Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor of Medicine and GU Medical Oncologist at Northwestern University. I am so excited to have here with me today, a friend and colleague, Dr. Ted Schaeffer, who is the Chair of the Department of Urology at the Feinberg School of Medicine and the Director of the GU Oncology Program at the Robert H. Lurie Comprehensive Cancer Center at Northwestern University where I am honored to work with him each day. Thank you so much for being here to speak with me about this COVID-19 pandemic and the implications for prostate cancer care. Thank you so much, Dr. Schaeffer.

Edward Schaeffer: Yeah, thanks for taking the time out of your busy schedule to chat about, I think, this very important issue. As most of the listeners know, both Dr. Morgans and I have a passion for taking care of men and their families with prostate cancer. Our country and our world have really been taken by storm with this widespread, rapidly progressive virus, this Coronavirus. This has really changed the landscape of how we are caring for patients in the here and in the now. Alicia and I, who have offices very close to each other, thought this would be a great opportunity to really answer patients' questions about their prostate cancer, and how to think about, and manage, and structure their prostate cancer in this particular unprecedented time in America and in the world.

And so, thanks for joining me, Alicia, and thanks for hosting us. I have been messaged by many patients about the timing for their "Lupron® shots" or their androgen deprivation therapy. As you know, this is definitely a fundamental principle in how we manage men who have recurrent prostate cancer. There are people that are worried that they missed the Lupron® shot by two weeks or they're maybe going to miss their Lupron® or their ADT shot. Can you just speak to the patients out there that are worried about that, Alicia, and provide some reassurance about how to think about that?

Alicia Morgans: Sure. So Lupron® shots, the purpose of these is to get your testicles to stop making testosterone, so to turn them off and stop them from making testosterone. This isn't an immediate off switch and it's actually when they "run out." It's not an immediate on switch. Lupron® injections have varying degrees of durations. They're depo injection, so injections that we expect to last for one month or three months or four months, sometimes six months. It depends on the dose that we give and the formulation that's given to understand how long they'll last. When they turn off, essentially as that duration wears to an end, is also really variable. It depends on how long you've been on your Lupron® injections or whatever that brand is that you're getting to lower your testosterone. It depends on how old you are as well among other things.

So for some men, especially young men who have not been on these GnRH agonists or antagonist injections for very long, when the time wears thin and the injections essentially are at their time point, their testosterone can start to recover or their bodies can start to make testosterone again in relatively short order. But for older men, especially older men who have been on these injections for many, many months, when the shot reaches its expiration time or when it's time to get the next one, it may be many months until men start to recover or their bodies start to make testosterone again.

Edward Schaeffer: That's great. Yeah.

Alicia Morgans: For the most part, when I see these guys, I say, "It can be weeks, many weeks, four weeks, six weeks until we even think about you needing to get this again."

Edward Schaeffer: Yeah. I think the other important thing for listeners out there if you do go in to get your shot because it's the right time or your doctor says it's safe to come into the office, ask if you can get a longer duration shot because we don't really know how long this pandemic will last and it's always nice peace of mind that if you get a six-month or a four-month shot, that's going to give you more flexibility. If it's still around at that time where there are some individuals who are still doing the monthly shots, and those can be easily extended and therefore provide more coverage for those patients and more peace of mind.

The treatment and management of advanced prostate cancer has just progressed so rapidly over the last several years that most patients or many patients are not just on, okay, a shot that blocks their testosterone, they're on more advanced medications. Do you have any special tips or tricks or things that these patients should be asking their providers and their telehealth visits if, for example, they're on abiraterone? I ask that one in particular because many patients are worried that they're on the steroid that they take with it and they're worried about being immunosuppressed and having a higher chance of getting these infections.

Alicia Morgans: Yeah, I completely agree and I understand those fears. I would say that for abiraterone specifically, it is important to continue to get tests including liver function tests because that drug is metabolized through the liver and can cause LFT abnormalities. So it's important to get liver function tests on a relatively regular basis, especially when you're first starting. As you are on that drug for longer and longer durations of time, it is not as necessary because it is something that hopefully your body has become accustomed to and your team is aware of how you're tolerating it. Blood pressure checks are also important, especially as you're starting that treatment.

But the amount of prednisone that you're getting with abiraterone is so low it's really just there to replace the native cortisol that your body should have had and it's not something that I think is really immunosuppressive. It's really hormone-sensitive setting. It's going to be five milligrams a day, and even in the castration-resistant setting, five milligrams twice a day. This is really, again, just to replace the native cortisol, so it shouldn't be something that's going to suppress the immune system. But regular lab tests are going to be necessary to make sure that you're not having a poor response or your body is not negatively reacting to that drug. But the prednisone itself is not going to be a problem.

