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Alicia Morgans: Hi, I am so excited to be here today with Dr. Michael Williams and Dr. Mark Fleming, who are joining us from Virginia to really talk about how we think about collaborative care between medical oncology and urology for patients with metastatic prostate cancer today. So I'd love to hear, guys, if you could just share where you are, where you practice, and how you actually know each other, how do you actually interrelate? So we'll start with you, Dr. Williams. Michael, please tell us, where do you practice?

Michael Williams: So we practice in the Norfolk, Virginia catchment area of approximately two million people and varied all the way down to the Outer Banks of North Carolina all the way up to Williamsburg and across to the central portion of Virginia. Essentially, Mark and I have known each other since 2006, whenever he came into practice out here. And I was still a resident out here before I did my fellowship.

And we all have a friendly rivalry between our fellowships because he was a Sloan Kettering guy, and I'm an MD Anderson guy. And so between the two, we all have fun. He thinks number one, but it's hard to prove it. Nonetheless, we have a lot of fun together. And as far as our particular group, we are in a separate group. I'm in a large urology group practice. We have approximately 20 physicians, of which three of us are urologic oncology-derived.

And we have another four people that focus on cancer specifically, in which all of us, all the seven, actually treat metastatic prostate cancer and the medical management all the way through to everything but chemotherapy. So between the two of us, we sit down and we'll discuss ways that we like to practice and how we like to come together and what our differences are. And we all try and streamline between our two groups because he has a very different group and a very different tax ID as well.

Alicia Morgans: Wonderful. Well, Dr. Fleming, Mark, we've known each other for years, and I know that you are a fantastic medical oncologist with an interest in prostate cancer. And I'd love to hear just a description of your practice in Virginia and how you interface really with Michael and his team.

Mark Fleming: Yes, thank you. I am a medical oncologist who essentially at this point just sees GU-related cancers. I tend to see advanced prostate cancer, second opinions for prostate cancer, and bladder, testicular, and kidney cancer. And our group, Virginia Oncology Associates, we're subspecialized; we're large enough that with over 40-plus doctors, we essentially have areas of expertise within our practice. And I do the GU care, or I'm the kind of the first original GU doctor expanding our treatment team here.

Alicia Morgans: Wonderful. So Dr. Williams, can you share with us a case? Because I'd love to frame our discussion around a patient. And I think you saw somebody just today that you thought might be a really good person to talk about when we think about multidisciplinary care in metastatic hormone-sensitive prostate cancer.

Michael Williams: Sure. This particular patient is kind of somewhat, it's a little bit different than what we might normally see with a presentation for androgen-sensitive prostate cancer. It's metastatic. But this particular patient showed up about nine months ago with a PSA of about six but unfortunately had very high volume disease with multiple liver metastases, lung nodules as well.

And ultimately, he was kind of treated through a different location in a different way than just thinking about him as I've seen him now nine months later and he's progressed through that first-line therapy that he had. And there are ways that I think the two of us sitting down and talking about this would actually make a different decision or come up with a different treatment plan for this particular patient than what was performed and may have led to a better outcome. Of course, that has yet to be determined.

Alicia Morgans: So can you just share, how was this patient treated? And certainly no one's pointing fingers or placing blame, but how was this patient treated? And then after you finish with that, I'd love to hear from you, Mark, how you might think about a patient like this if you had seen the patient as an initial consult.

Michael Williams: So with this high volume disease, he had had only a PSA of six, and that, of course, sets off a lot of alarm bells for me as far as other items with that high volume of disease. But technically, he's diagnosed with androgen-sensitive metastatic prostate cancer. And so he has a wide range of options available to him.

And in this particular case, he chose an oral LHRH antagonist and also gave him enzalutamide, for which he had a response initially and actually had a PSMA PET response initially. But that quickly dissipated and now has had significant progression worse than what it was before, just a few short months later.

Alicia Morgans: That is really unfortunate. And Mark, as a medical oncologist, if you see a patient with liver metastasis, high volume de novo metastatic hormone-sensitive prostate cancer, what do you think about for patients who are relatively fit and just happen to have this unfortunate diagnosis?

Mark Fleming: Yeah. So there's no one playbook for advanced metastatic hormone-sensitive prostate cancer. I walk patients through, in my mind, what I term PM sagas; they have had prior therapies, and it is really multidisciplinary, the M being now where the disease is. So liver metastasis, we all know for those of us who treat a lot of prostate cancer, is a much more aggressive disease.

