The Role of Urologists in Managing De Novo Metastatic Prostate Cancer - Benjamin Lowentritt

April 15, 2024

Alicia Morgans engages in a discussion with Benjamin Lowentritt, focusing on comprehensive care for prostate cancer patients, particularly those with de novo metastatic hormone-sensitive disease. Dr. Lowentritt shares a patient case illustrating the challenges and strategies in managing such cases over time. They emphasize the importance of multidisciplinary teams and seamless communication between urologists and medical oncologists to ensure optimal patient care. Dr. Lowentritt discusses his approach to discussing treatment options like chemotherapy, highlighting the importance of presenting it as a collaborative decision-making process. The conversation underscores the significance of building strong collaborative relationships and effective handoffs in providing comprehensive care for patients with advanced prostate cancer.


Benjamin Lowentritt, MD, FACS, Medical Director, Prostate Cancer Program, Chesapeake Urology, MD

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, MA

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Alicia Morgans: Hi. I'm so excited to be here today with Dr. Ben Lowentritt, who is joining me from Chesapeake Urology, where he is a urologist who runs the Comprehensive Prostate Cancer Program. I'm so excited to be here with you.

Benjamin Lowentritt: Thank you so much for having me.

Alicia Morgans: Wonderful. So, Ben, I really wanted to talk to folks who are doing their best across the country to ensure that multidisciplinary teams are providing the care that prostate cancer patients need, especially as they're diagnosed with de novo metastatic hormone-sensitive disease, which can be a really complex disease state, and there are so many boxes to check as we take care of these patients. I think you have a patient in mind that you wanted to share, and we can kind of talk about how you do this in your practice and make everything work.

Benjamin Lowentritt: No, thank you very much. I picked a patient that none of these... No two patients are the same. So I picked a patient with a little bit of an interesting story that we'll run through quickly and then hopefully spark some discussion. So thank you so much. So, this is my patient. He initially presented, this is back in 2014, at age 58. After attending a community cancer screening event, which is probably its own set of discussions at that point. But he, at the time, had only one previous PSA that we could find, which was 0.2. And when we screened him at age 58, it had gone up to 4.9. He did have a family history of prostate cancer, but like so many men, it hadn’t critically impacted his family members' lives, and they were both doing well.

At the time, he was not really experiencing any lower urinary tract symptoms. So we did do a biopsy based on that rise, which we confirmed first. And this was what the finding was. So the take home here was he had, based on the number of cores that he had, unfavorable intermediate risk disease, he had some Gleason group 2. But overall, not a terribly aggressive pattern and at the time, was counseled as to his options. Unfortunately, he chose the option of not responding to phone calls, letters, and other things that we tried to do to get him to follow up. Then we sort of fast-forward eight years, unfortunately. And at that point, he had been getting his PSAs occasionally by his primary care provider and when he came back to us, his PSA had jumped up to 47.

He remained asymptomatic. At that time, this was 2022, we had just seen the entrance of PSMA PET into the commercial space where we tried to get it for him, but his plan was not covering it. So conventional imaging was negative, and we were counseling him as to options for now his high-risk disease, which we were concerned about micrometastases but couldn't find any real evidence of specific areas. Unfortunately, he vanished again for about a seven, eight-month period. And when we did finally get him back in, he now had a palpable nodule above his left clavicle. So obviously, we were very concerned. He remained, though, otherwise doing very well. His PSA had gone up to 289 and this is actually his imaging.

So, this is a super scan with multiple lymph nodes up and down the retroperitoneum and mediastinum, and into the supraclavicular area, as well as a number of areas of bone involvement. So, he still has very good functional status. And at this point, we needed to discuss, "Okay. Clearly, this was no longer curative, but we needed to try to do what we could to help get this under control." He's, at this point, age 67 with metastatic hormone-sensitive prostate cancer. You would still call this essentially de novo metastatic hormone-sensitive prostate cancer or synchronous, but we actually saw his longer-term pattern over the course of about a nine-year period. We talked about options including at least ADT, the possibility of adding on an oral therapy and, given what has now become an option, the combination of triplet therapy was discussed. And he, at this point, was willing to be very aggressive and try to take what he considered a more modern approach.

At that point, I am in a urology practice where we do offer a number of the options that are real listing. I do not, though, give docetaxel in my practice and we partner with our local medical oncologists in general to do this, and he was referred to the medical oncologist in the adjacent hospital. At the same time, we planned and got a biopsy of that supraclavicular node which confirmed the prostate cancer. So, the next few weeks, we had a fairly optimal series of events that happened. He started on ADT with an antagonist, was started on darolutamide and within a few weeks his first cycle of docetaxel. So, once we got him to agree to treatment, we were able to coordinate that across our two sites of care between the hormonal therapies which were being managed in my practice and the docetaxel in the medical oncology practice. To get up to date, he's completed five cycles of docetaxel.

