ADT in Prostate Cancer: Managing Cardiovascular Risk - Episode 8
Susan F. Slovin, M.D., Ph.D.: I think it’s wonderful that you’ve had such a significant change in your attitude, and I think you have an inner core of strength. But what’s come out of this whole experience I think is very interesting for everyone, and we’re seeing this in different aspects of oncology, is the role of cardiology, and what we call cardio-oncology, which is a completely new area of endeavor. And we’re seeing that particularly with just about any potential drug that can cause a cardiac manifestation. We are now really monitoring these people very carefully. So this is really an extremely important area of endeavor. I think we could do better in prostate, quite frankly, especially with introducing cardiology input very early on.
Andy Rochester: Just make it a requirement really.
Susan F. Slovin, M.D., Ph.D.: But it’s hard to enforce. As much as I would agree with you, it’s very hard to enforce and there are insurance constraints. But I think communication.
Andy Rochester: Probably the first thing I’m going to ask somebody though, if I wind up talking to somebody who’s going on to ADT [androgen deprivation therapy], I’ll just say, how’s your cardiologist going on with all of it.
Susan F. Slovin, M.D., Ph.D.: You’re absolutely right. If you were to meet somebody today for the very first time and they have newly diagnosed prostate cancer, irrespective of the Gleason score, the number of cores, the scans are not done yet, how would you direct them? What would you tell them to do? A lot of people come and say, “Well we want to meet with this doctor, and then we’ll make a decision. We read this on the internet, we want to see this specific person.” So what’s your global gestalt? You’ve been through the mill now, you’ve met many different disciplines that were involved in your care, but when someone who’s newly diagnosed, they really don’t know where to go and how to do it. And I think they get a little misguided because Joe Blow next door makes a recommendation, and everybody seems to think that their cancer is the same, when it can be very different in every person.
Andy Rochester: I really like the idea of another opinion, and I like to get an opinion from somebody who is from what I’d call either a magnet system or a hospital of excellence, etcetera.
Susan F. Slovin, M.D., Ph.D.: So they should go for either a major comprehensive cancer center?
Andy Rochester: One of the upper tiers—Mayo Clinic, MSK [Memorial Sloan Kettering Cancer Center], the Boston ones. But it bears that because there can be very fine local physicians, but they’re not going to have the depth, perhaps, that someone who does that every day and is part of a team 60 other oncologists, and they’re feeding information, and so forth. This is one of those things that’s such a big moment in your life. And I’ve had people at work who, they get diagnosed with breast cancer, and they’re working with a very good regional center, and they’ve got questions. And I’ll say, “Have you considered going to a major center just to see if they think that’s really the same approach?” And if they agree, they’ll say, “Hey, you know what, you’re fine. Your regional center, they’ve got this thing.” And it’ll either be a tiebreaker, or it’ll make them feel better about the choice that they made.
Susan F. Slovin, M.D., Ph.D.: Should patients see a urologist, medical oncologist and radiation oncologist for the true multidisciplinary approach? Or do you think they should go in a step by step referral? Because sometimes so much information just floods the system.
Andy Rochester: Plus, you’ve got people who are in the watchful stage.
Susan F. Slovin, M.D., Ph.D.: That’s different, it’s a different category.
Andy Rochester: OK, not going there. So this is somebody who really is going to be moving into an active treatment setting.
Susan F. Slovin, M.D., Ph.D.: That’s exactly right.
Andy Rochester: OK. So if they’re going to go into active treatment then, yes. I would like to discuss it with the other people, the other specialists, because in my case it was very helpful. Because, you know the thing is, we used radiology. I didn’t start with radiology. We almost started with surgery. We went with you and chemical oncology. But the catch is that having the rapport and having already started a relationship with Dr. Michael Zelefsky M.D., I found to be helpful. There he is, part of the team and so forth. And so when you said, you’re going to radiology, then it’s like, who’s that?
Susan F. Slovin, M.D., Ph.D.: What about clinical trials? I believe that when you and I first met we were looking toward a clinical trial because we very often will use standard drugs, but in a very novel way. And I believe that because you had the metastases we couldn’t enroll you at that point.
Andy Rochester: Right.
Susan F. Slovin, M.D., Ph.D.: But as a patient, does that appeal to you? Because we hear so many misguided statements from patients, “Oh, I don’t want to be a victim; I don’t want to be a guinea pig.” And I think people sometimes lose the opportunity to try novel drugs that may really change the biology of their cancer very early on.
Andy Rochester: Yes.
Susan F. Slovin, M.D., Ph.D.: Were you disappointed when I had to tell you, no?
Andy Rochester: No. Because I pretty much trust you implicitly.
Susan F. Slovin, M.D., Ph.D.: Thank you.
Andy Rochester: Well you engender that. But here’s the thing. The catch is that if you get someone in a scenario like that, they have an opportunity to go in this, now correct me if I’m wrong because I don’t spend a lot of time doing background research. There’s been a change in how these trials are done. Before there would be a placebo arm and then there would be an active treatment arm. Then I would see some people that would then, they’d get flipped if it—and you’re the specialist in this area so please correct me—sometimes the studies would end and the placebo arm would never be treated with an active agent.
And more recently I’m seeing things where whether it’s drug A combination, a drug B combination, or a placebo and an active agent, there’s what I call a humane approach that’s been applied, which is as soon as the study has reached some point of findings where, yes, this is the way to go, that sometimes the other arm is flipped active. So I’m saying I’m beginning to see that happen. That may allay some of the people’s fears who are saying, I’m a guinea pig, I’ve got a 50% chance of getting something that will help me. And if I’m in the other arm, I’m only going to help science.
Susan F. Slovin, M.D., Ph.D.: You’re actually quite right. I guess in going forward for patients who come in, I think candor is very important.
Andy Rochester: Right.
Susan F. Slovin, M.D., Ph.D.: Although very often patients do really not want to hear what you have to say. Or sometimes people come in and they don’t want to change their lifestyle.
Transcript Edited for Clarity