Dr. Rana McKay
Appearances
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I'm doing great. Thanks for having me.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I do. You know, I've actually, I do run through the side effects because I think at the end of the day, patients want to know, And I hate it when somebody comes back in the clinic and they're like, nobody ever told me this was going to happen. So I really want patients to be informed about the side effects that they may experience and the different things that may happen.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And we certainly can't go through every little possible thing that could certainly happen. But I think it's key to go through the key ones that you're worried about when starting ADT. And I think it's important because then you can help with prevention. So that's going to be key. So I think the first thing is kind of going through the fatigue side effects.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Many patients want to know, am I going to be able to continue working? Am I going to be able to continue exercising? And so kind of level setting is important around there. The vasomotor symptoms, I think, are really important to describe.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, the other thing that I think is really important is the sexual side effects and not just with regards to libido, but the body dysmorphism that can happen from going on ADT. I think patients want to know that. And not be like, what is happening to me?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Like the testicular atrophy that could potentially happen, you know, hair loss, you know, changes in even smell, you know, the different kinds of things that can happen when patients are on treatment. I think it's important to go through that. You know, the other thing is the bone health.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Some patients might need a baseline DEXA scan if they're certainly if they're going to be on treatment for a prolonged period of time.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
and optimization around bone health, muscular loss, mood, you know, irritable mood, sleep, metabolic changes is critically important, you know, and some and actually even thinking about doing a cardiovascular risk assessment or make sure somebody is doing that, whether it be their internist, cardiologist or you yourself as their oncologic care provider. is important.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think kind of, I think it's key to go through that. I think this is also an opportunity where our nursing team can be leveraged, our APP team can be leveraged. You know, they're really fantastic and kind of going through the detailed summaries of the different things that patients may experience.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, you know, I think the big take home message is that, you know, you can't just like put somebody on their ADT and check out because what we saw from the PRONOUNCE study, which was actually designed to look at cardiovascular risk in people that were getting an agonist versus an antagonist. And in the context of the trial, they had very robust upfront cardiovascular risk assessment.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Patients on both arms were getting seen by cardiology or, you know, kind of getting ongoing kind of cardio prevention. And at the end of the day, the study had to close down because that rate was so low and in both arms and wasn't any different in either arm. So I think the key take home is Like prevention is key and staying on top of it is key.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Now, I think, you know, certainly if I have somebody before me who's got an extensive cardiac history and they really need to be on ADT, they've got high risk disease and you're treating them with a curative intent and they need to start treatment. Like, yeah, in that context, I'm going to go ahead and prescribe medication.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
an antagonist, you know, every day over an agonist just to do everything that I possibly can to mitigate their cardiovascular risk, like whether it be a thrombotic event or arrhythmia or something. So, you know, I think at the end of the day, I think there's probably a little bit more hype than true data. And I think the data that is out there has some flaws in it.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
But I think that, you know, it doesn't necessarily put the person in any worse off situation from an efficacy standpoint or side effects standpoint, and may potentially mitigate some CV tax.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, I do think the antagonists are associated with more rapid time to T recovery. And, you know, I think the other thing that we don't necessarily know is how that potentially plays into their long-term outcomes. You know what I mean?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I don't think there'll ever be a study that'll look at this, but when people, most of the older studies looked at the role with agonists and therapy was that much longer with an agonist as you waited for their T to recover. So does the fact that the T recovers faster, is that gonna impact long-term outcomes? I don't think we really know, but I think it's very much,
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You kind of want to give patients the duration of the treatment that you want to give them and stop as opposed to having this protracted time that you don't know when they're going to recover. And, you know, so I think it's it's nice to use the antagonist when the course of therapy is finite and you want their T to recover.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
