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Toward a common therapeutic framework in castration-resistant prostate cancer: A model for urologic oncology and medical oncology interaction

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Abstract

Background

The rapid evolution of palliative therapeutic choices in the last few years for patients with advanced castration-resistant prostate cancer (CRPC) has resulted in a dilemma currently troubling a few other epithelial malignancies: which systemic agent to choose and at what time? In addition, which specialty specifically directs the delivery of such care—Urology or Medical Oncology—has not been clearly established.

Approach

Recognizing the lack of consensus, we propose a framework for Urology and Medical Oncology interactions that is founded on models that have succeeded in the past.

Conclusion

This approach aims to focus the care on the patient with CRPC rather than on his physicians and promises to improve patient outcomes in this disease state.

Section snippets

Background

The therapeutic landscape in castration-resistant prostate cancer (CRPC) has rapidly evolved in just the past 6 years. Five new systemic agents, each with a different mechanism of action, have demonstrated improved survival when compared with a reasonable control arm in various contexts in a patient with CRPC. These agents include enzalutamide (an androgen receptor antagonist) [1], abiraterone (CYP17 inhibitor) [2], sipuleucel-T (immunotherapy) [3], cabazitaxel (cytotoxic chemotherapy) [4], and

Clinical dilemmas

This state of affairs has created new clinical dilemmas and questions. Notably, should all patients be treated similarly? Is this the optimal sequence: luteinizing hormone releasing hormone agonist or antagonist followed by additional hormonal therapy (such as abiraterone) and after failure on hormonal agents, referral for docetaxel-based chemotherapy? In practice, sipuleucel-T or radium 223 gets inserted along this continuum according to individual physician and patient preference. However,

Integrating care

The patient with CRPC should never be lost in this nebulous clinical scenario.

It is in the best interest of the patient with CRPC for all his caregivers to buy into an integrated and comprehensive approach, one that dissolves artificial boundaries and establishes seamless transitions of care. This requires joint management of the patient with CRPC by both specialties from the initial manifestations of castration resistance to the end of life. In the academic setting at the professional society

Summary

In summary, the patient with CRPC deserves no better than an integrated care team that includes both urologic and medical oncology specialties, rather than being managed by a temporal sequence of specialists separated in time and space. In this model, urologists and medical oncologists ought to care for the prostate cancer patient even before the development of castration resistance. There is a critical need to develop these partnerships based on existing models of successful collaboration

References (10)

There are more references available in the full text version of this article.

Cited by (2)

  • Implementation of the AUA Castration Resistant Prostate Cancer Guidelines into Practice: Establishing a Multidisciplinary Clinic

    2016, Urology Practice

  • Management of patients with castration-resistant prostate cancer (CRPC): Results of an Italian survey using the delphi method

    2016, Tumori
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