Edward Schaeffer: Great. What are your thoughts about the use and initiation of docetaxel or chemotherapy-based regimens for prostate cancer? Are you trying to in your practice look at alternatives to doing that because that definitely is an immunosuppressive regimen, right?

Alicia Morgans: I completely agree. Docetaxel is absolutely immunosuppressive as is cabazitaxel, the other chemotherapy that we use in this setting. And not all patients can get Neulasta®, which is a medication to boost a faster recovery of white blood cells after treatment with chemotherapy. So we're trying to use other medications whenever possible to avoid chemotherapy just in the midst of this pandemic. Certainly, we use those drugs regularly and they are very valuable tools for our use against prostate cancer. But in the midst of the pandemic, if we have alternatives that make sense, not that we would want to sequence androgen receptor-directed therapy after androgen receptor-directed therapy because we know that's not going to be effective. But if we have other options that make sense that can control the disease, we will use them. When we do have to use docetaxel or cabazitaxel, we are absolutely using them.

I'm starting a patient next week on cabazitaxel. I have another patient that will be starting in two weeks in cabazitaxel. This has to happen for some patients because that's the next treatment choice in their line of therapies and we don't have alternatives. And the drugs, as I said, are very effective, and when that's the case, we absolutely will use Neulasta® to boost immune system recovery as quickly as possible. We counsel patients right now to stay away from people, wash their hands, and take every, every precaution they can to avoid getting an opportunistic infection. So it's not just the infections from others that these patients can get, sometimes they get infections from their own native flora and that's unavoidable. We know that the beds in the hospital are actually quite limited, although of course at our institution and at other institutions, we are saving beds for patients with cancer because we know that they will need to come into the hospital.

In those cases, we hope the patients don't get infected, but if they do, we counsel them. If you have a temperature of around 100.4, let us know, come into the emergency room just as you always would and tell them that it's important that you get admitted or evaluated for possible neutropenic fever. These are things that have to happen. Whether there's a pandemic or not, we have to push forward.

Edward Schaeffer: That's great advice and obviously I think one of the key take-home messages is to really, for all the patients out there listening, is to really try to establish and solidify and strengthen your relationship with your care provider, because in these unknown times, things change really on a day-to-day basis. So it's important for you to establish a good relationship with your provider so that you can have your individual questions answered in a timely fashion. And how those questions are impacted by COVID-19, for example, are really changing on a day-to-day basis. Any other things that are coming to mind from your perspective that you wanted to emphasize in this kind of patient-facing podcast, Alicia?

Alicia Morgans: Sure. So this is actually for both of us, but I'll ask you first because I don't have the best answer right off the cuff because neither of us are radiation oncologists. Some patients with prostate cancer end up getting radiation treatment, whether it's for local disease or for metastatic disease. Patients have asked, "If I'm getting radiation for localized disease, should I interrupt my treatment course to pause while we have this COVID-19 pandemic?" I know what my first response would be to that. You're not, of course, a radiation oncologist, but what are your thoughts on that, Ted?

Edward Schaeffer: Yeah. I've had the pleasure of sitting on a series of phone calls with various members of the National Comprehensive Cancer Network and we've talking about and thinking about our advice to our patients. So I had the pleasure of listening to some really thoughtful radiation oncologists about this. So a couple of key take-home messages. First, if you're thinking about stopping your radiation treatment right in the middle, but I would not advise that. That's generally what most radiation oncologists are advising. If you have an aggressive prostate cancer, you generally have to get androgen deprivation therapy before, during, and after that radiation-based treatment. So the key thing would be to see if you can delay the initiation of radiation therapy if possible. Now, if your treatment is considered to be necessary to proceed forward with and it's radiation-based, then in general, my sense is that the radiation oncologists are really trying to emphasize shortened, more compact treatment cycles.

So if possible, moving from 40 to 24, that would be what we would conventional hypofractionation, and/or moving to more extreme hypofractionation with five to seven treatments. These are effective and these are considered to be completely appropriate. And this would minimize the amount of time a patient would need to be on treatment and coming into a hospital-based setting. So those are pieces of advice that I would give to the listeners based on what my very smart friends who are radiation oncologists would suggest as well.

Alicia Morgans: I agree. If patients are thinking about palliative radiation, they should think about and have conversations with their care teams and their radiation oncologists about how to deliver that in a very short course, whether that's a single fraction or whether that's maybe three to five fractions for palliation only that they can receive in a quick, short order that may then help them for longterm to prevent those complications and certainly pain issues that they may experience. So there can always be, I think, conversations that can happen with providers that can help them make some of these choices.