And so, liver metastasis and lung metastasis or greater than five bone lesions, I tend to use the classic CHAARTED definition of high burden disease. I'm more prone to offer those patients chemotherapy. And now we have, there's doublet regimens, which it sounds like that patient got, but it sounds like if I had seen this patient, I would want to know what the Gleason score was.

Someone with a high Gleason score, I suspect that they did with a low PSA, that I would likely offer this patient triplet therapy either with abiraterone, docetaxel and a hormonal therapy, or darolutamide, docetaxel plus an androgen deprivation therapy. It's nice that we're now moved into the realm of, we're seeing because we have a good group of urologists, they're using at least doublet therapy.

But I would say to your audience that there's not one playbook for every patient. And so you have to, what are the red flags? The red flags are when a patient has a high, they present with metastatic disease when they have high Gleason scores, low PSAs, which are all signs of concerning for androgen indifference. And so that's one of my kind of PM sagas.

And I know the nice thing working with Mike and his colleagues at Urology of Virginia, more likely than not, they've gotten some type of somatic mutational testing. And so that is also very important to get that upfront to know what that is. So it sounds like, without seeing the patient, offering a fit patient, as you referred to, triplet therapy would have been likely what I would have offered the patient had I been involved in the consultation.

Alicia Morgans: Great. Well, Michael, I'd love to hear how this would go in your clinic because, and these are assumptions, I assume that you as a urologist are not routinely giving chemotherapy yourself. And so I'd love to hear how you think about this kind of a patient and how you actually work together either with a medical oncologist like Dr. Fleming at another practice, or do you have a medical oncologist within your practice? How are you ensuring if you want to give that triplet therapy approach that you actually can deliver that?

Michael Williams: Really, it's a conversation. That's the most important thing. I think there have been multiple times where we've had patients that the urologist, not giving the treatment or the chemotherapy, may think that triplet therapy is in the best interest for the patient, but then of course the medical oncologist is going to look at it and say, "Well, maybe there are some things here that you're missing that may make this patient a bad candidate."

And I think those are things that we as surgeons know a lot too because a lot of people try to send them to surgery when they're not really great candidates for surgery. And those are all kinds of things that we're all very familiar with. So in this particular case, yes, we do deliver a lot of these therapies, but we don't deliver chemotherapy. And there are a lot of things that can change our minds.

So for example, for this guy who has a Gleason 10, PSA of six, multiple liver metastases, a biopsy simply of that may determine his next course. Maybe it's not even run-of-the-mill general prostate cancer; it's something different. And that could be a completely different management over time. And that's kind of where I would start. But it's also a conversation I have with him, particularly when we find significant high volume M1c disease.

But for the de novo, it may be something straightforward, and maybe something where this guy, he's 85, he's in decent enough shape, but he is definitely not going to be in shape enough for a triplet therapy combination. But there are other therapies out there that will get him further along, and anything that we can do to kind of work our way towards that, starting off with genetics, just like what he had said, just a baseline germline mutational differences with that.

Looking at somatics later, looking at PSMA scanning, of course, has come into play significantly. Those things have changed management for us dramatically. And as a urologist who trained at Anderson many, many years ago, we never even had any exposure to this. Once people there got hormonal therapy, they went to medical oncology.

And this was something that we kind of learned over time over the last 13, 14 years. So it's something that we focus on pretty extensively, and it's a collaboration between the two of us as far as how we want that patient to go. And for me, it involves starting a therapy, but maybe having a conversation on the sidebar, maybe a conversation where I just say, "You need to go and see this guy and see what he has to say about that triplet option too."

Alicia Morgans: Great. So I wonder, because you guys are not physically located in the same building, how do you communicate, how do you ensure that passage of patient from one to the next, and I see you, Mark, answering the question already. What is it? Is it superfast texting, great thumb strength?

Mark Fleming: Well, I think it's a combination. So having worked with Mike for so many years and his colleagues and partners, Dr. Givens and Dr. Martin, they know I'm a phone call away, I'm a text away. And so I think that's the challenging thing that we've worked out. And I think it's important. It's in the best interest of patient care that it's multidisciplinary.

So I just can't go upstairs when I was in training to go upstairs to urology. Our patients are going to have to go to a different facility, and they're going to have to check in. They're going to have to get repeat labs because we have different labs. We have different electronic medical records. So it can be challenging for patients. We're trying to work on those issues.

But if you focus on what's doing right for the patient and not looking at, I like to say, the tax IDs. Mike and I have worked that out that, "Hey, you do this, I'll do that." And I'm not going to give chemotherapy to every single patient, but we should have communication, I should get involved with most hormone-sensitive metastatic cancer patients.