He did hold his last dose because of some signs of neuropathy but remains on ADT and darolutamide. We did have the discussion about bone health, and he receives denosumab now in the urology office. During the timeframe of the early period that we were evaluating him and when he got the biopsy, the lymph node, we did both germline and somatic genomic testing and there were no actionable mutations. His most recent PSA is at a very good level, and we continue to follow him up more regularly in my clinic, but also periodically with the medical oncologist as needed. So that is my quick presentation. But I think in my approach to this, because we are so focused in our community-based practice on prostate cancer, it's essentially the main focus of a lot of our work in cancer that this is more typically how we treat these patients.

I think it is not necessarily true or similar to what other people do, but it's really about getting the optimal treatment for the patient. And I think some of my medical oncology colleagues in the community recognize that we have more resources because we've dedicated more resources very specifically to these patients.

Alicia Morgans: Well, I think this is, in some ways, kind of a tragedy that this transpired the way that it did. But it also, I think, is a success story in that you were able to keep that connection with the patient over time and identify a period of time when the patient was willing to get treatment. You connected, you were all on the same page, and you didn't just do the bare minimum. You actually did the guideline-recommended treatment for aggressive disease in this way. And he is, thankfully, having a great response. So I really do congratulate you and the team for sticking with the patient and the patient for sticking with it because it's not always easy as is very clear in this story. But one of the things that's also really important is that especially as patients are not as excited about their treatment and may have a history of non-adherence, it can be even harder to get them to go through the extra steps of reaching out to additional doctors, new teams, and trying to get other therapies that you may not provide in your clinic.

So how do you work with your medical oncology colleagues to make that as seamless as possible so that when you do connect and get those patients going, they don't feel as challenged by that sort of transition and co-management as they could?

Benjamin Lowentritt: I really appreciate the question and the opportunity to speak to this, and I wish I could say it always worked this seamlessly. It certainly doesn't, and I think there are many reasons for that. I mean, they can be as basic as my outpatient office setting not being on the same portal or EMR as the medical oncologist, and something as granular as that. But really, it is about developing the relationships and the understanding of what the patients are able to get from our type of practice, and what's the strength of the medical oncology practice that we're working with. For instance, we co-manage now fairly routinely patients who are going to be on, say, a PARP inhibitor that have more advanced disease with another candidate. And a lot of that is because of the comfort with some of the hematologic side effects, for example. And clearly, as a urologist, it's not what I'm most comfortable dealing with, there are some of the complications of these medicines that are used very commonly in medical oncology and not so much in urology.

At the same time, though, we are able to create a specialized focus for patients around some of the other things like bone health, and their GU symptoms, and other complications that tend to come up unfortunately, whether it's ureter obstruction, or urinary symptoms, or hematuria, or any of these. Oftentimes there are primarily urologic concerns going on for the patients as well who's actually giving the medications in some respects as long as they're being monitored appropriately and we're addressing some of the other surrounding concerns around their cancer, their general health, and other things. I mean, we focus heavily on that. We also have tried to create a bit of a multi-tiered service where we do as much monitoring and kind of routine treatment close to their home as possible and have specialized services that are a little bit more central. So the patients are often being seen by APPs within my practice in their local office.

It's not necessarily coming to the site where I personally am. But they're also coming to see me periodically and we share, we communicate. That same type of communication that happens with the medical oncologist as well. And in fact, we've cultivated relationships between our APPs and the APPs in the medical oncology practices because they're also involved similarly throughout the care. So it doesn't always work, and I think the challenge in a larger group with a larger geography, and I think it's true for anyone in any kind of geography. But there are a lot of different providers out there, a lot of different medical oncologists, a lot of different urologists, a lot of different primary care physicians, and a lot of different individual patient experiences that make all of this maybe need to change slightly. But it really all comes down to communication. And I have their cell phone number and they have mine, of my medical oncologists. We try to touch base whenever we have a patient like this so that, truly, they don't get lost like this patient had been previously.

But also, just to make sure that the patient isn't feeling like they're caught in the middle of something because they feel like they're hearing two different messages. And I think that, to me, is at the core of this: I've experienced where the patient feels like there's a bit of a tug-of-war because the recommendations may be slightly different, or the emphasis may be slightly different even if the recommendations aren't. So I think we've tried to mature those relationships as much as possible.

Alicia Morgans: Well, that's clear, and that's such a great message that it's really about communication between doctors and having the trust and understanding of what's going to be done at one place versus another. And probably, also being willing to double-check and say, "Okay. Well, bone health is being done here, but genetics was done here. And making sure that the boxes are all checked," as I said before. So that's great because, at the end of the day, like you said, it's all about the patient and making sure that who's doing it is less important than the fact that it is getting done. And so that's great. Now, I wonder, you said you have the medical oncologist's numbers ready to go. So I love that you are able to be available in a geographic spread for people, you might have different medical oncologists depending on where patients are.

