Better guidelines, coordination needed for prostate cancer specialists

With a deluge of promising new drug treatments for advanced prostate cancer on the market, a new model of care is needed that emphasizes collaboration between urologists and medical oncologists, according to UC Davis prostate cancer experts.

In an article published online today in the journal Urologic Oncology, urologist Ralph de Vere White and medical oncologist Primo Lara, Jr. of the UC Davis Comprehensive Cancer Center describe a framework for urology and medical oncology interactions to enhance patient care, improve outcomes and yield clinical research advances.

The physicians aim to address the general lack of collaboration between the two specialties when patients with prostate cancer develop resistance to drugs that block the hormone testosterone, which fuels prostate cancer growth. Until now, only a handful of medications, including chemotherapies, have been available for this group of patients. All of the new drugs on the market for prostate cancer are designed to treat these so-called "castrate-resistant" patients.

"Patients with castrate-resistant prostate cancer (CRPC) will benefit if all caregivers buy into an integrated and comprehensive approach," said de Vere White, who also directs the UC Davis Comprehensive Cancer Center. "When both specialties jointly manage the CRPC patient from the start, the artificial boundaries between specialties dissolve and transitions of care become seamless."

The UC Davis experts explain that castration-resistant prostate cancer patients are now often managed by either a medical oncologist (who specializes in chemotherapy treatment) or a urologist (who specializes in surgery to remove a cancerous prostate). Historically, urologists have referred patients to medical oncologists after their cancers become castrate resistant, and chemotherapy or other types of treatment are warranted.

The new drugs, sipuleucel-T, radium 223, enzalutamide, abiraterone, and cabazitaxel, vary in their mechanism of action, but all target castrate-resistant disease, and some can be prescribed by either medical specialist.

"There is an extra level of complication that this scenario engenders," Lara said. "It has become blurry - who manages what, and when."

Clinical dilemmas have arisen in which clinicians are not clear on whether patients should be treated similarly or which drugs should be used and in what order to be most effective.

"With so many new drugs, how do you use them, and in what sequence?" Lara asks. "Is one better than the other? While we don't have those answers, we can work on a framework to deliver patient-centered treatment."

Lara and de Vere White call for a urology-medical oncology partnership to establish consensus guidelines to identify the most appropriate sequence of available therapeutic options and clearly define treatment goals and responsibilities of each provider throughout the trajectory of a prostate cancer patient's care.