you know, I think it's slightly different because of the fact that they're going to be on therapy that much longer. You know, I think it's the, you know, muscular loss, the bone loss, metabolic changes can be way more pronounced.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, you have patients, they come into clinic, they're on 24 months of ADT and first visit, they're up two pounds, up two pounds, up two pounds in a year, they've gained 10 pounds and now they've got some, you know, pre-diabetes. And so, you know, The propensity for that to happen with somebody just being on therapy for six months is not as high as, you know, two years of therapy.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And so I do think that the counseling is important, especially for people that are doing longer course treatment.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I mean, like I said, DEXA scan for select individuals, depending on duration of therapy, making sure they're up to date with their lipid panel, making sure they've had a hemoglobin A1C, if you've looked at their fasting glucose, and somebody is tracking that, you know, some patients may warrant, you know, being on a statin or being on an aspirin if they're high risk when they go on ADT.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And so I think making sure that that's evaluated. You know, some of these therapies can cause high blood pressure, so monitoring against that. But I think with regards to testing, for me, it's basically a hemoglobin A1c, glucose level, you know, lipid panel. You know, there's been some recent enthusiasm around coronary calcium scores with regards to CV risk.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I don't know that that's been consistently implemented across oncologic practices, but I think the education is really key.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
On treatment?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Undetectable. You know, hope to get it down low. And then, you know, patients always ask me this question. Well, what about if we get it down to a certain level and whatever? And I'm like, everything that we do is to drive the levels even lower. And what we measure in the blood is like not even what is measured in the tumor.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And studies have actually demonstrated that the interprostatic and intratumoral androgen levels are even higher than what they are in circulation. And even when the levels are undetectable in circulation, you can still detect potent androgens within the tumor. So that's just my rationale to like continue to drive the T levels as low as you can get them. When you're on therapy, you're on.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
When you're off therapy, you're off. But
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, very good question. So I think certainly in the biochemical recurrence setting, that's where I'm thinking of more intermittent ADT. And there's really no data to suggest that continuous ADT is associated with better outcomes, probably increases the risk of toxicity. And so giving them opportunities where they can have, patients can have, you know, T recovery is critically key.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I think in the metastatic setting, I think in general continuous, but, you know, there are caveats to that. And I think a lot of the caveats stem from what PSMA PET imaging has done in the field, what Saber has done in the field with regards to localized treatment for metastatic disease, particularly in individuals with oligometastatic disease.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think we've really challenged the paradigm a little bit in the metastatic setting for those patients that have low volume oligometastatic disease, actually giving more finite treatment and actually thinking about introducing a holiday if the primary has been treated, the metastatic foci have been treated, and they've received intensified therapy.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I think that's sort of how I like to think about the continuous versus intermittent strategy.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, I mean, absolutely. I think, you know, androgen deprivation therapy has been the backbone of systemic treatment for patients with prostate cancer for decades, has been and will likely continue to be just given the addiction of prostate cancer to the androgen receptor and androgen receptor signaling pathway.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, it's all the above and everybody's different. And what I will say is you're never going to find in a textbook a number for which, yeah, when you hit that number, go ahead and resume because everybody's different. So I think it depends on what's their risk, their PSA kinetics, what's their rate of rise. What's their rate of rise in the context of what their testosterone is doing?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Are they just rapidly rising because their testosterone is recovering and that's what's driving their doubling time? Or are they... Do they have a stable testosterone and they're rising? What's the absolute number of the PSA? How do they do with hormone therapy before? Do they want to go back on hormone therapy? What does their PSMA PET scan shows when their PSA gets up to a certain level?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think it's all of these factors. that will weigh in when is the right time. And, you know, the right time is what's right for the patient, quite honestly. So there's no, you know, in the BCR setting, not to say you're treating a number, but you kind of are. There's no clinical symptoms. They don't have metastases.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You're trying to ward off the development of metastases and improve their longevity. But Whether you start at three months or at six months or wait a little bit longer, there's no data to say that doing something one way versus another way improves outcomes.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, no, very good. I mean, I think the way to approach it is to be systematic about it. and provide education. I think, you know, actually in communicating with patients about their different experiences in when they started ADT, I think one of the biggest take homes was like, everybody does it different. Every doc doesn't different. There isn't sort of like a system.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think like kind of being a little bit more systematic about, you know, these are the options that you have and these are the side effects and just, you know, You know, at our institution, you know, Aditya kind of we piloted together kind of like an ADT order set, you know, like when you're going to start ADT, these are the things to think of. These are the labs to think of.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
