Alicia Morgans, MD, MPH

How do you educate patients and caregivers in your practice about prostate cancer?

 When patients and their caregivers ask me for resources for education about prostate cancer, I often refer them to places like the Prostate Cancer Foundation to look up thoroughly curated, tested and checked material because there is the opportunity for misinformation on the internet when it comes to prostate cancer care or any kind of cancer care, for that matter. Having a trusted resource is really important. The Prostate Cancer Foundation has some great pamphlets and information that has been checked by physicians and clinical teams to make sure that all of the things in there are updated and true.

The other place that I often send patients is to the ZERO Prostate Cancer website, which is really nice because it also has curated information that I can trust and that patients can trust, but also has access to support group information so that patients, no matter where they live in the country, can find a support group that might be a place where they can go in person or perhaps online to hear stories from patients like them and to ask questions of other people who are going through what they've gone through or who have gone through what they're going through. These kinds of resources are really important.

I would also say that I encourage patients to ask their medical teams when they do have questions. Because even if you find something online at a trusted source, it may not necessarily translate in a way that makes sense to you when you read it, or you may have some misunderstanding about what you're reading because some of this stuff is really complicated. When things don't make sense, or even just to make sure that you have your information straight, it's really a good thing to ask your nursing team, your doctor team, your nutrition or dietitian team member, or your physical therapist about what you're reading and really make sure that what you're reading and think you understand is absolutely correct.

If I had to give some advice to someone who was newly diagnosed with prostate cancer and was heading to their doctor to work through a treatment plan, I would encourage people to say to their doctor, “Can you tell me and make sure that I understand, is this cancer curable or not? Is it treatable but not curable? What's the best treatment plan to be the most aggressive that I can be against my cancer? And what options do I have in terms of making sure that my quality of life and my day-to-day life is actually preserved as much as possible?”

I would also encourage people to be really candid about questions they have when it comes to their sexual health, mental health and physical health, because there are changes that happen in someone's body when they go through treatments like androgen deprivation therapy, or ADT, that affect all of those things and many other areas, too. Being bold to ask the questions that you really have is important. No doctor, nurse or health care team member is going to judge you. And if they do, it's okay to get another team or another doctor. If you wonder, “Is my sexual health going to be the same after I get treatment for prostate cancer?” Depending on what your treatment is, the answer will be different. Your sexual health can be improved, maintained, can be better even if you have some changes in it. But it's important to ask the questions, “How do I get there? Who can help me improve my erectile dysfunction? Who can help me improve issues that I have with libido?” Whatever the question is. But that is probably one of the most under-discussed areas in prostate cancer that is most meaningful to patients.

I would also really encourage people to talk with their doctor or their clinical team about mental health because having a cancer diagnosis in itself can put someone at very high risk for developing depression or having adjustment issues that may be helped by counseling or by medications. And it's not to say that it is anyone's fault or that you're weak if you develop mental health concerns like anxiety or depression. It's a physiologic change that happens because of the way bodies respond to stress. And we have treatments, including counseling and medicines, that can help you feel better. And finally, sleep is something that can be affected. Always ask about sleep and if there are any things that you can do to feel better. But I think the supportive needs of people with prostate cancer are things that we don't discuss enough. Be empowered to ask your doctor. Be empowered to say, “Is my treatment the right treatment for me? What options do I have?”, if you ever feel like you're going down the wrong road or you just want to make sure from the get-go.

Transcript is AI-generated and edited for clarity and readability.

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Alicia Morgans, MD, MPH, offers advice to patients newly diagnosed with prostate cancer and reviews educational resources available for patients and their caregivers.

Educating Patients and Caregivers About Prostate Cancer

For patients with metastatic hormone-sensitive prostate cancer, what are the treatment options?

 Metastatic hormone-sensitive prostate cancer is a particular type or stage of prostate cancer in which the cancer has spread outside of the prostate—that's the metastatic term—and hormone-sensitive means that it hasn't yet been treated with androgen deprivation therapy [ADT] to lower testosterone and shut down the cancer cells, so it's presumed to be sensitive to that hormonal manipulation or decrease of testosterone that we cause with androgen deprivation therapy.

