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Multidisciplinary care teams to optimize care for patients with bone metastatic CRPC

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Alicia Morgan: Hi. I am so excited to be at ASCO 2022, where I have the opportunity to speak with Dr. Tanya Dorff about how we use multidisciplinary care teams to truly optimize the care of our patients with metastatic CRPC bony. So thank you very much for speaking with me today.

Tanya Dorf: Thank you for.

Alicia Morgan: Tremendous. Radium is such an interesting treatment. It’s a radiopharmaceutical, it’s been around for a long time. I know you and I use it a lot in our clinics, but it’s not something I can just write a prescription for and send a patient for an infusion and make sure that patient gets the treatment this afternoon. . I really have to work with other members of the team, the nuclear medicine doctors in my case, in some settings, the radiation oncologists and, of course, our teams within the medical clinic, to make sure that we give this treatment safely. and efficiently. So from your perspective, how do we make all of this happen? How is it going in your clinic?

Tanya Dorf: So my institution is a bit special in that nuclear medicine and radiation oncology administer radium-223. So I can kind of see the best of both scenarios. With the nuclear medicine doctors, I think I tend to stay a lot more involved, dose by dose, sort of assessing the patient. But one of the benefits of having radiation oncology administered is that they can also really look at a patient’s pain and think about the focal radiation while a patient is undergoing treatment and if we’re accomplishing all that we want to accomplish for a symptomatic patient. It was obviously allowed in the ALSYMPCA trial to also have palliative radiation, either before or during. Radiation oncologists are therefore very used to observing patients suffering from bone pain and trying to give them optimal treatment.

Alicia Morgan: That’s a really good point because sometimes, as you progress through the radium treatment, you’re like, “Well, I’m not going to do targeted radiation on that bone right now, because maybe Maybe I’ll get enough of a response with radium,” because it can have a very pronounced effect on bone pain. However, after a few cycles, maybe you or your radiologist colleague will say, “You’re still in pain, and we can do better.” So having the ability to do that and knowing that you can do it safely like they did in the ALSYMPCA trial is very, very helpful.

Tanya Dorf: Yeah. So the challenge is that because radiation oncology is so used to managing patients, sometimes there’s maybe less involvement. So for physicians who want to stay involved, I think you just have to schedule your patient. You know you need that CBC a week in advance, and then is the perfect time to check in on your patient or when you see them for their LHRH therapy injection is another opportunity. But I love being able to watch a patient progress and think about what we do after radium and all sorts of adjustments that need to be made along the way as well.

Alicia Morgan: So it’s really interesting the different models where radiation oncologists can do a little more day-to-day care and symptom support and think about using targeted radiation in addition to radium, whereas our team members in nuclear medicine are also there. They are also engaged, but perhaps less on the ground, in day-to-day symptom management. When you work in nuclear medicine, are you the team that gets the CBC count a week before treatment and makes sure communication with nuclear medicine is done or is that what do they do in your practice?

Tanya Dorf: It’s a kind of collaboration. I mean, we usually order it, but it’s like having a second set of eyes. So we could look at the results, but also the nuc-med team is certainly double-checking to make sure the patient’s counts are within range and appropriate for treatment.

Alicia Morgan: Well, that makes sense, and that’s how it happens in my practice as well. The other thing that I really personally think about when treating a patient with radium, and I appreciate that a nuclear medicine doctor or radiation oncologist can also remind me if I’m missing something, c is bone health because I think all patients with metastatic CRPCs are definitely eligible for treatment for up to a month with bone health agents like zoledronic acid or denosumab to prevent related events to the skeleton. This is of course still important during radium treatment. But how do you handle that? Are all of your patients already taking bone health agents? Or is it something you sometimes start when you start radium?

Tanya Dorf: Yeah, that’s a good point. I think bone health workers are especially important in patients who have had a lot of exposure to targeted AR therapy. I mean, we don’t often use them in conjunction with radium because there hasn’t been any data showing a benefit to it. But even in patients who’ve been on them for many years, if they haven’t taken a bone health agent, then it’s kind of a reminder, “Oh, we’re starting this treatment. I absolutely have to ensuring they also get that other form of bone support.”

Alicia Morgans: We do, and not just because we need it with radium, we need it with all mCRPC treatments. Radium is only given in the mCRPC, so it always triggers that in my mind.

Tanya Dorf: Right. I mean, with the new initial intensification, when patients are not castration resistant, they may not receive bone support, certainly not with the stronger forms. It’s more of a prophylactic. So I think there are more patients who are about to receive radium who haven’t been on bone health than there were in the past where we used Avir and [inaudible 00:05:23] into the CRPC space and possibly start the bone support there. But yes, you are right, for any new treatment we start, we always have to remember that the mCRPC with the bone meds, we really have to give bone support agents.

Alicia Morgan: I agree. Well, what would be your last clinical gem as you consider guiding those starting or re-energizing their multidisciplinary care teams for radium radiopharmaceutical treatment?

Tanya Dorf: I think it’s always good practice to make sure there’s communication between the teams so that the patient’s progress and treatment goals are really clear between everyone who touches the patient. It can be very distressing for a patient if the physician administering the treatment tells them that it is palliative, when they are being told of a survival benefit. So to get everyone on the same page, the goal of treatment is prolonging survival, we’re also hoping for pain palliation, I think that’s helpful to have a consistent message.

Alicia Morgan: I think that’s great advice and it’s not just our colleagues who mean our doctors, it’s also our colleagues and collaborators in the nursing team, the imaging team and certainly our own team to ensure that we are clear about the purpose of the processing. Expectations really, really matter. Whether they’re communicated by our team or any other team, we really need to be consistent, so thank you for that. I always appreciate your time and expertise.

Tanya Dorf: Thanks.