Experts consider available professional society guidelines on prostate cancer and cardiovascular disease management.
Maria Lopes, MD, MS: We certainly do rely on NCCN [National Comprehensive Cancer Network] guidelines, usually if there’s a level of evidence that’s 2A or higher, and sometimes even going beyond the FDA label indication. As we get requests for off-label use, we’ll go to the NCCN to see if it’s in the compendia, if it’s appropriate. Usually, the NCCN is the most comprehensive and updated guideline of references we do use. If it’s not in NCCN, we’ll also look at any recent publications in peer-reviewed literature, or ASCO [American Society of Clinical Oncology] guidelines. But usually it is NCCN because they are the most updated and comprehensive.
John L. Fox, MD, MHA: Payers use professional society guidelines, and especially in cancer, we use the NCCN guidelines in formulating our coverage decisions. In the space of prostate cancer and cardiovascular disease [CVD], the NCCN guidelines are mostly silent on the topic. They certainly recommend screening and intervention for the prevention or treatment of CVD and then with receiving androgen deprivation therapy [ADT]. But they don’t distinguish between the different types of ADT, agonist vs. antagonist. I would say that payers, when we think about managing long-term adverse effects of medication, this really isn’t on our radar screen.
Bhavesh Shah, RPh, BCOP: We know there are a lot of guidelines that drive therapies for prostate cancer, that drive screening for prostate cancer, but there are not a lot of uniform guidelines that actually help in managing the downstream effects of treatments related to prostate cancer, such as the cardiovascular issue, the diabetes. I think that there are a lot of other adverse effects that patients will have in the course of their disease because we know that patients with prostate cancer will be at a higher risk of developing osteoporosis, diabetes, and cardiovascular events. They’re going to be more prone to developing bone metastasis. There’s a lot of general internal medicine that needs to be managed. I think that NCCN guidelines don’t do a great job in guiding providers in terms of how that should be done. I think there needs to be cross collaboration, which maybe already exists, between the cardiologist, the primary care [physician], the oncologist, and of course, identifying treatments that may be more beneficial for patients with specific preexisting cardiovascular events or other comorbidities that may drive them to have a negative outcome from that comorbidity vs. the malignancy that they have.
When you look across the multiple guidelines, there’s the AUA [American Urological Association], which has guidelines, ASCO has guidelines, NCCN, and I don’t think that we have a great uniform recommendation for treating these patients. The other thing I should mention, African American men usually have—even with low- or intermediate-risk prostate cancer—they have a very high risk in all-cause mortality after treatment, especially due to cardiovascular complications. I know the NCCN guidelines definitely call that out, and it kind of highlights the health inequities that we see in oncology, in cancer. I think we need to have more awareness around those aspects also from guidelines.
Transcript edited for clarity.