in urothelial cancer, she spent two years working in the Prostate Cancer Targeted Therapy Group at The Institute of Cancer Research / Royal Marsden.  From 2013 until 2018 I worked as a medical oncologist at Eastern Health and Monash University in Melbourne, where she participated in laboratory and clinical research programs. She was the deputy chair of the Australian and New Zealand Urogenital and Prostate trials group (ANZUP) prostate cancer subcommittee and was actively involved in collaborative and industry trials. Her research output includes 70 publications since 2008 and both chief and co-investigator grant funding. As a complement to her academic research interest, she undertook a Master of Health Professional Education, which I completed in mid-2018.  In October 2018 she moved to Sheffield to commence a 5-year clinical research fellowship with Yorkshire Cancer Research, alongside clinical duties.

Alicia Morgans, MD, MPH, Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois

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Alicia Morgans: Hi. I'm delighted to have here with me today Dr. Carmel Pezaro who is a medical oncologist at the Sheffield Teaching Hospitals in the UK. Thank you so much for being here.

Carmel Pezaro: It's my absolute pleasure. It's lovely to see you again.

Alicia Morgans: And to see you too, especially since you've been so busy in the last year or so, moving, actually, from Melbourne up to Sheffield, and really sort of reestablishing yourself and your vision, and I'd love to hear about, what are the core concepts that seem to traverse that divide that you've just made, and what are some things we can learn from your journey?

Carmel Pezaro: Yes. So, I did move, it's a long way, moving is hard.

Alicia Morgans: Yes.

Carmel Pezaro: But I think it was really worthwhile and certainly it's fascinating, every time you move, every time you move institution but also moving to a different health care system. You do get a really clear sense of some of the things that are done similarly, some of the things that actually are done really well in some health care systems and some of the things that perhaps need more work in some areas.

In terms of things that have been very similar, there are lots of men who have prostate cancer who need to treatments, there are lots of men who run out of treatments, and there are lots of men who are still looking for more and for better treatments for their prostate cancer. There are, I think, lots of similarities in the kind of support that men are looking for. Support from their families, support from the kind of services around us and around the care that we're providing. There's a huge complex set of emotional and psychological and exercise supports and social supports that people need to be able to access.

Some of the differences, I think, as I left Australia I became very aware of the willingness in Australia to really embrace some new technology, so obviously in Australia novel PSMA-based PET imaging has really raced ahead, and that's certainly not the case in other places around the world, still.

Alicia Morgans: True.

Carmel Pezaro: There's a lot of work still to be done to try and really, not just convince ourselves about the benefit but also convince funding bodies about the benefit, because otherwise we are actually stuck with our same old CTM bone scans which I think we all agree are not doing what we need. They're not providing enough information for the men that we treat, but they're actually the scans that we have access to.

Alicia Morgans: True.

Carmel Pezaro: I think moving into the NHS has been really interesting. The NHS is, in my opinion, an amazing socially based health care system, it's a bit familiar to me because I started off life in New Zealand and again that's a very social public health system, but you're also a bit more aware of some of the limitations of that kind of system in terms of being able to provide every new treatment as it comes along.

I remember when I was working in New Zealand, we had trouble providing Herceptin for women after that data came out on breast cancer so many years ago, and I think those challenges still exist. I was talking to someone the other day about using dual agent immunotherapy in GU cancer and I said that I worried about how we were going to afford to pay for these new treatments, and the response was, "Oh, but it's going to be a nice recommendation, so the government will pay for it." But, of course, the government doesn't manufacture money, it comes from somewhere, and I think for all of us working in a public health care system is a challenge in terms of knowing how the public dollar can be used as well as possible.

Alicia Morgans: It's true, and even in systems that are not public, aspects, for example, of the United States program, the Medicare program or the VA program, are systems where public dollars are funding these systems and I think we're all concerned, worldwide, about the burden of the costs in GU cancers and across cancer, and we hope for the new developments that continue to bring us these new treatments into move things forward in terms of helping our patients, hopefully, at some point, really have a cure for their cancers.

But it does come at a cost, and so I'm eager to see, and I know we have at ASCO some conversations about costs and disparities which I think are going to be for anyone listening or watching, those kinds of things that they can get from the ASCO website will also be really important.

One of the other things, though, that's so important about your move and one of the things that I think is so exciting is that you are yet another bridge that is connecting international collaborators around things like genomics and genetics, and around things like data sharing. So I'd love to hear how those processes work where you are now and what is your vision for continuing those collaborations and those exciting investigations, internationally, I hope, in the future.

Carmel Pezaro: Yeah. So one of the reasons I was so keen to move to the UK is that I've admired the STAMPEDE trial for a long time, and the idea behind the STAMPEDE trial of being able to do something... I mean, the STAMPEDE trial is far from simple, but to be able to ask relatively simple questions in large populations of men who are going through fairly similar to standard of care treatments.

