Personalizing Prostate Cancer Care with a Prognostic Biomarker
20:12 Share

Hey everybody, so welcome for this edition of one of our ACRO podcasts. Today our esteemed guest is Dr. Andrew Fairchild, and we're going to be focusing in on myriad, as well as our topic for today, personalizing prostate cancer care with a prognostic biomarker.

So I'll briefly introduce myself and then also our esteemed guest. My name is Dr. Kamra Hassanzadeh. I'm a radiation oncologist in Houston focusing on genitourinary cancer. And our guest today is going to be Dr. Andrew Fairchild of Novant Health. He is a radiation oncologist in Winston-Salem, North Carolina.

He has over eight years of experience and specializes in genitourinary cancers, as well as brain tumors, malignant hematology, and neuroradiation oncology. He earned his medical degree at University of Illinois in 2016 and followed that with an internship at UNC Chapel Hill and residency at Duke University.

He's committed to leveraging advanced technologies to deliver precise and efficient radiation treatments while building strong trust-based relationships with his patients. So with that, thanks for joining us, Dr. Fairchild. Yeah, no problem. Happy to be here. So, you know, we can lead into our first question. So,

You know, as far as prostate cancer goes, you know, when we're talking about treatment decisions, not as only as a radiation oncologist, but as the patient, it is a challenging landscape. And so when we talk about prognostic biomarkers, one of them is the Prolaris test with Myriad. And so I guess kind of to the first question,

You know, in talking about treating prostate cancer, do you think there's any unique obstacles in managing prostate cancer as a radiation oncologist compared to other cancers? Yes, I do. And I'm sure you've experienced this many times, but I think the consultation visit with a patient with low-risk disease or favorable intermediate risk disease is

That's a really extensive visit, especially compared to treatment of other sites. I mean, you're going into first, you know, the pros and cons of monitoring or active surveillance versus treatment, not to mention when you do talk about treatment, you know, when you talk about radiation, there's often multiple ways to treat, whether it's brachytherapy or, you know, SBRT or moderate to high fraction, even conventional fractionation.

And then sometimes you're talking about, you know, offering a different treatment modality altogether when you're talking about surgery as an alternative to radiation. So I think it's challenging for the radiation oncologist to, you know, strike that fine line between not overwhelming the patient with all the information, but giving them enough information for them to make an informed decision. So it's a tough visit, a significant challenge.

Yeah, I agree. You know, I think the intermediate risk prostate cancer consult is by far the most difficult consult for me as a radiation oncologist, but also my patients. Just a plethora of treatment options, a lot of information coming at the patient, trying to digest, you know, what should they be doing, active surveillance, surgery, radiation, etc.

what about hormone therapy and even things like brachytherapy, SPRT. So it gets more complicated. I feel like even since I was in training until now, it's gotten more complicated. So

I agree with you. Prostate cancer is really challenging just because of those options. So that leads me to the second question. What are challenges in incorporating molecular biomarkers, such as the Polaris test, into routine clinical practice for someone like ourselves as radiation oncologists?

Yeah, I think there are a few. One is kind of the timing of when the test is obtained. So it's difficult when I see the patient in consultation, then I have to order Polaris and wait for the result. It kind of leads to a loose end at the conclusion of the visit, and then I have to call them back. So it leads to inefficiency. So I've kind of talked with the urologist and the pathologist and getting it ordered ahead of time so that I have that information at the visit.

just helpful in terms of efficiency. It's also difficult when there's kind of a discordance between, you know, your NCCN risk category versus what the Polaris is saying, like say they're unfavorable intermediate risk, but Polaris is suggesting single modality treatment.

So talking about that, I think it really boils down to a conversation you have with the patient about their risk tolerance because it is a spectrum. They don't necessarily have to do one or the other. And it's also...

you know, we're in an era in which patients are able to see the information ahead of the visit. And I think Prolaris and other tests do a very good job of simplifying the language as much as possible. But at the same time, you know, there's like, you know, on the left-hand box in terms of the risk stratification talks about 10-year disease-specific mortality with conservative management. If I was a patient reading that, I'd be like,

What does that mean? So I think it still requires some amount of interpretation and sometimes patients can come in with confusion about their results. So discussing that with the patient and kind of going through with them is super helpful.

Yeah, I agree. I think a lot of these biomarkers, for better or worse, can have a lot of complicated language in their reports. And you're right, patients get it first. And they usually send me a message through the medical record saying, what does this mean? And I almost have to reserve that very long and nuanced conversation for the consult because there's just no other way to do it. But

But yeah, I agree. I think if anything, it gives you more information and I do like that you're ordering ahead of time because there is a wait period. So that you're having it at the time of consult, there's no delays and you can have a real conversation with all the needed information. So that's a nice, you know, nice thing that you've established in your own clinic. Yeah.

