Role of Medical Oncologist in Prostate Cancer Therapy?

Following an initial abdominal ultrasound that revealed an enlarged prostate, my PCP referred me to an Oncologic Urologist. Subsequent MRI and TRUS biopsy confirmed the diagnosis, and given the presence of local metastases, surgical intervention was not feasible. Consequently, I was directed to a Radiation Oncologist. Treatment commenced with Zoladex and Abiraterone prior to initiating radiation therapy. After completing radiation treatment, I now undergo monthly monitoring by my Medical Oncologist, who assesses my progress, addresses any concerns, and prescribes Abiraterone, Prednisolone, and Zoladex (10.8mg every three months) as part of my ongoing care regimen.

@proftom2

Who drives the cancer treatment bus is secondary to the route the bus is taking. You, the patient, should be in total accord with the route, or, at least in an ideal world, get off the bus you are on and take another bus. In the real world there is a spectrum of difficulty in switching buses from easy to impossible.

Using the bus metaphor when will the bus be a Waymo and the route chosen by Art Intel?

When I was initially diagnosed with prostate cancer by biopsy in 2021, the Urologist was the only bus driver. I did my due diligence and consulted multiple Urologists and Radiation Oncologists prior to deciding on RP, as the Imaging at that time revealed no spread outside the prostate gland. Unfortunately, 6 months later after a post op rising PSA (0.16 to 0.37) a PSMA PET revealed a solitary T8 met. Now the Radiation Oncologist took the wheel and did SBRT with curative intent to T8. Again, unfortunately, 4 months late my PSA had doubled, doubled, doubled and was now 4.6. Time for systemic therapy. My lead physician is now a MO at Johns Hopkins. He is heavily involved in prostate cancer research and has 30 years experience treating that disease. He directs my treatment (triplet therapy last Q 2022). I have received additional whole pelvic radiation on the advice of my MO. The RO was essentially following directions.

Yes, I suppose I am the ultimate driver in all of this. Despite having an MD and practicing Radiology for 40 years (most of the time at major medical centers) I feel inadequate to direct my care. I am very familiar with the Imaging of prostate cancer and even did US guided prostate biopsies in the day. I can't imagine a lay person deciding to direct their own care. The treatment of prostate cancer has become very complicated with numerous options depending on G score, Stage, response to prior treatment, patient age and co morbidities etc etc. I feel my role is to find the most competent specialists I can and pretty much follow his/her advice. Of course, I listen to the options presented and make a choice. But, I have told my MO that I want the most aggressive treatment that will give me the most time with a reasonable risk/reward ratio. He understands that. It's his job. I trust him. After my 3 months of triplet therapy he gave me 5 options. I said which one would you choose to give me the best chance? I chose that one.

I have extensively read the prostate cancer literature. I am used to reading medical journals and understand the language. It is still daunting to me. I don't necessarily want Standard of Care treatment. I want cutting edge treatment designed to obliterate as much of the cancer as possible. SOC usually lags cutting edge by several years. But you have to have an up to date, experienced MO at a COE who only treats GU cancer to get that cutting edge treatment.

At least that is my opinion. Good luck to everyone on this journey.

I originally went to an Orthopedic doctor for leg pain, he took an x-ray and sent me to my current MO (he's also the Director of the department) He drives the bus and I sit in back and wave out the window. Most times I can't remember the name of the meds I'm on, when posting on here I have to go get my phone to look them up. I understand what I have, stage4 but sometimes I feel like I jumped the line and missed all the struggles of different drs being involved. I have full confidence in my doctor and I always bring my wife in case I forget what he said to me. I tend not to read the summary from my visit but have noticed notations of consulting with other doctors. I couldn't ask for better care. best to all

@retireddoc

Definitions:
MO:=Medical Oncologist
SOC:=Standard of Care
COE:=Center of Excellence
GU:=???
CET:=Cutting Edge Treatment
TS:=Treatment Safari
PCa:=Prostate Cancer

Many thanks for the details of your TS.

I agree completely with your desires and choices. "The most aggressive treatment that will give me the most time with a reasonable risk/reward ratio." "Curative intent." CET.

I wonder if you were given multiple options whereas the care team for non-physician patients consider multiple options but only present the one they consider optimal to the patients. For myself, if there are multiple options I would like to know them along with the one considered optimal. Second opinions are standard for other aspects of PCa, why not for the most important aspect, your PCa TS?

By the way I am also a retired doc but my specialty, solid-earth geophysics, is somewhat less relevant to PCa than yours.

GU:= genitourinary?

A question for you? Several years ago, three, I started on abireterone and prednisone. About six months after that, my urologist switched me to Erleada which she provides through his own pharmacy. And now my number have run up to a PSA in the mid 20s he still does not want me to switch from Erleada and I am beginning to think it is because he sells it to me at $20,000 per month, I am thinking of going back to abireterone as my numbers were better then. Just curious if you took the one pill with food or you took the four pills on an empty stomach? Or is it possible to take two pills with food in the morning and two pills with food in the evening and get more positive results? My medical oncologist, hemmed, and hawed on that question.

@dirtdancer

Implicit in your question is the second opinion since you do not have complete trust/faith in opinion(s) given you. Easy to say get a second opinion for MRI, pathology, PSMA scan, whatever but where and how to judge the quality of the second opinion?

My go-to would be first this forum, then the PCRI forum and then the speakers on the PCRI videos if they give second opinions and of course the cost of said second opinion.

This topic deserves a thread.

Thank you for your response; I have been battling stage four since 2008 and have gone through most all treatment options. I’ve now begun to make my decisions based on one or two or three doctors opinions. I know I am getting jaded. Out of the seven doctors, I see in a semi regular timeframe. I am lucky if two have the same opinion. A couple years ago I started seeking treatment options that held out hope for a cure instead of just treatment.
I think you much for your response and your insight.

20k/month is shiesterism. My medical oncologist whose dad was a physician too, told me: one 250 mg. Pill Arbiterone with low fat meal/ 5mg prednisone. My results so far from this: PSA < .01. Also I found on the internet that people in India prefer this method as it’s cheaper and works just as well. Hope this helps ya.