Multidisciplinary Care Teams to Optimize Care of Patients with Bone Metastatic CRPC - Tanya Dorff
October 16, 2022
Tanya B. Dorff, MD., is an associate clinical professor in the Department of Medical Oncology & Therapeutics Research and serves as head of the genitourinary cancers program at City of Hope. She is an internationally recognized leader in prostate cancer and is renowned for her work in other genitourinary tumor types, including kidney, bladder, and penile cancer. City of Hope Comprehensive Cancer Center, Duarte, CA
Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, Massachusetts
Patient Selection for Treatment with Radium-223 - Tanya Dorff
Alicia Morgans: Hi. I'm so excited to be at ASCO 2022, where I have the opportunity to speak with Dr. Tanya Dorff about how we use multidisciplinary care teams to really optimize the care of our patients with bone metastatic CRPC. So thank you so much for talking with me today.
Tanya Dorff: Thanks for having me.
Alicia Morgans: Wonderful. Radium is such an interesting treatment. It's a radiopharmaceutical, it's been around for a long time. I know that you and I use it a lot in our clinics, but it's not something that I can just write an order for and send a patient to infusion and make sure that that patient gets the treatment this afternoon. I do need to put some work into really working with other team members, nuclear medicine physicians in my case, in some settings, radiation oncologists, and of course our teams within the med-onc clinic, to make sure that we give that treatment safely and effectively. So from your perspective, how do we best make all of that happen? How does it work in your clinic?
Tanya Dorff: So, my institution is a little unusual in that both nuclear medicine and radiation oncology administer radium-223. So I sort of get to see the best of both scenarios. With the nuclear medicine physicians, I think I tend to stay much more involved where dose by dose I'm sort of evaluating the patient. But one advantage of having radiation oncology administer is that they can also really look at a patient's pain and think about focal radiation as a patient's going through treatment and whether we're accomplishing everything we want to accomplish for a patient who is symptomatic. It was allowed in the ALSYMPCA trial, obviously to have palliative radiation as well, either before or during. So the radiation oncologists are very used to looking at patients with bone pain and trying to give them optimal treatment.
Alicia Morgans: That's such a great point because sometimes as you move through treatment with radium, you say to yourself, "Well, I'm not going to do targeted radiation to this bone at this time because maybe I'll get enough of a response with radium," because it can have a really pronounced effect on bone pain. However, after you get a few cycles in, maybe you'll say or maybe your radiation colleague would say, "You're still having pain, and we can do better." So having the opportunity to do that and knowing that you can do it safely as they did in the ALSYMPCA trial is very, very helpful.
Tanya Dorff: Yeah. So the challenge is that because radiation oncology is so used to managing patients, sometimes there's maybe less involvement. So for physicians who want to stay involved, I think you just schedule your patient. You know you need that CBC one week ahead, and then that's a great time to check on your patient or when you're seeing them for their LHRH therapy injection is another opportunity. But I like to be able to watch how a patient's progressing and be thinking about post-radium what we're doing and any sort of adjustments that need to be made along the way as well.
Alicia Morgans: So, it's really interesting the different models where radiation oncologists may take on a little more of the day-to-day care and the symptom support and thinking about using targeted radiation in addition to radium, whereas our nuclear medicine team members are also there. They're also engaged, but a little less hands-on perhaps in the day-to-day symptom management. When you are working with nuclear medicine, are you the team that is getting the CBC counts a week before treatment and ensuring that communication back with nuclear medicine or are they doing that in your practice?
Tanya Dorff: It's sort of a collaboration. I mean, we're typically the ones ordering it, but it's like having a second set of eyes. So, we might look at the results, but also the nuc-med team certainly doublechecks to make sure that the patient's counts are within range and appropriate for treatment.
Alicia Morgans: Well, that makes sense, and that's how it actually happens in my practice as well. The other thing that I really think about personally when I'm treating a patient with radium, and I appreciate when a nuclear medicine doctor or radiation oncologist might remind me too if I'm missing something, is bone health because I think all patients with metastatic CRPC are certainly eligible for up to monthly treatment with bone health agents like zoledronic acid or denosumab to prevent skeletal-related events. This of course remains important during treatment with radium. But how do you manage that? Are all of your patients already on bone health agents? Or is this something that you sometimes start as you're starting the radium?
Tanya Dorff: Yeah, that's a great point. I think bone health agents are particularly important in patients who have had a lot of exposure to AR-targeted therapy. I mean, we're not often using them concurrently with radium because there haven't been data showing an advantage to that. But even in those patients just who have been on them for many years, if they have not been on a bone health agent, then it is kind of a reminder, "Oh, we're starting this treatment. I absolutely need to make sure they're also getting that other form of bone support."
Alicia Morgans: It is, and not just because we need it with radium, we need it with all treatments in mCRPC. Radium's just only given in mCRPC so it always triggers that in my mind.
Tanya Dorff: Right. I mean, with the new upfront intensification, when patients are not castration-resistant, they may not be receiving bone support, certainly not with the stronger forms. It's more of a prophylactic. So, I do think there are more patients who are about to receive radium who have not been on bone health than might have been in the past where we're using Avir and [inaudible 00:05:23] in the CRPC space and maybe starting the bone support there. But yes, you're right, for any new treatment we're starting, we should always remember that mCRPC with bone mets we really need to be giving bone supportive agents.
Alicia Morgans: I agree. Well, what would your last little clinical pearl be as you're thinking about guiding those who are starting or are reinvigorating their multidisciplinary care teams for radiopharmaceutical treatment with radium?
Tanya Dorff: I think it's always good practice to just ensure there's communication among the teams so that sort of the patient's progress and the goals of the treatment are really clear between everyone who touches the patient. Can be really distressing for a patient if the physician administering the treatment tells them it's palliative, whereas we talk to them about a survival advantage. So getting everyone on the same page, the goal of the treatment is survival prolongation, we're also hoping for pain palliation, I think is helpful for having a consistent message.
Alicia Morgans: I think that's a great piece of advice and it's not just our colleagues meaning our physicians, it's also our colleagues and collaborators on the nursing team, the imaging team and certainly our own team to make sure that we're clear about the purpose of treatment. Expectations really, really matter. Whether they're communicated by our team or any other team, we should really be consistent, so thank you for that. I always appreciate your time and your expertise.
Tanya Dorff: Thanks.