Um, so the third question, you know, have there been instances and maybe we just focus on low risk prostate cancer first, but have there been instances where a biomarker test like Polaris significantly altered your treatment decision for low risk prostate cancer? Yeah. I mean, I'm sure you're in the same situation to me, but it's, it's often, I mean, um, you know, there's patients, I mean, specifically looking at the low risk patients, um,

those that are kind of on the fence, whether to proceed with active surveillance versus treatment. And the test comes back and it's, you know, they're very low risk of mortality in 10 years and it's recommending active surveillance. And that's what they proceed with. And I think even though they were potentially leaning towards that direction ahead of time, having that extra information to give them kind of the satisfaction that they are truly low risk, that personalization, I think they appreciate. And then conversely, there's patients in which

you know, they're undecided and it does recommend treatment and we proceed with treatment. So, so often, you know, and I, and I get it on all my low risk patients.

Yeah. And I agree. I think that active surveillance conversation is challenging. You know, we now have 15 year data from the PROTECT study saying that 50 to 60% of men are eventually going to need treatment if they, you know, live that long to see out a progression event. So it's not an insignificant number, more than half of them are going to need treatment. And so having this additional information to say, well, you know,

you know, maybe I'm willing to take that chance and, you know, you may fall into the camp that doesn't need treatment. And this prolares test fits that picture. So I think it gives patients more confidence in making that active surveillance decision, which can be a little bit anxiety producing. Right. So and then so let's shift gears a little bit. What about intermediate risk when we're talking about getting, you know,

How would you incorporate that? Does that mean you maybe treat pelvic lymph nodes? Does that mean you add ADT? How do you incorporate that for intermediate risk patients? Yeah, I mean, so for the favorable intermediate risk, which in which active surveillance is still an option, still getting it more often than not in the low risk patients, obviously.

it's recommending more single modality treatment, but it also occasionally, but rarely, does recommend multimodality treatment. So even though they're technically favorable intermediate risk, we'll talk about short-term ADT for those patients.

Um, and in the unfavorable, you know, particularly for patients that have maybe low volume four plus three, their PSA is, you know, less than 10, they're technically unfavorable intermediate risk. Um, but say they're elderly, multiple medical comorbidities, including like, you know, a history of heart problems. Um,

For those patients in which, you know, I'm getting it and if it says recommending single-dialysis treatment, I'm omitting, you know, hormone therapy, which I think is reasonable given the prolaris results and the risks associated with ADT. You know, so that's how I typically incorporate it for the underage.

unfavorable intermediate patients. I mean, there are patients though that have unfavorable intermediate risk disease, high volume 4+3, high PSA, very rapid PSA kinetics that I'm not ordering Prolarisone. So there are some patients because I want, if that test shows me conflicting results, I'm kind of at unease in terms of not recommending ADT in those kinds of circumstances.

Yeah, I agree. I think if I, in my mind, I want to do ADT, it's really a question of, do I feel like they need more than maybe four to six months? And that's the reason for getting something like Prolaris to say, maybe he's acting more like high risk. So yeah, I completely agree with that sentiment. And then I guess talking about high risk, who, which kind of high risk patients are you ordering Prolaris? Is it everybody? Is it just certain types? And how does that influence your decision for high risk patients? Yeah.

Yeah. So for the favorable high risk patients, I used to, you know, I originally started using prolares primarily in the low risk and favorable intermediate risk as a kind of additional information to decide on active surveillance or not. And I've started really transitioning even using a high risk patients like for the favorable high risk in which I would like to omit hormone therapy, just given age and comorbidities I've used in that. And then, you know,

Also for high-risk patients, if that number of needed treat is really low, their absolute risk reduction is really high. I've certainly recommended potentially longer duration of hormone therapy, treatment of pelvic lymph nodes in certain circumstances. So it leads to treatment intensification based off of the potential benefit for them.

And you mentioned absolute risk reduction. So you're saying if there's a certain risk reduction that you're seeing on the report, that would also influence your decision one way or the other? Correct.

Which I think, you know, for patients, I think number needed to treat is a little bit, I mean, even though they're statistically essentially the same, number needed to treat is, you know, a little bit easier for them to grasp in terms of the potential benefit for them than absolute risk reduction, like an absolute risk reduction of 2%. I mean, for a patient, I think it's difficult to grasp, or as you talk about 1 in 50, you know, I think that's easier for them to understand.

Yeah, I agree. I think number needed to treat is a more concrete number. You say it's one out of five patients that would get a benefit. And that's a very clear cut statement for patients. I think that's easier as a take home message. I agree. Yeah. You know, I guess we kind of answered this next question, but do you find that prostate cancer patients specifically get a value, additional value beyond what we've already discussed for these biomarkers and their treatment journey?

Yeah, I think you're probably in the same situation as I am, but...

patients in general appreciate your effort to provide more personalized care. You know, and I think the NCCN risk categories are very helpful, but they're also very broad and there's a wide range of patients that fit into those categories. But, you know, like not every patient with, you know, Gleason 4 plus 3 is the same. And so, yeah, I think they certainly appreciate it. You know, they tell me as such. So, yeah, I think they benefit from it.