This is the imaging. Here's the teaching. And I think that that really kind of takes out a lot of bias from the process. So I think standardization is important and also kind of seeing what the goals are for the patient and aligning with them is really key. I think what's really cool that's coming down the pike is, you know, we continue to bat away at the androgen receptor in prostate cancer.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And I think there's been definitely an evolution over the last several decades in how we facilitate a medical decline in testosterone levels with a therapeutic intent to treat prostate cancer. Historically, before we had GnRH analogs, we just used good old bilateral orchiectomy to treat patients.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And I think the next generation of hormonal agents, we've got CYP11 inhibitors that now not, you know, the abiraterone is a CYP17 inhibitor, blocks a little bit lower down in the adrenal hormonal axis. You know, MK5684 is a CYP11 inhibitor that blocks even higher up. preventing cholesterol from entering into the hormone production pathway.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And it can be associated with adrenal insufficiency type symptoms. So mineralocorticoid deficiency in addition to glucocorticoid deficiency. And so that is coming down the pike. We've seen some pretty promising data. There's also AR degraders, AR protags. There are different kinds of ways to further kind of block the androgen access.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think there's a lot of cool stuff coming down the pike that hopefully will enhance patients' survival and not be associated with too much toxicity.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Thank you, Aditya.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And, you know, there's still a role for that even in the modern era, if you will, if we think about the cost of care and in people who are going to be on indefinite ADT without any reason to discontinue therapy, it still plays a role in the modern era for a select number of patients.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And certainly as we think about underserved, you know, regions of the world where there's a lack of access to drugs and treatments. I think as we think about the GnRH analogs, I think there's been an evolution. Classically, we think of GnRH agonists that have been kind of the backbone of treatment. And if we go back to normal physiology, typically the LH and FSH are released in a
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
let's say, pulsatile fashion, if you will, when there's a continuous stimulation of the pituitary hypothalamus access, it results in complete kind of shutdown of the access, you know, pulsatile therapy versus continuous therapy. And that's basically how we achieve suppressed T levels with the GnRH agonist.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And then the antagonists have come around, which instead of, you know, working first to turn on the access before they turn it off, immediately suppress. And then, you know, now we've got androgen receptor pathway inhibitors. I mean, there's many of them out there that further suppress or block androgen signaling that have really entered into the landscape.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think we've seen an evolution from surgery to the injectable analogs to now next generation potent oral agents.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, absolutely. So very good question. You know, I think in the localized setting for individuals that are undergoing surgery, at the present time, there's no role for perioperative therapy, though there are clinical trials that are looking at investigating that, but currently no role.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I think for people that have, that are undergoing radiation, there absolutely is a role for ADT and the duration and intensity varies dependent on the risk of the patient. And so in the context of intermediate risk disease, six months of a GnRH analog would be sufficient for patients with high risk disease, two years of therapy.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And for patients with very high risk disease defined as a PSA of greater than 40, at least an 8, 9, 10 disease or T3 disease, having two out of three of those factors, they're getting the addition of abiraterone to ADT. So that's treatment in the definitive setting with a curative intent. And we know that there are some patients that go on to relapse following definitive treatment.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
for those individuals that relapse post-surgery, there certainly is a role for ADT combined with radiation. And particularly, it's largely dependent on what's the PSA level at the time of radiation, and also what's the patient's risk factors coming in to the radiation therapy, whether they should or shouldn't undergo ADT. And then for those individuals that have a relapse
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
post definitive treatment, post salvage radiation, post definitive radiation. They're not really a candidate for any more pelvic directed therapy. We're treating with intermittent ADT in the BCR setting. And again, the potency, of treatment is largely dependent on risk of disease.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
For patients with a rapid PSA doubling time, we're generally now leaning towards doublet therapy with ADT plus an ARSI, particularly enzalutamide, which has been tested in this setting for intermittent duration. So one year of therapy and then off treatment.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
everybody does it different, every doc doesn't different, there isn't sort of like a system. So I think like kind of being a little bit more systematic about, you know, these are the options that you have.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And then in the metastatic disease setting, you know, that's where we're really thinking about more continuous therapy with more lifelong hormonal therapy, though I think that many are beginning to challenge that paradigm a little bit. But more lifelong therapy and particularly for those individuals with high risk disease or de novo metastatic disease, adding an additional RSI.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And I think, you know, the one caveat to everything that I've just stated is like PSMA PET imaging has really kind of wreaked havoc in our defining of different stages of prostate cancer. And so we're identifying disease earlier, we're identifying low volume metastatic disease,