In addition, there's also radiation oncology and the multidisciplinary management of prostate cancer. So with the advent of things like lutetium and Radium 223, it's important that we work together and collaborate. And the pathologist is absolutely key. Those who can tell us that, "Hey, this is Gleason nine, this is neuroendocrine," and we have that nice relationship of being able to do that.

Michael Williams: And I would just say even further, that one of the things patients love is that communication. Just saying, "Hey, I'm going to call him really fast," or "I'm going to text him really fast right in front of them." And they get that quick consult and that quick communication between the two, and they didn't have to leave anywhere. That by itself means an immense amount to patients because they love seeing that people are all on the same page. And they may hear the exact same discussion in a different way from him as they do from me. But in the end, it's all about finding the right spot for both of them.

Mark Fleming: He draws better pictures than me. That's what the patients say.

Alicia Morgans: My urologist draws much better pictures than I do too. I wonder if it's just a trait of the urologist, but it's quite impressive. So I wonder though, for those practices that have not set up this sort of teamwork collaboration or it's in process but not yet solidified, how do you really make it gel? How do you really make it work? Because ultimately our therapies, whether it is triplet therapy in the metastatic castration-sensitive setting, or whether it is radiopharmaceuticals or other things where we have to work together, we are moving in a direction where we have to be a team regardless of geographic separation. So how do you make it gel?

Mark Fleming: So I think, and Mike said it earlier in terms of his initial training was not in advanced prostate cancer. He's learned that. And I understand and I can appreciate there are things that urologists are able and comfortable and should be able to manage. But being a medical oncologist, we come from a different perspective. And I think you have to value that everything is not necessarily a one-stop-shop.

And so there's an advantage of urology, anything that has to do with plumbing, I don't deal with plumbing. So if you're having any type of those issues, I'm going to refer back to urology. When it has to do with drug management, that's what we do. That's our bread and butter. We're very, very comfortable with that.

And I don't have a problem with urologists starting someone on initial therapy. I do have a problem if you use the same playbook for every single patient, and that's concerning. But luckily, we educate each other, it's nice to see. GU Symposium was this past week. We had a great time, and Mike was there. I had one of my junior colleagues there, and we're all learning together in terms of how to best care for patients and collaborate.

Alicia Morgans: Well, I love that. And I think that ultimately that is the direction that we're moving. And I would love to hear from you, Mike, sort of final words on this collaboration. Sometimes we feel like we own that patient, that that patient is in our clinic, and it can be hard sometimes to share or feel like, "I'm going to give control of some of this therapy to this other team." How do you manage that and how do you trust in your partners to continue to have a collaborative partnership in the care of these patients even as the disease progresses over time?

Michael Williams: I think that the biggest key is honestly finding people that have a focus and an interest in that specialty, in that area, in that arena. I think that it's kind of something we talk about a lot. If you come to me and you're coming to me to see me for BPH and a BPH operation, I'm not your guy. That's not what I do within urology.

I would say the same probably goes for Mark. If you're talking about lymphoma, leukemia type stuff, that is not his focus of area. Can he get by? Yeah, I bet he can. I bet I could probably do it too, but not as well as the person who's actually very interested in it. So finding that person is probably the biggest key to setting up a good collaboration. On top of that, finding good pathologists, pathologists that specialize and emphasize that.

Everything we do in cancer is based on that. If we don't have good pathology, we really can't do any type of effective treatment. So, but in the end, it is a patient. Yes, we want to take care of that patient, but those patients really love collaboration. Even if it means that they have to spend an hour waiting in my waiting room and then seeing me for 30 minutes and then going over to see Mark for another hour or two hours in his waiting room and seeing him for another hour or two, those things mean a lot to patients.

And I just can't tell you how many times that has just come up over and over again. Yes, it would be great if we could all sit down in one room and just have all the same conversation all at one time, but I think in the community, that's really not the way that it's ever going to happen. And I think we just really have to kind of be focused on what's best for that patient. And I'm not going to have all the right answers. And that's something that is just part of medicine. And if you think that you do have all the answers, you're probably in the wrong field.

Alicia Morgans: Yeah. Well, you know what? I love that. And I think it's a wonderful way to end that at the end of the day, we all have our areas of expertise and we can all work together to get the best outcome for the patient. And that certainly is appreciated by the patient but is what makes our job more enjoyable as well. So thank you both so much for your time, for your expertise. We wish the best for the patient that you saw today, Michael, and we certainly appreciate hearing how the two of you make it happen for patients with metastatic hormone-sensitive prostate cancer. Thank you.

Mark Fleming: Thank you.

Michael Williams: Thank you.