Alicia Morgans: Yeah.

Carmel Pezaro: And I think that philosophy is really, really important. While I was in Australia I had the privilege of joining the IMDC Consortium, so I worked with Danny Heng and we provided de-identified patient data into that big data that they run, and we were able to answer some really interesting and important questions using real-world collected patient data. And I think that there is an enormous gap in prostate cancer. There are lots of fascinating studies being done, there are lots of really, good, big studies that are coming through. There's the beautiful Movember initiative, IRONMEN looking to prospectively collect information about men's experiences.

But over and above that, I don't think we're actually using data of the men we're currently treating for prostate cancer as well as we could. What I would love to see happen is for us all to come together with a similar concept to the IMDC to actually be able to share data of men going through this treatment in different treatment pathways, to actually be able to answer some really fundamental questions.

At the moment we either try and extrapolate from studies. Now, no matter how well a study is set up, it's always going to be limited by a size and by an inclusion and inclusion criteria sect. We make assumptions that men are a homogenous group and they're all the same and they respond the same, and we know that that's not the case, but actually to be able to drill down and ask this vexed question of volume versus response, "Is this really, fundamentally, the important point or are there some men whose prostate cancer actually responds in a different way? Is it because of genomics? Is there a subset that we can drill in and actually study in more detail?"

Those fundamental questions can actually come out of looking at big sets of de-identified patient data, and I think there's so much capacity and room to do that for prostate cancer, and I think there's some beautiful collaborations that are going on at the moment. There's the advanced prostate cancer consensus group out of St. Gallen. I think that kind of collaboration and willingness to work together actually could extend beautifully to looking at data and learning far more about the men that we're treating.

Alicia Morgans: You make an excellent point. So, are you now just thinking about some other things that you've mentioned, thinking about how our patients, the ones we treat in the clinic, don't necessarily fit all of the inclusion/exclusion criteria and in fact many times don't because of comorbid disease or other complicating factors. Those are the patients that really become the focus of the APCCC you know biannual meeting where we get together and discuss areas of gray data so that we can use the data that we have and expert consensus to guide our actual clinical practice because it is so far outside of the data itself in many cases.

And if that group, that consensus group, could potentially then also be a springboard for an international collaboration, that would be wonderful.

Carmel Pezaro: I think so too.

Alicia Morgans: So, we'll have to continue that conversation. I think that sounds great and we'll talk to Silka and Aurelius about that as well. So, I guess, your move and all that we aspire to and all that you aspire to are really such messages of hope. I'd love to hear, what is your overarching message to folks either dealing with prostate cancer or clinicians or researchers who are tackling this illness from a different vantage point? What is your message as an individual continuing to do her best to fight prostate cancer?

Carmel Pezaro: Yes. So, my message to men with prostate cancer is that, well, you're not alone. Not only are you not alone in the journey in your own country but there are men all over the world who are going through similar issues. We know it's not easy. We know that in some places actually the supports you might ideally have to help you deal with the financial impact of cancer, the social and emotional and psychological impact of prostate cancer, and the impact on your family through things like genomic testing and understanding more about why prostate cancer is actually occurring in you.

Those supports are challenging to provide and we don't have enough of any of those things, probably in every country, but we're trying and I think the more we can come together international and work with our international colleagues, the more we can start to understand. Perhaps there's something unique about your particular cancer and you might feel like it's not doing the same as the textbooks say it ought to or the trials say it ought to, but actually if we bring together huge amounts of patient data we can then learn why actually some groups are doing differently, and we may be able to then really explore and have something more suited to you in particular.

Alicia Morgans: Absolutely. So, really, continuing to participate in clinical trials, continuing to give your data to that, or, if you can't do clinical trials, to get engaged through participating in large data sets, things like the IRONMEN registry or even allowing your data to be used without your name attached through other registries or the Count Me In registry through the Dana-Farber. There are lots of ways where the data that you provide just by being a patient, in a system, could potentially help collaborate to work together to find new ways to personalize treatment and support services and other supports for patients, hopefully around the world. So, getting engaged, and there's definitely hope that we can and will do better.

Carmel Pezaro: Yeah. And I think for men with prostate cancer and for their families actually really getting in and advocating for saying, "Yes, we do want our particular situation to help teach us more about men with prostate cancer," because I think there are some challenges. There are challenges in terms of getting the legalities of sharing data, there are challenges in terms of getting through ethical hoops to actually make sure that we have all of the right permissions in the right countries, but actually, none of those are insurmountable. The value of every single person's data is enormous because it helps us to understand that actually men with prostate cancer are not all the same and they are not all the same as any of the important new trials coming through, and we actually need to study more about that.

Alicia Morgans: Absolutely. Thank you so much for your time today.

Carmel Pezaro: It was my pleasure. I'm really excited for this ASCO. I think it's going to be a great meeting.
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