IMPLEMENT Study Finds Gaps in How Urologists, Oncologist View First-Line Treatment Intensification for Prostate Cancer

Despite guidelines recommending first-line treatment intensification (TI)—consisting of androgen-deprivation therapy (ADT) with chemotherapy, novel hormonal therapies, or both—for metastatic castrate-sensitive prostate cancer (mCSPC), only 13% of patients treated by urologists and 37% of patients treated by oncologists are actually receiving TI.

Doctor talking to patient about prostate cancer | Image credit: kenchiro168 – stock.adobe.com

First-line TI is recommended in American Urological Association (AUA) and National Comprehensive Cancer Network guidelines due to improved overall survival without affecting quality of life. Presented at the AUA 2024 Annual Meeting, the IMPLEMENT study identified various barriers to TI implementation, such as knowledge gaps, costs, habit, and anticipated regret, and assessed how first-line TI barriers and facilitators differ between urologic specialties.

The study included 18 urologists and 18 oncologists based in the US, all of whom treated at least 1 patient with mCSPC in the previous 6 months. Virtual, double-blind, semistructured interviews were conducted based on the Theoretical Domains Framework, which were then coded into 11 domains to generate themes from the interview responses.

Stacy Loeb, MD, presenting author and professor of urology and population health at NYU Grossman School of Medicine, noted some commonality among barriers. Some key barriers to TI implementation that both urologists and oncologists faced included:

• Lack of knowledge of TI outcomes (61% of urologists; 61% of oncologists)
• Belief that there is insufficient data supporting TI (39% of urologists; 22% of oncologists)
• Waiting until the second line of treatment for TI (50% of urologists; 39% of oncologists)
• Only using first-line TI to treat severe disease (22% of urologists; 28% of oncologists)

There were also 2 main peripheral facilitators in TI that urologists and oncologists agreed on: having confidence in first-line TI (33% of urologists; 50% of oncologists) and being comfortable with TI management (39% of urologists; 22% of oncologists).

However, there were also some key differences in each specialist’s beliefs. Urologists were more likely to see good interdisciplinary collaboration, referring patients to an oncologist if TI is not possible at their practice, and the belief that urologists should be able to intensify treatment as positive facilitators for TI implementation. Meanwhile, 5 oncologists said that when urologists wait too long to refer a patient to them, it can pose a barrier, and 1 urologist agreed with this sentiment.

When looking at the domain of decision processes, most oncologists said that not limiting TI based solely on age or performance status was a facilitator, while more urologists said the habit of not intensifying treatment first line was a barrier. Additionally, looking at environmental context, oncologists were more likely to say there was sufficient clinical support of TI, while half of urologists said there is insufficient support.

Overall, oncologists were inclined to highlight factors supporting TI, such as the ability to effectively consider age and performance status when determining treatment impact and having sufficient clinical assistance, while mentioning delayed referral to urologists as a hindrance. Conversely, urologists frequently cited barriers to TI, including inadequate clinical support and the tendency to initiate patients on ADT either alone or with a first-generation anti-androgen out of habit. However, they acknowledged positive collaboration with oncologists as a facilitator to TI implementation.

Loeb said she hopes doctors in both specialties look at these findings and identify potential ways to address the gap. In fact, the study is now in phase 2, where the researchers are partnering with urologists and oncologists to create resources to minimize these gaps in first-line TI implementation.

Reference

Loeb S, Agarwal N, El-Chaar N, et al. Differences in barriers and facilitators to first-line treatment intensification in metastatic castration-sensitive prostate cancer between urologists and oncologists: a sub-analysis of the IMPLEMENT study. Presented at: AUA 2024 Annual Meeting; May 3, 2024; San Antonio, TX. https://www.auajournals.org/doi/10.1097/01.JU.0001009540.33579.43.02