But it also sounds like you and your nurse practitioners, your PA team members also have connections with their counterparts in the medical oncology and probably, radiation oncology clinics too. Is this something that you've really emulated from a top-down sort of an approach to ensure it is also being emulated, I should say, by the team?

Benjamin Lowentritt: Yes. And really, the APPs, I should have mentioned the navigators as well, and actually, maybe more importantly, the navigators because they tend to be the ones trying to get the patients back and forth to the different locations and the way things work. But yes, absolutely. And in fact, I would say in some ways that's even more important. In a lot of the medical oncology groups that we send to, even though I might have my one that I want the patient to see, they end up seeing whoever was available most quickly within that practice, who may or may not have a GU focus. So oftentimes, it is that navigator or that APP, that's the common link within a practice that may not have a GU specialist. So I think it's actually been in some ways more helpful to have some of those broader connections as opposed to just the doctor-to-doctor connection to make this most effective.

Alicia Morgans: That's great. And then the last question for you, because you've shared so many great insights, is how do you, as a urologist, speak to things like chemotherapy or you mentioned PARP inhibitors so that they don't feel like these are incredibly scary and foreign things. Because I think that that conversation when started by a urologist is so much easier when a medical oncologist then approaches the topic. And so I would just love to hear your insights there.

Benjamin Lowentritt: I think I've evolved on this. I think it's both because I do think that the role of docetaxel and with triplet therapy now as an option, and so clearly proven as an advantage, the triplet therapy over the doublet therapy, I do feel like I have been able to have those conversations in a much clearer way with patients to say, "Listen, I want to send you to an expert in this who's going to be able to assess if you're a good candidate for it." I don't try to tell them that they are because I've had many patients come back and they're telling me, "Oh, the doctor says I'm not fit enough," because I didn't understand one of their underlying medical conditions that was a concern. So I try to tee it up as, "Hey, this is truly going to be a discussion. I'm not sending you there to get chemo. I'm sending you there to discuss chemo. I believe it's your best possible option."

Now, during that time, I'm generally starting them on an oral therapy so they don't feel like they're caught in no man's land, and they can begin therapy. And I think that helps as well because then they can say, "Hey..." It's a very easy story to tell someone that we're going to be aggressive with this really high-risk disease and attack it from multiple angles. That's a very simple message that I'm able to deliver. And then I think it's easier for the medical oncologist to take it from there. I have tried to start sending patients that I think are even more borderline, not letting myself make the biased opinion that, "Hey, chemo is bad," or something. And understand that, "Listen, some of these patients, we're going to have to manage them through chemo, but it still probably will give them an advantage over time."

And so I think it has been a learning experience on my behalf, but I've tried to... Once again, as I get more comfortable with some of those relationships, it's a lot easier to lean on them and think it's going to be a continuing positive discussion, also with the patient coming back because there have been interactions where the patient comes back and feels like, "Well, the medical oncologist says, 'I don't need to see you anymore.'" And that's not positive for the overall discussion. And I think that actually just came from a bit of a misunderstanding of the interest in continuing to manage patients versus not and sort of the typical medical oncology experience. So we've gotten past a lot of that, hopefully now.

Alicia Morgans: Wow. Well, really, so impressive, and I love the way that you're calling it really a conversation and just like I could say, "Hey, I'm going to send you to the urologist because it's possible you may benefit from a TURP, or maybe you need self-intermittent catheterization, or whatever it is. But they're going to help you understand what the right option is for you. And maybe it's just time and waiting." That's how I can tee that up. And in a similar way, you tee up, "This is a conversation, I think it's a great idea for you to consider. Why don't you talk to that doctor about it?" That's really, really great advice, Ben. So thank you for that really insightful piece. So as we wrap up, what would your final words be to listeners as they're trying to make their own really successful collaborative relationships and work with patients with advanced prostate cancer?

Benjamin Lowentritt: When I talk to my urology colleagues about this, obviously, we've accepted that we want to be involved maybe a little bit more deeply than some might. I think the key components are still, though, recognizing when to involve a colleague and making sure that you've had some of these discussions so that you know the most effective way to make that happen. The last thing in the world you want to do is to be able to just hand something to the patient and say, "Here are some phone numbers. Good luck. I've done all I can." That's where you feel broken inside. So I think that developing the relationships and the way to do the handoffs, whether they're one way, or two-way, or whatever it may be, is really critical and where to spend some time.

Alicia Morgans: I think that's great advice. So keep up the great work, Dr. Lowentritt. And thank you so much for taking the time to talk today.

Benjamin Lowentritt: Of course. Thank you very much.