We see patients with all versions of metastatic hormone-sensitive prostate cancer, in that it can be de novo metastatic, meaning that from the time of diagnosis, the first time someone heard he had prostate cancer, it had spread outside of the prostate and was metastatic from the start. It can be recurrent metastatic hormone-sensitive prostate cancer, meaning that the patient was diagnosed with prostate cancer that was all in the prostate or just around the prostate in the past but it came back after initial treatment and now is metastatic and has spread outside. It can be a small amount of metastatic hormone-sensitive prostate cancer, with maybe one spot of metastatic spread into the bone or a lymph node outside of the prostate somewhere. Or it can be really high-volume metastatic hormone-sensitive prostate cancer, with many spots of areas of spread of prostate cancer outside of the prostate into other areas.

No matter where prostate cancer spreads, whether it's into the bone, liver, lungs or lymph nodes, it is still prostate cancer cells that are in those areas. Metastatic prostate cancer just means the cancer cells that used to be in the prostate picked up and have moved outside and now live somewhere else but there are still prostate cancer cells. We treat metastatic hormone-sensitive prostate cancer with various things, but the backbone of what we do is androgen deprivation therapy, lowering testosterone to starve those cancer cells wherever they are in the body [to] really shut them down.

We know, based on data from multiple clinical trials, that lowering testosterone with ADT alone is not enough to really shut down these cells effectively for as long as possible, and we can do better by adding on additional pills that can further decrease the testosterone signaling and, sometimes, by adding on chemotherapy to really use another form of medicines to attack even more intensely and aggressively. We use an understanding of how much prostate cancer has spread outside of the prostate to help us make some of these decisions with the use of chemotherapy added on to ADT and hormonal-targeting pills for people who have high-volume prostate cancer and de novo metastatic prostate cancer much more commonly than we do for low-volume prostate cancer or recurrent prostate cancer. To put that a little more clearly, we try to target more advanced or aggressive prostate cancer—de novo metastatic and high-volume metastatic cancer—by using more intensive therapies that include ADT, hormonal pills and, often, chemotherapy. Of course, this is only going to work in settings where the patient is actually well enough, strong enough and fit enough to get chemotherapy and wants to get chemotherapy. But that is the setting where we use triplet therapy with ADT, hormonal pills and chemotherapy to try to be really aggressive against the cancer.

When patients have recurrent prostate cancer or low amounts of prostate cancer, low-volume prostate cancer, we sometimes think about using just the ADT and the hormonal pills and sometimes even add on radiation to the prostate to try to use the tools that we can to have the best control of the cancer cells and hopefully the longest prolongation of survival for the person—we want to help the person live for as long as he possibly can. And we're always, no matter what we're choosing for treatment, trying to make sure that the therapies that we're choosing help the person feel as well as he can feel during treatment. We think a lot about which choices for therapy we want for an individual patient, and we talk with patients and make shared decisions about which approach might be best. But understanding the amount of cancer spread that's metastatic and understanding if it has come back after we've previously treated the prostate or is newly metastatic right out of the gate can help us make some of those decisions, as well as thinking about how the patient feels and what he wants in terms of his treatment.

A comprehensive review of treatment options for patients with metastatic hormone-sensitive prostate cancer.

Metastatic Hormone-Sensitive Prostate Cancer Treatment Options

 Androgen deprivation therapy, sometimes called ADT or hormonal therapy, is a way of treating prostate cancer that is used pretty ubiquitously or used pretty uniformly for patients when the cancer is more advanced or has spread outside of the prostate, perhaps even throughout the body. This form of treatment is not giving androgens or giving hormones but actually decreasing hormone levels, particularly testosterone, that male hormone that goes up in patients or individuals when they go through puberty, and is also the hormone that drives prostate cancer cells to grow, divide, spread and cause the trouble that they cause.