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And sort of some thought around, you know, intermittent therapy for people with metastatic disease by PSMA PET imaging, but conventional imaging negative and not wetting those patients to lifelong ADT. So that's still sort of also being tested.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
But that's sort of the spectrum, I think, across the way, the intensity and the potency and the duration is really largely been driven by the risk, the patient risk factors.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And these are the side effects, you know, at our institution, a DTF kind of we piloted together kind of like an ADT order set, you know, like when you're going to start ADT, these are the things to think of, these are the labs to think of, this is the imaging, here's the teaching. And I think that that really kind of takes out a lot of bias from the process.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
For just ADT alone without an ARSI, just straight up by itself?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, you know, I think that's a very good question. You know, I think at the end of the day, it depends on the patient's symptoms, their goals of care, their quality of life. I think if there's somebody that is maybe has high risk localized disease, the treatment's going to be resultant in a lot of morbidity from surgery or morbidity from radiation.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
but they're high risk enough that you really don't want them to develop metastases. And there could be the potential that they would develop metastases in their lifetime. You can certainly think about doing ADT in that context, but I think it's very personalized depending on the patient's comorbidities and also what their goals of care are.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Yeah, no, very good question. You know, I think that, you know, a lot of times we're talking about one, what's the intent of treatment, but we're going through a lot of the side effects, you know, a lot of times, the bulk of the clinic visit is spent around, well, this is all the risks that are associated with ADT.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And these are all the things we need to guard against when you go on hormonal therapy. So I think it's an overview of sort of the risk and the toxicity. But I think with regards to the different agents, there's a ton of different agents that are out there. And
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
There are certain things that I think we do in clinical practice because they're just very practical and feasible to orchestrate in the clinic. But, you know, technically at the end of the day, there's like Degarelix that can be given as a one month subcutaneous injection. There's, you know, Luprolide or Trelstar that are given as
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
Once a month, three months, four months, six month injections, you know, and now there's also an oral agent called Relagolix that can be utilized. What we've seen with the GnRH antagonist is that there does seem to be a little bit more faster time to T recovery post discontinuation of the treatment. And I think there's very controversial data about GnRH.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
the potential cardiovascular, not to say risk, but mitigated risk with antagonist versus agonist. But I think there's a choice in the matter. Some patients may have a strong preference one way or another, and in which case they do, there's options, which is a good thing. Some patients are very
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
So I think standardization is important and also kind of seeing what the goals are for the patient and aligning with them is really key.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
fearful of side effects where you may not necessarily want to give them a six-month injection and the way to actually help encourage that they get evidence-based you know treatment is by saying you know what let's just do one month at a time or let's just do the pills and then if you have any side effects we'll just stop so I think that can be very appealing to some individuals yeah totally couldn't agree more I think you know that idea like a bit of a of a trial and
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
You know, very good question. I think there's probably a lot more, you know, hand-waving around the testosterone flare when people first start on an agonist than anything else. You know, I think when it's absolutely necessary are in individuals who have symptoms, urinary
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
symptoms that you're worried about obstruction, metastatic disease, pain, cord compression, that's where it's like absolutely critical to, you know, ensure that you kind of guard against the testosterone flare that can happen. You know, certainly an antagonist avoids that completely.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
you know, I think it has gotten complicated because of the ARSI and the fact that we use ARSI a lot in multiple settings. And, you know, are you going to put somebody on Lupron or biclutamide, then Lupron, wait for their Abbey script to come in and then switch them from the biclutamide to like, what are you actually doing with the biclutamide?
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
And are you actually impacting their survival in any way by giving them the two or four weeks of biclutamide? So I think, you know, not to say that there's been a movement away, but I think we are seeing less utilization of the first generation antiandrogens in the clinic because of the fact that we have these next generation agents and many individuals are getting such agents.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
I don't feel so strongly that somebody must absolutely get biclutamide to suppress the T-flare. I think in the localized context, where I'm not using an ARSI, then I will absolutely do that.
BackTable Urology
Ep. 210 Personalizing ADT Across the Prostate Cancer Spectrum with Dr. Rana McKay
But when I am using an ARSI, I think it just gets very complicated for the patients to also have to worry about getting their first generation antiandrogen while we're getting their Abby on board or Enza on board. You know, we may just tell them to start their Abby or Enza first and then come in later for the injection. So at the end of the day, do I think that that impacts overall survival? No.