Alicia Morgans: Well, thank you so much for having me. I'm excited to be here.
Zachary Klaassen: This could be a 60-minute answer, but in terms of the landscape of where we're in, doublet therapy, triplet therapy, what are we looking at? What's important about survival, quality of life that leads to these shared decision-making discussions?
Alicia Morgans: Well, it's such a good and important question because it's not even just in the metastatic hormone-sensitive setting anymore. I mean, we have so many options even coming into that space, but also in the mCRPC space. And it's so critical that we take the time to make sure that we match the right treatment to the right patient, but we don't have the time necessarily to sit for half a day and have a conversation about these things. I really try in whatever brief amount of time that I have to understand going in what I think the best option or options might be for a patient. I don't try to necessarily make that decision for them, of course, but I try to understand what I think I want to do before I get in, because if you get in and everybody is a zone of gray, then you're not going to actually ever get to your conclusion.
I then would want to, of course, talk to the patient about what are your priorities, and what do you want out of this treatment? And I try to do that again in a bit of a directed way. What are your goals? At this point, we have metastatic hormone-sensitive disease.
We're not able to treat this disease with curative intent. If you are on a spectrum from, I want to maximize my survival, and I don't care at all about my quality of life, versus I want to maximize my quality of life, and I don't care at all about life prolongation, where do you sit on that spectrum? And I use that pretty regularly, and try to get people to help me understand where they sit. And that's a pretty directed question that people are usually able to come to the table with.
I also try to understand and be very observant in that visit, what is the patient's functional status? I watch them as they're walking in, sitting down. What is their support system? And I try to understand what are they dealing with. And when I think about things, again, maybe in a later disease setting than MHSPC, like radioligand therapy, what restrictions might you have in terms of isolating, being away from individuals?
I'm often surprised to hear people have grandchildren or other people in the family that they need to take care of. And so this can be a barrier, but really, actually, with radioligand therapy, that's very specific, but we never know when these things ultimately may come into the metastatic hormone-sensitive setting and be important aspects of that decision-making.
Zachary Klaassen: That's a great answer. You know what? I think about shared decision-making. It's almost like it takes some practice for us to learn how to do it.
Alicia Morgans: Yeah.
Zachary Klaassen: Is there a way that you do it efficiently, where the patient feels like they've got the amount of time that they need? Is there a playbook? Do you sort of adjust the playbook based on what you're seeing from the patient?
Alicia Morgans: Well, I think making sure that there's a little bit of time to do this over visits is really helpful because some patients are able to make that decision pretty quickly when they reflect and when you're pointed about these questions, and know, again, what you think should happen going into it. But some patients do need a little bit more time, and I think there's nothing more uncomfortable than feeling like your doctor is pushing you to do something, or not listening when you feel like you have concerns or questions that are unanswered. So doing this over a couple of visits is helpful, and in MHSPC, we have the opportunity to do that. I often start ADT, then a month later have them come back for a safety and tolerance check, then we'll start my ARPI, and we're always talking about if chemotherapy is in the mix, whether chemo should be added, and we think about that over time.
The other thing that I try to do is use my team. So, I am fortunate to have nurses, nurse navigators, as well as NP and PA team members, who can also reach out on the side if there's something that I feel is left undone, or a person is having some difficulty, we can set up another visit, maybe with them. Because sometimes patients feel like having a different person listening is allowing them to either think things through a little differently, or maybe share in ways that they didn't feel comfortable with the doctor. And I mean, we should never take that personally, but sometimes people or their family just feel more comfortable talking about things with different team members. So engaging them, and having them listen, too, can be a really helpful way of making these choices.
Zachary Klaassen: It's very helpful. When we see some of these older patients, and maybe it's a granddaughter brings a patient in, maybe it's the brother, maybe it's their neighbor, how do you engage the other people in the room? Because they'll often tell us stuff that the patient may or may not say, and that's important. How do you use that in your clinic?
Alicia Morgans: Yeah, I think I do try to involve them in the discussion. Sometimes it can be challenging because sometimes the person's preferences, the other person in the room don't necessarily align with what the patient wants to do.
Zachary Klaassen: Good point.
Alicia Morgans: So, I try to suss it out but then use them to the extent that the patient feels is helpful. As an example, I have had partners sometimes say do everything or basically do nothing where the patient is either more middle of the road or in the opposite direction, and that can be a little bit of a challenge. So I try to work between the two of them, and say, "Well, what I'm hearing from you is this, but what I'm hearing from him is that. So, where can we meet in the middle?" And then kind of let them hash it out a little bit in between.
Otherwise though, I think these individuals can be so helpful as I try to understand what limitations, what barriers might this person have that are not really being shared out in the open: concerns about memory loss, concerns about safety around chemotherapy can be brought to the table more often sometimes by family, rather than the patient himself who still feels like the king of the world and that he can do everything and anything, and I want him to, but not if it's not going to be safe for us to take care of him that way.
Zachary Klaassen: Yeah, that's true. There may be some trainees or residents and fellows listening to us. This is not easy. It does take some practice as you mentioned. Any other tips or tricks we haven't hit on before we wrap up?
Alicia Morgans: One of the things I've learned after doing this for many, many years is that we, as physicians, do need to help guide our patients a little bit.
Zachary Klaassen: Yes.
Alicia Morgans: I remember coming out of medical school and thinking, "Shared decision-making means 100% patient autonomy. I give them the decision, I back off, and I just let them decide." But that's actually not what it is. It is a partnership in the decision-making, and sometimes it's completely appropriate for a patient to say, "I don't know. And I feel so anxious because you're giving all of this to me, help guide me."
And it's really important for us to not let patients get to that position, and help them arrive with us at a point of decision. So that would be my biggest piece of advice for young people. It's you are not taking away someone's autonomy by guiding them appropriately. That is what we're supposed to do, and don't feel like you're dictating your wishes over theirs when we work together.
Zachary Klaassen: It's okay to answer the question, Doc, what would you do?
Alicia Morgans: Yes. Yes, it is.
Zachary Klaassen: I think that's important, too. Alicia, always so gracious with your time. Fantastic discussion. Shared decision-making is something we're seeing in all aspects of prostate cancer, for sure in the metastatic hormone-sensitive prostate cancer state. Thank you so much.
Alicia Morgans: Thank you so much.