As you're thinking about patients making decisions, one other thing I would emphasize, and I'd love to hear your thoughts on this too, is that it's really important to keep that open line of communication with providers because we never want to compromise cancer care for fear of COVID-19. At the same time, we want to make sure that we are smart and we're not putting patients at risk. So it's really a balance and those balances can best be achieved by having those conversations with the clinicians and teams that are taking care of each individual person.

Edward Schaeffer: Yeah, I think that's a great point. The other line of communication, I think, is really, really important for the patient listeners to think about is actually the communication that they have with their family members. What I mean by that is really having the family understand and document the goals of a patient's care, particularly those that have rapidly advancing prostate cancer, to understand things like their advanced directives, understand things like their durable power of attorney, and their emergency contacts and so forth, so that if something progresses rapidly in their cancer or within their cancer that there's no confusion. So I think communication between the patient and their provider is key, but communication and discussion by the patient with their provider, but also their family about some of their end-of-life decisions and what they'd want to have done are really important at this particular time because there's a lot of things in play. So not to be negative, but I do see it as positive because those are very helpful and productive discussions to have.

Alicia Morgans: I completely agree. And along those lines, what would you say to patients and to caregivers who are normally so involved in every visit? A lot of hospital systems are right now limiting patients that patients can be the only person in the room, no caregivers allowed at this point, only one person there. What would you say to those individuals?

Edward Schaeffer: Well, I think we've converted 95% of our clinic visits to virtual visits. I encourage anyone who wants to participate in the call to do that. So I'm routinely merging calls with daughters or wives or spouses. The e-visits are actually easy. And then when we have to have patients come in for something major, we try to be proactive and inform them that, "Yes, we know that you got a ride here with your spouse and your spouse will need to stay in the car. They can't come into the hospital because of just public health concerns about the virus." In general, I haven't found that that's actually been negatively received. I think everybody, at least in Chicago, has really teamed up to try to make a difference to really flatten the curve here, so to speak. So people have been very receptive to it and our staff has been great and helping patients with more limited mobility get into and out of our clinics and into and out of our building spaces.

So overall it's been a really great, very good process and I do think that patients clearly understand what's going on and are pretty flexible because they're just happy to have their care continued in this particular time in America.

Alicia Morgans: I agree and I think that thankfully technology has made it such that we can include caregivers. If we're in a clinic visit in person, we can include them on the telephone for sure, if we are all remote, then patients and caregivers can be in the same room and same space and on the same speakerphone for example, or perhaps the web-based applications that might allow telehealth or web-based health to occur. So the technology that we have at this point is really helping us to make sure that everybody is engaged as they wish to be and we're all really very thankful for that. As you think about other questions or other things that have come up, Ted, I'm sure that there must be some overarching message or some message that you'd want to share with everyone as they do face this in their day-to-day.

Edward Schaeffer: Yeah. I think it's unprecedented times in our world, and that in general, I think people have acknowledged that and are very aware of that. I would say that I have a couple of general thoughts for the listeners. One, I've worked with leaders at about 15 to 20 major cancer centers in the US in collaboration with the National Comprehensive Cancer Network. We have now posted on nccn.org just our thoughts about managing prostate cancer during the COVID-19 pandemic. These are generally focused more towards providers and so I think that that would be one nice balance to what we've just done today, which is to talk about more patient-specific concerns. But I do think it's important for patients to go to that site and download that document because there's very important links on there.

There's links to the CDC, the Center for Disease Control, cdc.gov. That is a tremendous resource that is really the gold standard for us understanding the state of the art for this COVID-19 pandemic. I highly recommend that. It's very, very informative. It's updated all the time. I think it's very helpful because one of the things I struggle with is just actually understanding what is real news about this epidemic and what is fake news about this epidemic, and that really is the go-to gold standard.

So I would say it's been a tremendous break in my busy schedule to speak with you this afternoon about these important patient-facing issues. We'd love to hear more questions and we would be willing to do this again, I'd love to do this again, and do it in a way where we can provide answers for patients that are worried about their prostate cancer, we're worried about their prostate cancer too, and certainly my pleasure to have participated in this podcast today.

Alicia Morgans: As with everything you've said, I agree wholeheartedly and I would just encourage patients that we should all have hope. This will be over at some point. My hope in addition to us getting to the other side and being better off for it, is that we can truly become better off for it, that we design systems that continue to support our men with prostate cancer, their caregivers, their loved ones, and everyone involved in this activity of getting the best outcomes for our patients in ways that are most convenient for patients, that are safest for patients, and that make the most sense.

So stick with it and don't give up on your care just because you're afraid. Reach out to your clinicians and ask them how you can best care for yourselves. Please wash your hands, stay home when you can, and do what you can to take care of each other because it is an unprecedented time. It is really challenging and we are all in this together. So thank you for your time, Ted.

Edward Schaeffer: Well, thanks for hosting, Alicia. I appreciate it.