Yeah, I think I agree. I think personalized medicine is like the, you know, catchy phrase of the day. It's true, right? Patients, we shouldn't be treating every unfavorable intermediate risk patients with six months of hormone therapy and prostate and pelvic radiation when that's probably overkill for some. And, you know, similarly for Euclid 3 plus 3, there's maybe some that actually benefit from treatment and that fall on that, you

that are going to progress on active surveillance in a year. And eventually, you know, maybe you do the treatment up front and don't have to worry about that progression event and needing additional hormone therapies and intensification. So that leads me to this, the next question, you know, Gleason 3 plus 3, Gleason 6 prostate cancer is kind of an odd topic. Yeah.

Yeah, I talked to a neurologist and they're saying this is not cancer. And I think that is maybe where a lot of the consensus lays that Gleason 6 prostate cancer is not really cancer. It's almost like

akin to maybe DCIS. It's a precancerous lesion. We can treat it, but maybe we don't need to. We're really, you know, maybe over-treating a lot of these patients. So we've talked about how Prolaris plays into low risk, but specifically, you know, when you're dealing with a patient who comes in and says, I have prostate cancer. I was told it's not a big deal. You know, how does Prolaris play into that?

Yeah, I think you kind of touched on it just a minute ago that there are certain, you know, at least in six patients that are going to progress on actor surveillance and not, it's a heterogeneous patient population. And so I think, you know, I think prolaris does have a role in those patients because it could potentially pick up some patients that are more likely to progress, I think, of

you know, your intraductal patients that, you know, have a misleadingly low PSA and low Gleason score that are actually have likely more aggressive disease in certain patient populations, particularly African-Americans that I feel like, you know, it's, you're, you're not truly demonstrating their risk of progression with purely just the PSA and Gleason score. So I

And I fall in the line of, I mean, just my personal opinion that Gleason 6 is, you know, still prostate cancer. And I think just...

there needs to be a better job in terms of educating patients and clinicians as to the benefits and the safety of active surveillance. And I think it's sometimes confusing for certain patients when they're told, well, you have precancerous disease, but potentially they have an MRI with PI-RADS 5 lesion or something avid on their PSMA scan, although that would be unlikely if

they got that imaging with lower cyst disease. But regardless, when there's a discrepancy of findings, it leads to confusion on the part of the patient, which you want to avoid.

Yeah, and I think you mentioned intraductal. I think that's something that we're not going to pick up. We're going to say Gleason takes prostate cancer, but intraductal component. We know that drives the whole prognosis. Probably acts like intermediate or even high risk. So I think that's a big component and an important point. And then also you mentioned it under sampling. So when you get an MRI, you see a huge PI-RADS 5 lesion on the left gland. When you look at your biopsy report, the left gland was clean.

That's discordant. And that's a red flag for me. I go talk to my urologist and say, was this a targeted biopsy? Was this a template? Did we talk about repeating an MRI and getting a targeted biopsy? Did we miss Gleason 7 or higher prostate cancer? So these targeted biopsies that are being incorporated more and more into practice,

I think are probably going to show that a lot of patients that otherwise would have been Gleason 6 are now not really Gleason 6. Yeah, I think there's a lot more nuance to this than we fully appreciate. You know, to the last question, I guess,

So what are your predictions and hopes? We've talked about some kind of cutting edge things that are coming out with Polaris, but in general, in prostate cancer landscape over the next maybe five to 10 years, what are your hopes and predictions on where we go with prostate cancer treatment? Yeah. So I think AI is here to stay.

You know, for better, for worse, I think it's for better. I think there's so many opportunities for it to, you know, streamline treatment planning, you know, monitor patients on treatment in terms of evaluating their cone beam and evaluating for toxicity, especially when it deviates from your original planning scan. I think there's going to be, you know, continued advancements in theranostics, both in terms of new agents, but also, you know, putting them earlier in the treatment pipeline, you

you know, those are the things. And this is not even mentioned like focal treatment, you know, intra treatment tracking of the tumor. There's all these, you know, potential advanced things are going to benefit patients. Yeah. I think prostate cancer, even with the advent of

biomarkers and PSMA PET in the last five to seven years that really even revolutionized a lot of our management as it is. And I feel like we don't even fully understand the impacts of something as simple as PSMA PET and what it means for that patient. So I think it's an exciting landscape. Prostate cancer has come a long way from saying that we should treat everybody kind of in the same

same realm, right? Gleason 6, you're going to get X or Gleason 7X. So I think it's really exciting. I guess any take-home points or any last-minute thoughts regarding prostate cancer or the Polaris test? Yeah, I mean, I think it's a step in the right direction.

kind of the theme that is pervasive throughout a lot of other disease sites is just personalization that you kind of touched on just a second ago with, you know, rather than, you know, putting every patient into a, you know, a box in terms of what type of treatment they're going to get.

you know, evaluating, writing more kind of risk stratification for them so that they kind of make an informed decision and better treat their disease. So yeah, I think, I think Prolaris and other, you know, genomic tests are helpful, super helpful for that.

Perfect. I love it. Couldn't agree more. And with that, I guess we will be closing out today's podcast. Thanks to Dr. Fairchild for joining us today on Personalizing Prostate Cancer Care with a Prognostic Bioworker. This is Dr. Hasan Zahra with the Acro Podcast signing off. Thanks so much. Thanks a lot.