When we use androgen deprivation therapy, we are lowering testosterone levels typically by turning off the testes from making testosterone. This starves cancer cells, causing them to shut down, causing some to essentially self-destruct or die, and causing others to go into a deep hibernation state where they are not going to be able to grow, divide, spread and cause trouble. They just sort of sit still and shrink. And that from a patient perspective and from a doctor perspective is really important and is what we want. We want to shut it all down. There are other things that we can add that are more hormonal therapies to further decrease that testosterone from driving cancer cells. But the ADT, or androgen deprivation therapy, is really just shutting off the testes.

It's important to know that there are several types of ADT. Of course, one is a surgical type, so you can remove the part of the testes on both sides that makes testosterone, and that's a surgical procedure. But more commonly, people use medications to have ADT or use treatment with ADT. Those medications can either be GnRH agonists, which is just a type of a hormonal therapy that causes a surge in testosterone before it causes low levels. That needs to be considered when you're starting the treatment. The other kind, which is a GnRH antagonist, causes the testosterone levels to go down right away. Both of these are really effective ways of lowering testosterone. They are both used really commonly, and they both can be given as injections. The GnRH antagonist form can also be given as a pill. There are lots of different ways and options for us to cause androgen deprivation and to treat prostate cancer with hormonal deprivation therapy. It's important with talk to your doctor about which one might be right for you.

Alicia Morgans, MD, MPH, discusses androgen deprivation therapy and its role in treating prostate cancer.

Androgen Deprivation Therapy for Prostate Cancer

How do clinical trials and real-world evidence contribute to treatment decisions?

 Clinical trials are essentially ways that we, as physicians and scientists, try to understand which treatment or which approach to therapy or care of an individual is the best. We typically compare maybe 2 different treatment options or sometimes 3 treatment options and put them head-to-head to help us understand what is the best way to move forward for an individual type of patient or an individual patient. I would say that we are very conscious to make sure that all of the options that are compared in clinical trials are equally likely to help the patient. We don’t put patients in situations in clinical trials where they’re not really receiving the best therapy or care that they can get. I usually think of it as a comparison of the standard treatment vs the standard treatment plus something else. We don’t usually remove therapy or remove treatments from these kinds of trials unless our goal is to deintensify or reduce the intensity of the treatment because we think we’re overtreating people. There are trials that are made up that way. And certainly, that would be discussed as people are considering clinical trials and they’re making their choice to get involved.

One other important caveat is that when patients do get involved in clinical trials, evidence suggests that they actually do better on clinical trials in general than they do in standard treatment. Just enrolling in a clinical trial, participating in that process, and getting the extra care from the research team members can help you do better in the long run, which I think is a really wonderful bonus as you’re doing something that’s so altruistic, like participating in a clinical trial.

Another form of research and investigation that we do in medicine, and particularly in cancer care, is to look at groups of patients who are being treated in the real world with the standard therapies that we have using compilations of medical records or perhaps Medicare data or other database data to understand in that real-world setting how people are really doing and how they’re being treated, what complications they’re experiencing, and how well they’re doing on a particular therapy. And those real-world studies can be done without actually even engaging directly with the patient but by using data that’s already contributed through medical records that a patient is providing and the way that they’re actually being cared for in the clinic.

This kind of investigation is not burdensome to patients. It can be really challenging for clinical teams and investigation teams because they have to weed out a lot of noise as they’re trying to understand what’s going on in that kind of a data setup, but it can be a nice way to try to get an understanding of not just how people are doing when they are engaging in those clinical trials and putting in that extra effort and time, but also how they’re doing in clinics like mine, or like the one down the street, or the one in Tennessee where I used to work, or wherever it is throughout the world. People around the world may be treated slightly differently and our real-world cohorts can help us understand what geographic differences exist or what similarities exist, and how we can really raise the level of care for everybody to do our best.

Expert perspectives on how clinical trials and real-world evidence contribute to treatment decisions in prostate cancer.

Alicia Morgans, MD, MPH

Educating Patients and Caregivers About Prostate Cancer

Metastatic Hormone-Sensitive Prostate Cancer Treatment Options

Androgen Deprivation Therapy for Prostate Cancer

Informing Prostate Cancer Treatment Decisions with Clinical Trials and Real-World Evidence

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