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Castration-Resistant Prostate Cancer: Guiding Patients Through Treatment With Brenda Martone, MSN, ANP-BC, AOCNP

Brenda Martone, MSN, ANP-BC, AOCNP.

Androgen deprivation therapy is a cornerstone of treatment for progressive prostate cancer, but over time, many patients stop responding to this treatment, developing a resistance to castration. Until recently, nonmetastatic castration-resistant prostate cancer (CRPC) lacked effective treatment options; this situation has changed dramatically with the rise of several new agents. Metastatic CRPC is the primary cause of prostate-related mortality, yet advances in treatment are extending survival. In this interview with i3 Health, Brenda Martone, MSN, ANP-BC, AOCNP, a nurse practitioner at Northwestern Medicine, shares her perspectives on new treatment developments and the challenges of working with patients with CRPC. In addition, she shares advice for oncology nurses as they seek to provide the best care for patients with both nonmetastatic and metastatic disease.

What led you to work with patients with prostate cancer?

Brenda Martone, MSN, ANP-BC, AOCNP: I have been an oncology nurse my entire nursing career. I have worked in various roles, ranging from inpatient staff nurse and chemotherapy nurse to clinical nurse specialist working in oncology clinical trials. I "landed" in genitourinary oncology in 1999 and have been focused on this patient population ever since. I returned to school to get my nurse practitioner post master's certificate to allow me to spend as much time as possible with prostate cancer patients.

How have the prospects changed for patients with CRPC since you first began working with this population?

Ms. Martone: I would describe the changes in the CRPC world as a "treatment landslide." We now have a better understanding of prostate cancer cell behavior, and we know that the androgen receptor remains active in CRPC.

For those patients with CRPC that do not have evidence of metastatic disease, we have three new agents that have been approved since 2018. All three of these agents were approved based on results of phase 3 randomized double-blind clinical trials that each demonstrated a significant delay in the time to the development of metastatic disease when compared with placebo. Why is this important? Invisible prostate cancer does not kill. It is metastatic spread—visible cancer—that kills men.

In men with metastatic CRPC, we have therapies that delay time to progression as well as extend overall survival. We are studying poly ADP-ribose polymerase (PARP) inhibitors in men with DNA repair mutations, and we are anxiously awaiting FDA approval of new agents.

What are the greatest challenges involved in working with patients with CRPC?

Ms. Martone: I can divide the greatest challenges into two categories, financial and medical.

Financial toxicity is a new "adverse event." Trying to get treatments and imaging studies approved for my patients is challenging. It takes several steps to get insurance to approve the medications, and then more time and effort is needed to get the medication to the patient at a cost that is not prohibitive. In terms of scans, it seems that over 50% of the scans I order require a peer-to-peer review. There are letters of medical necessity that are written for a patient whose drug plan does not include the treatment on the formulary, for whom we have to justify an FDA-approved medication or treatment.

Medical challenges related to the oral therapies include making sure that patients are taking their medications at home as prescribed, checking the potential for drug-drug and drug-supplement interactions, and monitoring for side effects. For example, abiraterone needs to be taken on an empty stomach. The prednisone that is part of the regimen needs to be taken with food. Enzalutamide is dosed at four 60-mg tablets once daily, not one tablet every six hours or two tablets every 12 hours.

In general, prostate cancer patients may be on medications for other medical conditions; these may include antihypertensives, statins, and anticoagulants. There may be interactions with patients' concomitant medications, with the prostate cancer treatment either increasing or decreasing the other medications' therapeutic effects, or the other medications impacting the therapeutic effect of the prostate cancer-directed therapy.

In terms of side effect monitoring and management, first the patient needs to inform me of the side effect. When patients are not directly in front of us in the office, nurses and advanced practice providers need to know what questions to ask based on expected side effects from the treatment.

What questions do you commonly encounter from patients with CRPC, and how do you counsel them?

Ms. Martone: How long will the treatment work? Even before starting a medication or new treatment, a majority of my patients want to know the median time that the medication is expected to work. To be able to answer this question, it is important for me to understand the clinical trial data and the primary end point of the study that led to the approval of this treatment.

What are the options when this treatment stops working? While this can be a very difficult question to answer, I find that what patients are looking for is hope. They want to know that there are other options that are available to them. I try to focus on the present and let patients know that there are new treatments, and I let them know of the potential for more clinical trials in the future.

What are the side effects? I educate my patients regarding potential side effects most frequently seen in clinical trials, as well as those seen in my experience as a provider. I provide written information regarding dosing and potential side effects. In my clinical practice, we see patients more frequently when initiating a new therapy and therefore have the opportunity for additional teaching and reinforcement. In addition, we make follow-up phone calls in between visits to reinforce current medication administration, assess for side effects, and provide ongoing patient education.

What advice can you share with oncology nurses and nurse practitioners working with patients with CRPC?

Ms. Martone: There are treatment options now for men with nonmetastatic CRPC that delay the development of metastatic disease. To obtain benefit from treatment, we need to monitor closely for side effects, intervene early, and strive to improve their quality of life during treatment.

For men with metastatic CRPC, genomic sequencing is an important consideration to identify potential actionable mutations that may provide additional treatment strategies. This includes not only germline mutations but also somatic mutations in the prostate cancer tissue. The sequencing of treatment is being looked at in clinical trials, as is combination therapy. Encourage men to consider participation in a clinical trial when available.

All treatment is associated with side effects. We need to ensure that we are keeping ourselves educated in order to educate our patients and provide the highest level of quality care.

Finally, it is important to keep in mind that prostate cancer is a marathon and not a sprint. We are always hoping for a cure.

About Ms. Martone

Brenda Martone, MSN, ANP-BC, AOCNP, is a nurse practitioner at Northwestern Medicine, where she provides direct patient care, consultation, and education to collaboratively formulate care plans for patients with genitourinary malignancies. Ms. Martone is a member of the Advanced Practitioner Society for Hematology and Oncology, the American Association of Nurse Practitioners, and the Oncology Nursing Society (ONS). During this past year, she presented on CRPC at the ONS 44th Annual Congress. In addition, she has co-authored publications in journals such as the Journal of Clinical Oncology, Clinical Cancer Research, and Clinical Genitourinary Cancer.

For More Information

To gain additional expert perspectives from Ms. Martone on the management of CRPC, complete i3 Health's free CNE-approved online Strategy Session:

Enhancing Treatment Experiences in Castration-Resistant Prostate Cancer: The Nurse's View

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.

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