ADT as Foundational Therapy, and the Need for Consensus on Consistent T Suppression, Goals, Monitoring, and Delaying Time to CRPC

In a program supported by Verity Pharmaceuticals, E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego; Neal D. Shore, MD, FACS, Medical Director for the Carolina Urologic Research Center; and Benjamin H. Lowentritt, MD, FACS, Director of Prostate Cancer Services for United Urology Group discuss androgen deprivation therapy (ADT) as a foundational therapy for prostate cancer. They discuss managing testosterone (T) levels, adherence to T dosing schedules, and castrate-resistant prostate cancer (CRPC).

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Dr. Crawford first notes the challenges for both the physician administering and the patient receiving ADT. Namely, T escapes, T levels rising from a number of causes, how castration is defined, and dealing with side effects like osteoporosis, weight gain, sexual side effects, and cardiac events. He then presents guidelines supporting the reduction of testosterone to <20 ng/dL and the history of clinical trials that originally proposed <50 ng/dL before asking Drs. Lowentritt and Shore for their input. Dr. Shore contends that physicians must know the stage of the disease before making a recommendation about T suppression. Dr. Lowentritt comments that the relative importance of a T level of 18 vs 35, for example, is not fully understood. He adds that if T suppression is the only treatment, then lower is better, but that the difference in T levels might not be as important when other therapies are used. He points out that the goal is to identify what is most effective in treating cancer, not just reducing testosterone.

Dr. Crawford then discusses the impact of late luteinizing hormone-releasing hormone (LHRH) agonist dosing on T suppression when the injection is late by any amount of time, even by several days. Dr. Shore notes that the importance of dose timing will vary based on disease progression. Dr. Lowentritt points out how impractical a precise dosing schedule can be when considering patients’ schedules.

Next, Dr. Shore compares how different guidelines define CRPC and proposes a readjustment of the current definition. As a follow up, Dr. Crawford asks Dr. Lowentritt about assessing a patient’s baseline T level before determining whether they have CRPC, especially if they have rising PSA. The panel proceeds to discuss ADT therapies and clinical trials looking at Triptorelin.

The program concludes with takeaway messages from each participant and their recommendations for a treatment approach for a patient with high-volume disease.

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ABOUT THE AUTHOR

E. David Crawford, MD

Researcher-physician E. David Crawford, MD, Jack A. Vickers Director of Prostate Research and Professor of Urology at the University of California, San Diego, has devoted his career in medicine to educating the public about men's health issues and finding effective techniques and procedures to address prostate cancer, the most common malignancy affecting men in the United States.

About The Author

E. David Crawford, MD

Researcher-physician E. David Crawford, MD, Jack A. Vickers Director of Prostate Research and Professor of Urology at the University of California, San Diego, has devoted his career in medicine to educating the public about men's health issues and finding effective techniques and procedures to address prostate cancer, the most common malignancy affecting men in the United States. Dr. Crawford received his medical degree from the University of Cincinnati and his postgraduate training included an internship and residency in urology at the Good Samaritan Hospital in Cincinnati. He subsequently completed a genitourinary cancer fellowship at the University of California Medical Center in Los Angeles. Dr. Crawford is an internationally recognized expert in benign prostate hypertrophy, urologic cancers, and in particular, prostate cancer. He has conducted research in the treatment of advanced bladder cancer, metastatic adenocarcinoma of the prostate, hormone-refractory prostate cancer, and other areas of urological infections and malignancies. He has authored or coauthored over 810 scientific articles, has published seven textbooks, authored over 60 book chapters, and provided more than 2,200 educational talks for patients and physicians. In an effort to raise public awareness about prostate health, Crawford in 1989 founded the Prostate Conditions Education Council (PCEC). The non-profit organization is comprised of a consortium of leading physicians, health educators, scientists, and men's health advocates. PCEC's advocacy for free or low-cost prostate screening has affected the lives of millions of American men. He currently chairs the PCEC. Crawford is an active member of many national and international organizations, including the American Society of Clinical Oncology, the American Urological Association (AUA), and the American Association for the Advancement of Science. Within the AUA, he has been a member of the Committee to Study Urologic Research Funding and the prostate cancer clinical trials subcommittee. Crawford served on the board of governors, the scientific advisory board of the Southwest Oncology Group, and was chairman of the Genitourinary Cancer Committee for 27 years. This group is the largest clinical trials group in the world. Crawford's involvement in the national prostate cancer arena has been widely recognized. He has received many honors and awards, including the CAP Cure Annual Award for Scientific Presentation in 1999 In 1997, he was presented with a 'Freddie Award" at the AMA International Health and Medical Film Competition for the program, ITV: The Cutting Edge Medical Report (Prostate Cancer: Understanding, Diagnosing, and Defeating), which Crawford hosted with special guest, retired General Norman Schwarzkopf. Crawford again won a prestigious 'Freddie Award" 5 years ago... He is a member of Best Doctors of America and was named Healthcare Provider of the Year in the Denver Metro area by the Denver Business Journal. He has been recognized as one of the Best Doctors of America for the past two decades and is recognized as one of the top 20 urologists in the country, for men, by Men’s Health Magazine. In 2018 he received the honor of being named the Distinguished Alumnus of the Year from the University of Cincinnati School of Medicine. In May of 2019, he received the Presidential citation from the American Urological Association recognizing for his “tireless role in genitourinary cancer research that has benefited countless urologic cancer patients.” He accepted the position of Editor in Chief of Grand Rounds in Urology in June of 2019. In 2021, he was the recipient of the Merle Stringer, M.D. annual award for excellence in medicine by the Florida State Medical Association.

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